Ohio WC Guide: Medical Benefits

Ohio Workers' Compensation Guide

Medical Benefits

Overview

The Ohio workers' compensation system has three different medical programs:

1. state fund employers participate in a managed care program, called a “Health Partnership Program” (HPP);
2. self-insured employers can choose to set up a managed care program, referred to as a “Qualified Health Plan” (QHP);
3. self-insurers who do not set up a QHP, must follow the criteria for medical management in O.A.C. 4123-19-03(K).

The BWC provides a statewide list of BWC certified providers.

State Fund Employers

Each employer chooses an MCO. If an employer does not chose an MCO, the BWC will assign the employer to an MCO. The BWC provides a page to search which MCO serves which employer. The injured worker can choose which doctor to use in the managed care organization (MCO) panel, but must use a BWC certified doctor. If the injured worker does not like their doctor, they can switch to any BWC certified provider.

Self Insured Employers

A self-insurer may either:

1. set up a QHP (a self-administered MCO), or
2. follow the O.A.C. 4123-19-03(K) criteria for medical management.

The procedures followed by the BWC's MCO apply to the QHP. If a self-insurer sets up a QHP, it must inform the employees what medical providers are in the QHP. The self-insurer must choose providers from the list of BWC certified providers. If the self-insurer does not set up a QHP, the injured worker has the freedom to chose a doctor. The employer cannot restrict the injured worker's choice of doctor.

What the MCO Does

The MCO manages the medical aspects of the claim, works with providers and pays provider bills. The MCO also enters into contracts with the various providers and shares with the employer the responsibility for informing employees of the panel of providers.

Providers

Any provider can apply for certification. Once certified, a provider may contract with many MCOs. The provider sends their bill for service to the MCO which, if it approves the bill, sends it to the BWC for payment. The BWC sends payments for the bill to the MCOs who then pay the providers.

Appeals

The injured worker or provider can appeal an MCO's rejection of a provider's request for authorization. The injured worker or provider must appeal in writing (use form C-11) within 14 days of receipt of the MCO's decision. MCOs have 21 days from receipt of the appeal to perform a file review and make a final decision. When the review requires an Independent Medical Exam (IME), the timeframe is tolled until the MCO obtains a completed report. Once the MCO receives the report, an order must issue within 7 days. The MCO sends its decision to the BWC, which will publish it as an order. The injured worker or employer can appeal the BWC order to the Industrial Commission within 14 days of the order. Only the injured worker or employer may appeal to the Industrial Commission — neither the provider nor the MCO can appeal to the Industrial Commission. If no party appeals the BWC order, it becomes a final order.

BWC Compensability Determinations

The BWC, not the MCO, makes compensability determinations (such as causal relationship, work-relatedness, additional allowances.)

Pharmaceutical Benefits

OptumRX is the pharmaceutical manager and acts administratively to manage pharmaceutical benefits. OptumRX will not dispense medicine. Local pharmacies fill the prescriptions. You can contact OptumRX by calling (877)615-6330.