Ohio Admin. Code 4123-3-36 - Immediate allowance and payment of medical bills in claims

(A) In accordance with division (A) of section 4123.511 of the Revised Code the administrator has established a program to immediately allow specific medical conditions which have a historical record of being allowed whenever included in a claim and having low medical costs.

The medical conditions that the administrator has determined to be included in the program are indicated in the appendix to this rule.

(1) The administrator used historical statistical criteria to determine the appropriate specific medical conditions to include in the program. The criteria included but was not limited to the following:

(a) Number of claims for the medical condition;

(b) Per cent of claims for the medical condition disputed;

(c) Per cent of claims for the medical condition appealed;

(d) Per cent of claims for the medical condition disallowed; and

(e) Average cost for the medical condition per claim.

(2) The medical conditions that the administrator determined to be included are attached as appendix A to this rule.

(B) Upon the initial filing of a claim, the administrator shall investigate the claim and issue an order on the claim as required by section 4123.511 of the Revised Code. The administrator shall consider all of the necessary evidence and relevant laws and rules for the determination of the allowance of a claim. For any medical condition identified in appendix A to this rule, however, the administrator may grant immediate allowance of the medical condition and may make immediate payment of the medical bills relating to that condition, regardless of the receipt of the medical reports for that medical condition or the employer's certification of the claim.
(C) The employer retains the right to contest the immediate allowance and payment of a medical condition in a claim under this rule. If the employer appeals the allowance and payment and the claim is disallowed, the payment for the medical treatment provided prior to the date of the disallowance of that claim shall be charged to and paid from the surplus fund created under section 4123.34 of the Revised Code. The administrator shall not seek reimbursement of the payment from the injured worker claimant or the provider.

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Ohio Admin. Code 4123-3-36
Effective: 7/1/2019
Five Year Review (FYR) Dates: 4/8/2019 and 07/01/2024
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4123.511
Prior Effective Dates: 12/17/2001, 02/10/2009, 04/01/2014, 10/01/2015

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