(A) This rule shall provide for procedures for the resolution of medical disputes that may arise between any of the following: an employer, an employee, a provider, the bureau, or an MCO. This rule applies to reviews of records, medical disputes arising over issues such as, but not limited, to quality assurance, utilization review, determinations that a service provided to an employee is not covered, is covered or is medically unnecessary; or involving individual health care providers.
(B) An employee or employer must exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code on an issue relating to the delivery of medical services.
(C) Any MCO participating in the bureau's HPP must have a medical dispute resolution process that includes a minimum of two independent levels of review. If an individual health-care provider is involved in the dispute, at least one of the levels of review shall contain a peer review consisting of an individual or individuals licensed pursuant to the same section of the Revised Code as the health-care provider. The MCO must identify the providers performing the peer review. The MCO must complete its internal medical dispute resolution process and must notify the parties to the dispute and their representatives of the decision in writing within twenty-one days of notice of a dispute. The twenty-one days shall be measured from the time the written notice of the medical dispute is received by the MCO. Notice of the medical dispute received by telephone only does not constitute formal notification as described above. Any unresolved disputes shall be referred by the MCO to the bureau within seven days.
(D) Within fourteen days after receipt of an unresolved medical dispute as stated in paragraph (C) of this rule, the bureau shall conduct an independent review of the unresolved medical dispute received from the MCO and enter a final bureau order pursuant to section 4123.511 of the Revised Code. This order shall be mailed to all parties and may be appealed to the Industrial Commission pursuant to section 4123.511 of the Revised Code. Neither the provider nor the MCO is a party entitled to file an appeal under section 4123.511 of the Revised Code.
Effective date: Feb. 16, 1996