OHIO
OHIO HHP (STATE FUND)
Employee Selects
Except as provided in paragraph (A)(2) of this rule, an injured employee may seek medical care for an industrial injury from:
(a) A bureau certified provider; or (b) A non-bureau certified provider, subject to an employee's payment responsibilities as delineated below.
(2) Except in cases of emergency, an injured employee may not seek medical care for an industrial injury from himself, herself, or an immediate family member. An injured employee may not select as physician of record, himself, herself, or an immediate family member. The MCO, bureau, employer, and industrial commission shall not reimburse treatment to an injured employee delivered, rendered or directly supervised by the injured employee or an immediate family member. "Immediate family member" shall have the same meaning as in paragraph (A)(3)(b) of rule 4123-6-02.51.
(3) At the time of an injury, the employee may seek medical care directly from a provider or may seek assistance from the MCO in selecting a provider. If the employee has not already sought medical care or selected a provider, the MCO may refer the employee to a provider or list of providers. The employee may, but is not required to, seek medical care from the referred provider or providers. The MCO shall not discriminate against any category of health care provider when referring the employee to a provider. (4123-6-06.2(A))

Change of Provider
MCO guidelines may not be more restrictive for a non-panel provider than for an MCO panel provider. An MCO may not create a procedure that restricts an employee's option to change providers. (4123-6-04.3(D))

An injured worker wishing to change physicians should notify the managed care organization of this request. (OH Bureau of Workers' Compensation website: http://www.ohiobwc.com/basics/guidedtour/generalinfo/InjuredWorker(FAQ).asp)

Notwithstanding any other provision of this rule, if the employee's date of injury is prior to October 20, 1993 and the employee's physician of record is a non-bureau certified provider, the employee may continue treatment with that non-bureau certified provider. The employer's MCO shall manage the medical care and treatment and return to work services in the claim and shall manage medical payment for the provider. However, if the employee changes the physician of record for any reason, the employee shall select a bureau certified provider as physician of record. If the employee selects a physician of record who is a non-bureau certified provider, payment for the provider shall be governed by the provisions of this rule applicable to non-bureau certified providers. (4123-6-06.2(A)(6))

Panels
Not addressed

Panel Provisions
See Direction of Care law.

OHIO QHP
Employee Selects from Network
An employee of an employer that participates in a Qualified Health Plan has freedom of choice of providers within the QHP network of providers established by the employer's QHP. If the employee's date of injury is prior to the establishment of the employer's QHP, and the employee's physician of record is not a provider on the panel of the QHP when established, the employee may continue treatment with that physician of record. The physician of record shall be subject to and participate in the dispute resolution process as provided in rule 4123-6-69 of the Administrative Code. After the establishment of the QHP, the employer's QHP shall manage the medical care and treatment in the claim. If an injured worker changes from the physician of record who is not in the QHP for any reason, the employee shall select a QHP panel provider as the physician of record. (4123-6-06.2 (B)(1))

Change of Provider
An employee of an employer that participates in a QHP, who is dissatisfied with the health care services of a provider in the QHP, after written notice to the QHP, may request a change of providers and may select another provider within the QHP, or any bureau certified provider. An employee's request for change of provider does not require notification to the bureau, but shall contain the reasons for the request. The QHP shall approve written requests for a change of provider within the QHP, or to any bureau certified provider, within seven days of receipt. (4123-6-06.2 (B)(2))

Notwithstanding the provisions contained in paragraph (B)(2) of this rule, an employee who incurs a new medical condition, injury or claim requiring medical treatment, not related to a prior medical condition, injury or claim, shall first seek treatment from a provider on the panel of the injured worker's employer's QHP. (4123-6-06.2 (B)(3))

Panels
Not addressed

Panel Provisions
See Direction of Care law.

OHIO SELF-INSURED/NON-QHP
Employee Selects
In claims with a date of injury on or after November 2, 1959, employees of self-insuring employers have free choice to select licensed physicians for treatment, as well as other medical services, including, but not limited to, hospital and nursing services. In claims with a date of injury prior to November 2, 1959, medical services furnished by the self-insuring employer must be utilized. (2) Emergency treatment shall not constitute an exercise of free choice of physician. (OAC 4123-6-06.2(C)(1))

Change of Provider
Once an employee of a self-insuring employer goes to a physician for treatment other than on an emergency basis, the employee is deemed to have made a choice of physician and the employee shall notify the employer of a change of physician. (a) Change of physician requests shall be made to the self-insuring employer in writing, and shall include the name and address of the new physician and the proposed treatment. (b) Self-insuring employers shall approve written requests for a change of physician within seven days of receipt. (OAC 4123-6-06.2(C)(3))

Panels
Not addressed

Panel Provisions
See Direction of Care law.

The information on this website constitutes summary information only and does not constitute legal advice. Review of the full text of the referenced statutes and regulations may be necessary. Coventry Health Care Workers' Compensation, Inc. makes no representations or warranties about the accuracy of the information contained on this website.