Ohio Admin. Code 4123-6-38.2 - Payment of nursing home and residential care/assisted living services
(A) Payment to a
nursing home or residential care/assisted living facility for the care of
a claimant
an
injured worker who sustained an injury or contracted an occupational
disease in the course of and arising out of employment shall be made only when
the need for such care is the direct result of the allowed conditions in the
claim.
(B) Payment will be made
only for care provided in nursing homes and residential care/ assisted living
facilities meeting the qualifications specified in paragraph (C) of rule
4123-6-02.2 of the
Administrative Code.
(C) Nursing
home or residential care/assisted living facility care must be pre-authorized,
except when a nursing home or residential care/assisted living facility is used
immediately following an approved or emergency hospitalization.
(1) The allowed per diem rate for
a claimant
an
injured worker shall be no greater than the bureau's fee schedule or the
rate negotiated between the nursing home or residential care/assisted living
facility and the bureau, MCO, QHP, or selfinsuring employer.
(2) Nursing home care shall be provided on a
semiprivate bed basis, unless a situation exists when the use of a private room
is medically necessary due to the allowed industrial condition. In these cases, the use of
such a private room must be preauthorized, except in cases of emergency, as
defined in rule
4123-6-01 of the Administrative
Code, or where the claimant's
injured worker's condition would be endangered by
delay.
(3)
Fee bills for prescription medication provided to
claimants in nursing homes and residential care/assisted living facilities for
the treatment of the allowed industrial injury or occupational disease shall be
submitted by the providing pharmacy in compliance with the rules of this
chapter of the Administrative Code
Prescription
medication provided to an injured worker in a nursing home for the treatment of
an allowed injury or occupational disease is included in the nursing home's per
diem rate, and is not separately payable.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 02/14/2005, 02/01/2010, 07/01/2013
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