As used in the rules of this chapter and Chapter 4123-7 of the Administrative Code:
(A) "Health Partnership Program" or "HPP" means:
The Bureau of Workers' Compensation's comprehensive managed-care program under the
direction of the chief of medical management and cost containment as provided in sections
4121.44 and 4121.441 of the Revised Code.
(B) "Qualified Health Plan" or "QHP" means:
A health-care plan sponsored by an employer or a group of employers that meets the
standards for qualification developed by the Health Care Quality Advisory Council and is
certified as a qualified health-care plan with the bureau.
(C) "Managed care organization" or "MCO" means:
A vendor as defined under section 4121.44 of the Revised Code who has contracted with
the bureau to provide medical management and cost containment services as part of the HPP
as provided in sections 4121.44 and 4121.441 of the Revised Code. Any vendor may
participate in the HPP as an MCO if it is certified by the bureau pursuant to the rules of
this chapter. As used in these rules, a managed care organization is not a health-care
provider.
(D) "Physician" means:
As defined in division (B) of section 4730.01 of the Revised Code, a doctor of medicine,
doctor of osteopathic medicine or surgery, or doctor of podiatric medicine who holds a
current, valid certificate of licensure to practice medicine or surgery, osteopathic
medicine or surgery, or podiatry under Chapter 4731. of the Revised Code; as provided in
section 4734.09 of the Revised Code, a doctor of chiropractic who holds a current, valid
certificate of licensure to practice chiropractic under Chapter 4734. of the Revised Code;
as provided in section 4731.151 of the Revised Code, a doctor of mechanotherapy who holds
a current, valid certificate of licensure to practice mechanotherapy under Chapter 4731.
of the Revised Code and who was licensed prior to Nov. 3, 1985; a psychologist who holds a
current, valid certificate of licensure to practice psychology under Chapter 4732. of the
Revised Code; or a dentist who holds a current, valid certificate of licensure to practice
dentistry under Chapter 4715. of the Revised Code. A physician licensed pursuant to the
equivalent law of another state shall qualify as a physician under this rule.
(E) "Physician of record" or "attending
physician" means:
For the purposes of Chapters 4121. And 4123. of the Revised Code, the authorized physician
chosen by the employee to direct treatment.
(F) "Practitioner" means:
A physician, or a physical therapist, occupational therapist, optometrist, or any other
person currently licensed and duly authorized to practice within their respective
health-care fields.
(G) "Health-care provider" or "provider" means:
A physician or practitioner, or any person, firm, corporation, limited liability
corporation, partnership, association, agency, institution, or other legal entity
licensed, certified, or approved by a professional standard-setting body and approved by
the bureau, or by a regulatory agency under title XIII or XIX of the Social Security Act
and approved by the bureau, to provide particular medical services or supplies, including,
but not limited to: a hospital, qualified rehabilitation provider, pharmacist, or durable
medical equipment supplier.
(H) "Credentialing" or "recredentialing" means:
A process by which the bureau validates or reviews the application of a provider for
eligibility for participation in the HPP.
(I) "Certification" or "recertification" means:
A process by which the bureau approves and contracts with a provider or MCO for
participation in the HPP.
(J) "Provider application" means:
A bureau form requesting background information and documentation that must be
completed by a health-care provider for credentialing for participation in the HPP as a
bureau-certified provider.
(K) Bureau "provider agreement" means:
A written, contractual agreement between the bureau and a provider. The provider
agreement may include a provider statement or affirmation that the statements made in the
application are true.
(L) "Bureau-certified provider" means:
A credentialed provider who signs a provider agreement with the bureau and is approved
by the bureau for participation in the HPP.
(M) "Non-bureau-certified provider" means:
A provider who has not signed a provider agreement with the bureau and is not approved by
the bureau for participation in the HPP. A non-bureau-certified provider may participate
in the HPP pursuant to rule 4123-6-027 of the Administrative Code.
(N) "MCO panel provider" means:
A bureau-certified provider who is a provider included within an HPP certified MCO.
(O) "Employee" means:
As used in the rules of this Chapter, the term "employee" includes the terms
"injured worker" and "claimant" and all employees of employers covered
under HPP.
(P) "Emergency" means:
Medical services that are required for the immediate diagnosis and treatment of a
condition that, if not immediately diagnosed and treated, could lead to serious physical
or mental disability or death, or that are immediately necessary to alleviate severe pain.
Emergency treatment includes treatment delivered in response to symptoms that may or may
not represent an actual emergency, but is necessary to determine whether an emergency
exists.
(Q) "Medically necessary" means:
Services that are necessary for the diagnosis or treatment of disease, illness, and
injury, and meet accepted guidelines of medical practice. A medically necessary service
must be appropriate to the illness or injury for which it is performed regarding type,
intensity, and duration of service and setting of treatment.
(R) "Authorization" or "prior authorization"
means:
Notification by an authorized representative of the MCO, that a specific treatment,
service, or equipment is medically necessary for the diagnosis and/or treatment of an
allowed condition, except that the bureau reserves the authority to authorize or prior
authorize the following services: caregiver, and home and van.
(S) "Dispute resolution" means:
Procedures developed by the MCO or the bureau to resolve medical disputes prior to
filing an appeal under section 4123.511 of the Revised Code.
(T) "Provider profiling" means:
A medical management analysis tool used by the bureau or MCO that at a minimum, utilizes
line- item detail from a medical bill and employee specific information such as
demographics, diagnosis allowances and other data regarding treatment, to evaluate a
health care provider on the basis of cost, utilization and treatment outcomes.
(U) "Utilization review" means:
The assessment of an employee's medical care by the MCO. This assessment typically
considers medical necessity, the appropriateness of the place of care, level of care, and
the duration, frequency or quality of services provided in relation to the allowed
condition being treated.
(V) "Treatment guidelines" mean:
Guidelines of medical practice developed through consensus of practitioner
representatives, that assist a practitioner and a patient in making decisions about
appropriate health care for specific medical conditions.
(W) "Formulary" means:
A list of medications determined to be safe and effective by the food and drug
administration that the bureau shall consider for reimbursement. The list shall be
regularly reviewed and updated by the bureau to reflect current medical standards of drug
therapy.
(X) "Medication" means:
The same as drug as defined by division (C) of section 4729.02 of the Revised Code.
(Y) "Injury" means:
For the purposes of the rules of this chapter and Chapter 4123-7 of the Administrative
Code only, an injury as defined in division (C) of section 4123.01 of the Revised Code or
an occupational disease as defined in division (F) of section 4123.01 of the Revised Code.
Effective date: Feb. 16, 1996