(A) Upon request by a managed care organization, the bureau shall mail a managed care organization an MCO application for certification.
(B) The MCO application for certification shall include a list of bureau-certified providers.
(C) A provider identified by an MCO for inclusion in its panel of providers that is not a bureau-certified provider may be assisted by the MCO in applying for bureau provider credentialing and certification.
(D) The bureau or MCO shall not discriminate against any category of health-care provider when establishing categories of providers for participation in the HPP. However, neither the bureau nor an MCO is required to accept or retain any individual provider in the HPP.
(E) An MCO shall demonstrate arrangements and reimbursement agreements with a substantial number of medical, professional and pharmacy providers currently being used by injured employees. An MCO may limit the number of providers on its MCO provider panel but must do so based upon objective data approved by the bureau, such as reasonable patient access, community needs, the potential number of employees the MCO is applying to service, and other performance criteria, without discrimination by provider type.
(F) The MCO application for certification shall include, at a
minimum, the following provisions, as more fully detailed within the MCO application for
certification itself:
(1) A statement that the application is without misrepresentation, misstatement, or
omission of a relevant fact or other acts involving dishonesty, fraud, or deceit. The
managed care organization shall provide to the bureau any additional documentation
requested and shall permit the bureau, upon reasonable notice, to conduct a review of the
managed care organization.
(2) A description of the geographic area of the State of Ohio for which the managed
care organization wishes to be certified by the bureau. The minimum geographic area shall
be a county. The bureau shall certify MCO participation on a county basis, subject to the
provisions in rule 4123-6-033 of the Administrative Code. The managed care organization
may apply for coverage in more than one county or statewide.
(3) A description of the managed care organization that includes, but is not
limited to a profile that includes a disclosure statement regarding the managed care
organization's organizational structure, including subsidiary, parent and affiliate
relationships. Historical and current data shall be provided. The managed care
organization must identify its principals; provide the managed care organization's date of
incorporation or formation of partnership or limited liability company, if applicable;
provide any fictitious names the managed care organization is, or has been, doing business
under; provide the number of years the managed care organization has operated in Ohio;
provide a table of organization with the number of employees; identify other states in
which the managed care organization is doing business or has done business in the last
five years, and identify any banking relationships, including all account information with
any financial institutions doing business in Ohio.
(4) A description of the structure of the health care provider network to be
offered by the managed care organization.
(5) A description of the process and methodology of credentialing of providers in
the managed care organization's network.
(6) A description of the managed care organization's payment process and
methodology to providers in the managed care organization's network.
(7) An explanation how the managed care organization will provide timely,
geographically convenient access to medical care.
(8) A description of the managed care organization's policies and procedures for
sanctioning and terminating providers in the managed care organization's network; and a
description of the managed care organization's methodology to notify the bureau, employers
and employees of any changes in the network.
(9) A description of the managed care organization's methodology for distributing
provider directories and updated provider directories to employers and/or employees.
(10) A description of the managed care organization's treatment guidelines,
including a description of the rationale underlying the development of the treatment
guidelines.
(11) A description of the managed care organization's utilization review process.
(12) A description of the managed care organization's quality assurance/improvement
standards program and process, including the use of satisfaction surveys.
(13) A description of the managed care organization's provider profiling system.
(14) A description of the managed care organization's medical dispute resolution
process that meets the requirements of rule 4123-6-16 of the Administrative Code.
(15) A description of the managed care organization's non-medical service grievance
process.
(16) A description of the managed care organization's information system
capabilities and capacities.
(17) A description of the managed care organization's medical case management
policies and procedures.
(18) A description of the managed care organization's policies and procedures
regarding the confidentiality and protection of records.
(19) A description of the managed care organization's policies and procedures
regarding retention of information.
(20) A description of the managed care organization's provider relations and
education program.
(21) A description of the managed care organization's employer and employee
relations and education program; including but not limited to a description of
methodologies to be used to explain options available to injured workers, including
treatment by non-network providers and the dispute resolution process.
(22) A description of the managed care organization's system for reporting the
necessary data elements required for bureau calculation of performance measurements.
(23) Other descriptions and requirements as contained in divisions (D)(1) through
(D)(11) of section 4121.44 of the Revised Code.
(24) A description, with at least galley proofs or the equivalent, of the managed
care organization's marketing materials to be used in marketing to employers.
(25) Proof of current public liability insurance, the adequacy of which shall be
determined by the bureau.
(G) The bureau shall review the application for certification submitted by the managed care organization. The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.
(H) The bureau shall hold as confidential and proprietary the managed care organization's descriptions of process, methodology, policies, procedures and systems as required for the application for certification.
Effective date: Feb. 16, 1996