|OhioBWC - Employer: (Self-insuring) - Medical management guidelines|
|Self-insuring medical management guidelines|
A self-insuring employer must be able to furnish or make arrangements for reasonable medical services for injured employees during all work hours and the management of any medical claims. The employer must provide BWC a medical services plan that includes:
All self-insuring employers must administer either a Qualified Health Plan (QHP) or a Medical Management Plan. A Medical Management Plan must incorporate the five elements listed above. A QHP must incorporate the five elements listed above, and it must meet additional nationally recognized standards as outlined in Ohio Revised Code 4121.442.
Qualified Health Plan
All self-insuring employers with a QHP are required to have an alternative dispute resolution (ADR) process. Employers who do not participate in an approved QHP may not use the ADR process. ADR is intended to handle medical disputes regarding quality assurance, utilization review, medical necessity, and other treatment and provider issues. ADR provides due process regarding conflicts in medical treatment issues. However, this does not include fee schedule grievances. Disputed issues may include:
There are at least two levels of peer review by the QHP administrator. BWC is not involved in this process. If the injured worker does not agree with the self-insuring employer's decision on a treatment issue, the injured worker must follow the ADR process as outlined by the employer's QHP. If there continues to be a dispute after the ADR process has been completed, the injured worker may file a motion requesting an Industrial Commission of Ohio hearing.
Employers with an active QHP must be recertified every three years pursuant to Ohio Administrative Code 4123-6-52. Current employers who have a QHP may opt out during their renewal period. The self-insuring employer must notify BWC in writing at least 30 days prior to the date of opting out. Upon opting out, the self-insuring employer must provide its active Medical Management Plan to BWC.
If you have questions regarding the medical services requirements for a self-insuring employer, please email BWC's self-insured department.