with division (A) of section
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
(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
(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.
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
of the Revised Code. The
administrator shall not seek reimbursement of the payment from the
or the provider.
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Ohio Admin. Code
Five Year Review (FYR) Dates:
Effective Dates: 12/17/2001, 02/10/2009, 04/01/2014,