(E)(1) Information contained in a vendor's application for | 78 |
certification in the health partnership program, and other | 79 |
information furnished to the bureau by a vendor for purposes of | 80 |
obtaining certification or to comply with performance and | 81 |
financial auditing requirements established by the administrator, | 82 |
is for the exclusive use and information of the bureau in the | 83 |
discharge of its official duties, and shall not be open to the | 84 |
public or be used in any court in any proceeding pending therein, | 85 |
unless the bureau is a party to the action or proceeding, but the | 86 |
information may be tabulated and published by the bureau in | 87 |
statistical form for the use and information of other state | 88 |
departments and the public. No employee of the bureau, except as | 89 |
otherwise authorized by the administrator, shall divulge any | 90 |
information secured by the employee while in the employ of the | 91 |
bureau in respect to a vendor's application for certification or | 92 |
in respect to the business or other trade processes of any vendor | 93 |
to any person other than the administrator or to the employee's | 94 |
superior. | 95 |
(2) Notwithstanding the restrictions imposed by division | 96 |
(D)(E)(1) of this section, the governor, members of select or | 97 |
standing committees of the senate or house of representatives, the | 98 |
auditor of state, the attorney general, or their designees, | 99 |
pursuant to the authority granted in this chapter and Chapter | 100 |
4123. of the Revised Code, may examine any vendor application or | 101 |
other information furnished to the bureau by the vendor. None of | 102 |
those individuals shall divulge any information secured in the | 103 |
exercise of that authority in respect to a vendor's application | 104 |
for certification or in respect to the business or other trade | 105 |
processes of any vendor to any person. | 106 |
(F)(G) The administrator may limit freedom of choice of | 112 |
health care provider or supplier by requiring, beginning with the | 113 |
period set forth in division (B)(1) or (2) of this sectionthe | 114 |
forty-sixth day after the date of the injury or the forty-sixth | 115 |
day after the beginning date for treatment for the occupational | 116 |
disease, that claimants shall pay an appropriate out-of-plan | 117 |
copayment for selecting a medical provider not within the provider | 118 |
panel of a health partnership program vendor as provided for in | 119 |
this section. | 120 |
(G)(H) The administrator, six months prior to the expiration | 121 |
of the bureau's certification or recertification of the vendor or | 122 |
vendors as set forth in division (B)(1) or (2) of this section, | 123 |
may certify and provide evidence to the governor, the speaker of | 124 |
the house of representatives, and the president of the senate that | 125 |
the existing bureau staff is able to match or exceed the | 126 |
performance and outcomes of the external vendor or vendors and | 127 |
that the bureau should be permitted to internally administer the | 128 |
health partnership program upon the expiration of the | 129 |
certification or recertification as set forth in division (B)(1) | 130 |
or (2) of this section. | 131 |
(J) In(K) Notwithstanding division (G) of this section, in | 161 |
areas outside the state or within the state where no qualified | 162 |
health plan or an inadequate number of providers within the health | 163 |
partnership program exist, the administrator shall permit | 164 |
employees to use a provider not within the provider panel of a | 165 |
qualified health plan or health partnership program vendor, | 166 |
including, if necessary, a nonplan or nonprogram health care | 167 |
provider and shall pay the provider for the services or supplies | 168 |
provided to or on behalf of an employee for an injury or | 169 |
occupational disease that is compensable under this chapter or | 170 |
Chapter 4123., 4127., or 4131. of the Revised Code on a fee | 171 |
schedule the administrator adopts. | 172 |
(K)(L) No health care provider, whether certified or not, | 173 |
shall charge, assess, or otherwise attempt to collect from an | 174 |
employee, employer, a managed care organization, or the bureau any | 175 |
amount for covered services or supplies that is in excess of the | 176 |
allowed amount paid by a managed care organization, the bureau, or | 177 |
a qualified health plan. | 178 |
(L)(M) The administrator shall permit any employer or group | 179 |
of employers who agree to abide by the rules adopted under this | 180 |
section and sections 4121.441 and 4121.442 of the Revised Code to | 181 |
provide services or supplies to or on behalf of an employee for an | 182 |
injury or occupational disease that is compensable under this | 183 |
chapter or Chapter 4123., 4127., or 4131. of the Revised Code | 184 |
through qualified health plans of the Ohio workers' compensation | 185 |
qualified health plan system pursuant to section 4121.442 of the | 186 |
Revised Code or through the health partnership program pursuant to | 187 |
section 4121.441 of the Revised Code. No amount paid under the | 188 |
qualified health plan system pursuant to section 4121.442 of the | 189 |
Revised Code by an employer who is a state fund employer shall be | 190 |
charged to the employer's experience or otherwise be used in | 191 |
merit-rating or determining the risk of that employer for the | 192 |
purpose of the payment of premiums under this chapter, and if the | 193 |
employer is a self-insuring employer, the employer shall not | 194 |
include that amount in the paid compensation the employer reports | 195 |
under section 4123.35 of the Revised Code. | 196 |
Sec. 4121.441. (A) The administrator of workers' | 197 |
compensation, with the advice and consent of the bureau of | 198 |
workers' compensation board of directors, shall adopt rules under | 199 |
Chapter 119. of the Revised Code for the health care partnership | 200 |
program administered by the bureau of workers' compensation to | 201 |
provide medical, surgical, nursing, drug, hospital, and | 202 |
rehabilitation services and supplies to an employee for an injury | 203 |
or occupational disease that is compensable under this chapter or | 204 |
Chapter 4123., 4127., or 4131. of the Revised Code. | 205 |
(1) Procedures for the resolution of medical disputes between | 208 |
an employer and an employee, an employee and a provider, or an | 209 |
employer and a provider, prior to an appeal under section 4123.511 | 210 |
of the Revised Code. Rules the administrator adopts pursuant to | 211 |
division (A)(1) of this section may specify that the resolution | 212 |
procedures shall not be used to resolve disputes concerning | 213 |
medical services rendered that have been approved through standard | 214 |
treatment guidelines, pathways, or presumptive authorization | 215 |
guidelines. | 216 |
(B) The administrator shall implement the health partnership | 250 |
program according to the rules the administrator adopts under this | 251 |
section for the provision and payment of medical, surgical, | 252 |
nursing, drug, hospital, and rehabilitation services and supplies | 253 |
to an employee for an injury or occupational disease that is | 254 |
compensable under this chapter or Chapter 4123., 4127., or 4131. | 255 |
of the Revised Code. | 256 |
Sec. 4121.63. Claimants who the administrator of workers' | 257 |
compensation determines could probably be rehabilitated to achieve | 258 |
the goals established by section 4121.61 of the Revised Code and | 259 |
who agree to undergo rehabilitation shall be paid living | 260 |
maintenance payments for a period or periods which do not exceed | 261 |
six months in the aggregate, unless review by the administrator or | 262 |
the administrator's designee reveals that the claimant will be | 263 |
benefited by an extension of such payments. | 264 |
If, without good cause, a claimant refuses to undertake or | 277 |
unreasonably delays undertaking rehabilitation services, | 278 |
counseling, or training in accordance with an approved | 279 |
rehabilitation plan, the claimant forfeits the claimant's right to | 280 |
have the claimant's claim for compensation or benefits considered, | 281 |
if the claim is pending before the administrator or the industrial | 282 |
commission, or to receive living maintenance payments or any other | 283 |
payment for compensation or benefits pertaining to the period of | 284 |
refusal. The period of refusal or obstruction shall not toll any | 285 |
time frame for the exercise of continuing jurisdiction by the | 286 |
administrator or commission under section 4123.52 of the Revised | 287 |
Code. | 288 |
Sec. 4123.511. (A) Within seven days after receipt of any | 289 |
claim under this chapter, the bureau of workers' compensation | 290 |
shall notify the claimant and the employer of the claimant of the | 291 |
receipt of the claim and of the facts alleged therein. If the | 292 |
bureau receives from a person other than the claimant written or | 293 |
facsimile information or information communicated verbally over | 294 |
the telephone indicating that an injury or occupational disease | 295 |
has occurred or been contracted which may be compensable under | 296 |
this chapter, the bureau shall notify the employee and the | 297 |
employer of the information. If the information is provided | 298 |
verbally over the telephone, the person providing the information | 299 |
shall provide written verification of the information to the | 300 |
bureau according to division (E) of section 4123.84 of the Revised | 301 |
Code. The receipt of the information in writing or facsimile, or | 302 |
if initially by telephone, the subsequent written verification, | 303 |
and the notice by the bureau shall be considered an application | 304 |
for compensation under section 4123.84 or 4123.85 of the Revised | 305 |
Code, provided that the conditions of division (E) of section | 306 |
4123.84 of the Revised Code apply to information provided verbally | 307 |
over the telephone. Upon receipt of a claim, the bureau shall | 308 |
advise the claimant of the claim number assigned and the | 309 |
claimant's right to representation in the processing of a claim or | 310 |
to elect no representation. If the bureau determines that a claim | 311 |
is determined to be a compensable lost-time claim, the bureau | 312 |
shall notify the claimant and the employer of the availability of | 313 |
rehabilitation services. No bureau or industrial commission | 314 |
employee shall directly or indirectly convey any information in | 315 |
derogation of this right. This section shall in no way abrogate | 316 |
the bureau's responsibility to aid and assist a claimant in the | 317 |
filing of a claim and to advise the claimant of the claimant's | 318 |
rights under the law. | 319 |
The administrator, with the advice and consent of the bureau | 328 |
of workers' compensation board of directors, may adopt rules that | 329 |
identify specified medical conditions that have a historical | 330 |
record of being allowed whenever included in a claim. The | 331 |
administrator may grant immediate allowance of any medical | 332 |
condition identified in those rules upon the filing of a claim | 333 |
involving that medical condition and may make immediate payment of | 334 |
medical bills for any medical condition identified in those rules | 335 |
that is included in a claim. If an employer contests the allowance | 336 |
of a claim involving any medical condition identified in those | 337 |
rules, and the claim is disallowed, payment for the medical | 338 |
condition included in that claim shall be charged to and paid from | 339 |
the surplus fund created under section 4123.34 of the Revised | 340 |
Code. | 341 |
(B)(1) Except as provided in division (B)(2) of this section, | 342 |
in claims other than those in which the employer is a | 343 |
self-insuring employer, if the administrator determines under | 344 |
division (A) of this section that a claimant is or is not entitled | 345 |
to an award of compensation or benefits, the administrator shall | 346 |
issue an order no later than twenty-eight days after the sending | 347 |
of the notice under division (A) of this section, granting or | 348 |
denying the payment of the compensation or benefits, or both as is | 349 |
appropriate to the claimant. After conducting an investigation, if | 350 |
the administrator determines that insufficient medical information | 351 |
exists to grant or deny the payment of compensation, benefits, or | 352 |
both to the claimant, the administrator may, with notice to both | 353 |
parties, dismiss the claim without prejudice. Notwithstanding the | 354 |
time limitation specified in this division for the issuance of an | 355 |
order, if a medical examination of the claimant is required by | 356 |
statute, the administrator promptly shall schedule the claimant | 357 |
for that examination and shall issue an order no later than | 358 |
twenty-eight days after receipt of the report of the examination. | 359 |
The administrator shall notify the claimant and the employer of | 360 |
the claimant and their respective representatives in writing of | 361 |
the nature of the order and the amounts of compensation and | 362 |
benefit payments involved. The employer or claimant may appeal the | 363 |
order pursuant to division (C) of this section within fourteen | 364 |
days after the date of the receipt of the order. The employer and | 365 |
claimant may waive, in writing, their rights to an appeal under | 366 |
this division. | 367 |
(2) Notwithstanding the time limitation specified in division | 368 |
(B)(1) of this section for the issuance of an order, if the | 369 |
employer certifies a claim for payment of compensation or | 370 |
benefits, or both, to a claimant, and the administrator has | 371 |
completed the investigation of the claim, the payment of benefits | 372 |
or compensation, or both, as is appropriate, shall commence upon | 373 |
the later of the date of the certification or completion of the | 374 |
investigation and issuance of the order by the administrator, | 375 |
provided that the administrator shall issue the order no later | 376 |
than the time limitation specified in division (B)(1) of this | 377 |
section. | 378 |
(3) If an appeal is made under division (B)(1) or (2) of this | 379 |
section, the administrator shall forward the claim file to the | 380 |
appropriate district hearing officer within seven days of the | 381 |
appeal. In contested claims other than state fund claims, the | 382 |
administrator shall forward the claim within seven days of the | 383 |
administrator's receipt of the claim to the industrial commission, | 384 |
which shall refer the claim to an appropriate district hearing | 385 |
officer for a hearing in accordance with division (C) of this | 386 |
section. | 387 |
(C) If an employer or claimant timely appeals the order of | 388 |
the administrator issued under division (B) of this section or in | 389 |
the case of other contested claims other than state fund claims, | 390 |
the commission shall refer the claim to an appropriate district | 391 |
hearing officer according to rules the commission adopts under | 392 |
section 4121.36 of the Revised Code. The district hearing officer | 393 |
shall notify the parties and their respective representatives of | 394 |
the time and place of the hearing. | 395 |
The district hearing officer shall hold a hearing on a | 396 |
disputed issue or claim within forty-five days after the filing of | 397 |
the appeal under this division and issue a decision within seven | 398 |
days after holding the hearing. The district hearing officer shall | 399 |
notify the parties and their respective representatives in writing | 400 |
of the order. Any party may appeal an order issued under this | 401 |
division pursuant to division (D) of this section within fourteen | 402 |
days after receipt of the order under this division. | 403 |
(D) Upon the timely filing of an appeal of the order of the | 404 |
district hearing officer issued under division (C) of this | 405 |
section, the commission shall refer the claim file to an | 406 |
appropriate staff hearing officer according to its rules adopted | 407 |
under section 4121.36 of the Revised Code. The staff hearing | 408 |
officer shall hold a hearing within forty-five days after the | 409 |
filing of an appeal under this division and issue a decision | 410 |
within seven days after holding the hearing under this division. | 411 |
The staff hearing officer shall notify the parties and their | 412 |
respective representatives in writing of the staff hearing | 413 |
officer's order. Any party may appeal an order issued under this | 414 |
division pursuant to division (E) of this section within fourteen | 415 |
days after receipt of the order under this division. | 416 |
(E) Upon the filing of a timely appeal of the order of the | 417 |
staff hearing officer issued under division (D) of this section, | 418 |
the commission or a designated staff hearing officer, on behalf of | 419 |
the commission, shall determine whether the commission will hear | 420 |
the appeal. If the commission or the designated staff hearing | 421 |
officer decides to hear the appeal, the commission or the | 422 |
designated staff hearing officer shall notify the parties and | 423 |
their respective representatives in writing of the time and place | 424 |
of the hearing. The commission shall hold the hearing within | 425 |
forty-five days after the filing of the notice of appeal and, | 426 |
within seven days after the conclusion of the hearing, the | 427 |
commission shall issue its order affirming, modifying, or | 428 |
reversing the order issued under division (D) of this section. The | 429 |
commission shall notify the parties and their respective | 430 |
representatives in writing of the order. If the commission or the | 431 |
designated staff hearing officer determines not to hear the | 432 |
appeal, within fourteen days after the expiration of the period in | 433 |
which an appeal of the order of the staff hearing officer may be | 434 |
filed as provided in division (D) of this section, the commission | 435 |
or the designated staff hearing officer shall issue an order to | 436 |
that effect and notify the parties and their respective | 437 |
representatives in writing of that order. | 438 |
(3) The administrator is a party and may appear and | 458 |
participate at all administrative proceedings on behalf of the | 459 |
state insurance fund. However, in cases in which the employer is | 460 |
represented, the administrator shall neither present arguments nor | 461 |
introduce testimony that is cumulative to that presented or | 462 |
introduced by the employer or the employer's representative. The | 463 |
administrator may file an appeal under this section on behalf of | 464 |
the state insurance fund; however, except in cases arising under | 465 |
section 4123.343 of the Revised Code, the administrator only may | 466 |
appeal questions of law or issues of fraud when the employer | 467 |
appears in person or by representative. | 468 |
(J) The administrator shall charge the compensation payments | 496 |
made in accordance with division (H) of this section or medical | 497 |
benefits payments made in accordance with division (I) of this | 498 |
section to an employer's experience immediately after the employer | 499 |
has exhausted the employer's administrative appeals as provided in | 500 |
this section or has waived the employer's right to an | 501 |
administrative appeal under division (B) of this section, subject | 502 |
to the adjustment specified in division (H) of section 4123.512 of | 503 |
the Revised Code. | 504 |
(K) Upon the final administrative or judicial determination | 505 |
under this section or section 4123.512 of the Revised Code of an | 506 |
appeal of an order to pay compensation, if a claimant is found to | 507 |
have received compensation pursuant to a prior order which is | 508 |
reversed upon subsequent appeal, the claimant's employer, if a | 509 |
self-insuring employer, or the bureau, shall withhold from any | 510 |
amount to which the claimant becomes entitled pursuant to any | 511 |
claim, past, present, or future, under Chapter 4121., 4123., | 512 |
4127., or 4131. of the Revised Code, the amount of previously paid | 513 |
compensation to the claimant which, due to reversal upon appeal, | 514 |
the claimant is not entitled, pursuant to the following criteria: | 515 |
The administrator and self-insuring employers, as | 529 |
appropriate, are subject to the repayment schedule of this | 530 |
division only with respect to an order to pay compensation that | 531 |
was properly paid under a previous order, but which is | 532 |
subsequently reversed upon an administrative or judicial appeal. | 533 |
The administrator and self-insuring employers are not subject to, | 534 |
but may utilize, the repayment schedule of this division, or any | 535 |
other lawful means, to collect payment of compensation made to a | 536 |
person who was not entitled to the compensation due to fraud as | 537 |
determined by the administrator or the industrial commission. | 538 |
(L) If a staff hearing officer or the commission fails to | 539 |
issue a decision or the commission fails to refuse to hear an | 540 |
appeal within the time periods required by this section, payments | 541 |
to a claimant shall cease until the staff hearing officer or | 542 |
commission issues a decision or hears the appeal, unless the | 543 |
failure was due to the fault or neglect of the employer or the | 544 |
employer agrees that the payments should continue for a longer | 545 |
period of time. | 546 |
(2) "Disaster" means any natural catastrophe or fire, flood, | 567 |
or explosion, regardless of the cause, that causes damage of | 568 |
sufficient magnitude that the governor of Ohio or the president of | 569 |
the United States, through a public declaration, orders state or | 570 |
federal assistance to alleviate damage, loss, hardship, or | 571 |
suffering that results from the occurrence. | 572 |
Sec. 4123.53. (A) The administrator of workers' compensation | 573 |
or the industrial commission may require any employee claiming the | 574 |
right to receive compensation to submit to a medical examination, | 575 |
vocational evaluation, or vocational questionnaire at any time, | 576 |
and from time to time, at a place reasonably convenient for the | 577 |
employee, and as provided by the rules of the commission or the | 578 |
administrator of workers' compensation. A claimant required by the | 579 |
commission or administrator to submit to a medical examination or | 580 |
vocational evaluation, at a point outside of the place of | 581 |
permanent or temporary residence of the claimant, as provided in | 582 |
this section, is entitled to have paid to the claimant by the | 583 |
bureau of workers' compensation the necessary and actual expenses | 584 |
on account of the attendance for the medical examination or | 585 |
vocational evaluation after approval of the expense statement by | 586 |
the bureau. Under extraordinary circumstances and with the | 587 |
unanimous approval of the commission, if the commission requires | 588 |
the medical examination or vocational evaluation, or with the | 589 |
approval of the administrator, if the administrator requires the | 590 |
medical examination or vocational evaluation, the bureau shall pay | 591 |
an injured or diseased employee the necessary, actual, and | 592 |
authorized expenses of treatment at a point outside the place of | 593 |
permanent or temporary residence of the claimant. | 594 |
(B) When an employee initially receives temporary total | 595 |
disability compensation pursuant to section 4123.56 of the Revised | 596 |
Code for a consecutive ninety-day period, the administrator shall | 597 |
refer the employee to the bureau medical section for a medical | 598 |
examination to determine the employee's continued entitlement to | 599 |
such compensation, the employee's rehabilitation potential, and | 600 |
the appropriateness of the medical treatment the employee is | 601 |
receiving. The bureau medical section shall conduct the | 602 |
examination not later than thirty days following the end of the | 603 |
initial ninety-day period. If the medical examiner, upon an | 604 |
initial or any subsequent examination recommended by the medical | 605 |
examiner under this division, determines that the employee is | 606 |
temporarily and totally impaired, the medical examiner shall | 607 |
recommend a date when the employee should be reexamined. Upon the | 608 |
issuance of the medical examination report containing a | 609 |
recommendation for reexamination, the administrator shall schedule | 610 |
an examination and, if at the date of reexamination the employee | 611 |
is receiving temporary total disability compensation, the employee | 612 |
shall be examined. The administrator shall adopt a rule, pursuant | 613 |
to Chapter 119. of the Revised Code, permitting employers to waive | 614 |
the administrator's scheduling of any such examinations. | 615 |
(C) If, without good cause, an employee refuses to submit to | 616 |
any medical examination or vocational evaluation scheduled | 617 |
pursuant to this section or obstructs the same, or refuses to | 618 |
complete and submit to the bureau or commission a vocational | 619 |
questionnaire within thirty days after the bureau or commission | 620 |
mails the request to complete and submit the questionnaire the | 621 |
employee forfeits the employee's right to have his or herthe | 622 |
employee's claim for compensation considered, if the claim is | 623 |
pending before the bureau or commission, or to receive any payment | 624 |
for compensation theretofore granted, is suspended duringor | 625 |
benefits pertaining to the period of the refusal or obstruction. | 626 |
The period of refusal or obstruction shall not toll any time frame | 627 |
for the exercise of continuing jurisdiction by the administrator | 628 |
or commission under section 4123.52 of the Revised Code. | 629 |
Notwithstanding this section, an employee's failure to submit to a | 630 |
medical examination or vocational evaluation, or to complete and | 631 |
submit a vocational questionnaire, shall not result in the | 632 |
dismissal of the employee's claim. | 633 |
Sec. 4123.651. (A) The employer of a claimant who is injured | 637 |
or disabled in the course of
histhe claimant's employment may | 638 |
require, without the approval of the administrator or the | 639 |
industrial commission, that the claimant be examined by a | 640 |
physician of the employer's choice one time upon any issue | 641 |
asserted by the employee or a physician of the employee's choice | 642 |
or which is to be considered by the commission. Any further | 643 |
requests for medical examinations shall be made to the commission | 644 |
which shall consider and rule on the request. The employer shall | 645 |
pay the cost of any examinations initiated by the employer. | 646 |
(B) The bureau of workers' compensation shall prepare a form | 647 |
for the release of medical information, records, and reports | 648 |
relative to the issues necessary for the administration of a claim | 649 |
under this chapter. The claimant promptly shall provide a current | 650 |
signed release of the information, records, and reports when | 651 |
requested by the employer. The employer promptly shall provide | 652 |
copies of all medical information, records, and reports to the | 653 |
bureau and to the claimant or histhe claimant's representative | 654 |
upon request. | 655 |
(C) If, without good cause, an employee refuses to submit to | 656 |
any examination scheduled under this section or refuses to release | 657 |
or execute a release for any medical information, record, or | 658 |
report that is required to be released under this section and | 659 |
involves an issue pertinent to the condition alleged in the claim, | 660 |
histhe employee forfeits the employee's right to have histhe | 661 |
employee's claim for compensation or benefits considered, if his | 662 |
the employee's claim is pending before the administrator,or | 663 |
commission, or a district or staff hearing officer, or to receive | 664 |
any payment for compensation or benefits previously granted, is | 665 |
suspended duringpertaining to the period of refusal. The period | 666 |
of refusal or obstruction shall not toll any time frame for the | 667 |
exercise of continuing jurisdiction by the administrator or | 668 |
commission under section 4123.52 of the Revised Code. | 669 |
(D) No bureau or commission employee shall alter any medical | 670 |
report obtained from a health care provider the bureau or | 671 |
commission has selected or cause or request the health care | 672 |
provider to alter or change a report. The bureau and commission | 673 |
shall make any request for clarification of a health care | 674 |
provider's report in writing and shall provide a copy of the | 675 |
request to the affected parties and their representatives at the | 676 |
time of making the request. | 677 |
Sec. 4123.66. (A) In addition to the compensation provided | 678 |
for in this chapter, the administrator of workers' compensation | 679 |
shall disburse and pay from the state insurance fund the amounts | 680 |
for medical, nurse, and hospital services and medicine as the | 681 |
administrator deems proper and, in case death ensues from the | 682 |
injury or occupational disease, the administrator shall disburse | 683 |
and pay from the fund reasonable funeral expenses in an amount not | 684 |
to exceed fifty-five hundred dollars. The bureau of workers' | 685 |
compensation shall reimburse anyone, whether dependent, volunteer, | 686 |
or otherwise, who pays the funeral expenses of any employee whose | 687 |
death ensues from any injury or occupational disease as provided | 688 |
in this section. The administrator may adopt rules, with the | 689 |
advice and consent of the bureau of workers' compensation board of | 690 |
directors, with respect to furnishing medical, nurse, and hospital | 691 |
service and medicine to injured or disabled employees entitled | 692 |
thereto, and for the payment therefor. In case an injury or | 693 |
industrial accident that injures an employee also causes damage to | 694 |
the employee's eyeglasses, artificial teeth or other denture, or | 695 |
hearing aid, or in the event an injury or occupational disease | 696 |
makes it necessary or advisable to replace, repair, or adjust the | 697 |
same, the bureau shall disburse and pay a reasonable amount to | 698 |
repair or replace the same. | 699 |
(B) The administrator, in the rules the administrator adopts | 700 |
pursuant to division (A) of this section, may identify specified | 701 |
medical services that are presumptively authorized and payable to | 702 |
a provider who provides any of the services identified in, and | 703 |
complies with the requirements set forth in, the rules the | 704 |
administrator adopts for the services rendered. The administrator, | 705 |
in the rules the administrator adopts under this division, shall | 706 |
limit the payment for these services to only those services | 707 |
rendered to a claimant during the time period beginning the date | 708 |
the administrator issues an order pursuant to division (B) of | 709 |
section 4123.511 of the Revised Code allowing a claim or allowing | 710 |
an additional condition to which the services relate and ending | 711 |
forty-five days after the date the order was issued. | 712 |
If the claim or additional condition is ultimately disallowed | 713 |
in a final administrative or judicial order, and if the employer | 714 |
is a state fund employer who pays assessments into the surplus | 715 |
fund account created under section 4123.34 of the Revised Code, | 716 |
the payments for medical services made pursuant to this division | 717 |
for that claim or condition shall be charged to and paid from the | 718 |
surplus fund account and not charged through the state insurance | 719 |
fund to the employer against whom the claim or additional | 720 |
condition was filed. | 721 |
(C) The administrator, in the rules the administrator adopts | 722 |
pursuant to division (A) of this section, may adopt rules | 723 |
specifying the circumstances under which the bureau may make | 724 |
immediate payment for the first fill of prescription drugs for | 725 |
medical conditions identified in an application for compensation | 726 |
or benefits under section 4123.84 or 4123.85 of the Revised Code | 727 |
that occurs prior to the date the administrator issues an initial | 728 |
determination order under division (B) of this section. If the | 729 |
claim is ultimately disallowed in a final administrative or | 730 |
judicial order, and if the employer is a state fund employer who | 731 |
pays assessments into the surplus fund account created under | 732 |
section 4123.34 of the Revised Code, the payments for medical | 733 |
services made pursuant to this division for the first fill of | 734 |
prescription drugs shall be charged to and paid from the surplus | 735 |
fund account and not charged through the state insurance fund to | 736 |
the employer against whom the claim was filed. | 737 |
(D) If, without good cause, an employee refuses to undertake | 738 |
or unreasonably delays undertaking medical, nursing, and hospital | 739 |
services and medicine that are ordered by the employee's treating | 740 |
physician and that are payable under division (I) of section | 741 |
4123.511 of the Revised Code, the employee forfeits the employee's | 742 |
right to have the employee's claim for compensation or benefits | 743 |
considered, if the claim is pending before the administrator or | 744 |
the industrial commission, or to receive any payment for | 745 |
compensation or benefits pertaining to the period of refusal. The | 746 |
period of refusal or obstruction shall not toll any time frame for | 747 |
the exercise of continuing jurisdiction by the administrator or | 748 |
commission under section 4123.52 of the Revised Code. | 749 |
(E)(1) If an employer or a welfare plan has provided to or on | 750 |
behalf of an employee any benefits or compensation for an injury | 751 |
or occupational disease and that injury or occupational disease is | 752 |
determined compensable under this chapter, the employer or a | 753 |
welfare plan may request that the administrator reimburse the | 754 |
employer or welfare plan for the amount the employer or welfare | 755 |
plan paid to or on behalf of the employee in compensation or | 756 |
benefits. The administrator shall reimburse the employer or | 757 |
welfare plan for the compensation and benefits paid if, at the | 758 |
time the employer or welfare plan provides the benefits or | 759 |
compensation to or on behalf of employee, the injury or | 760 |
occupational disease had not been determined to be compensable | 761 |
under this chapter and if the employee was not receiving | 762 |
compensation or benefits under this chapter for that injury or | 763 |
occupational disease. The administrator shall reimburse the | 764 |
employer or welfare plan in the amount that the administrator | 765 |
would have paid to or on behalf of the employee under this chapter | 766 |
if the injury or occupational disease originally would have been | 767 |
determined compensable under this chapter. If the employer is a | 768 |
merit-rated employer, the administrator shall adjust the amount of | 769 |
premium next due from the employer according to the amount the | 770 |
administrator pays the employer. The administrator shall adopt | 771 |
rules, in accordance with Chapter 119. of the Revised Code, to | 772 |
implement this division. | 773 |
(2) If the administrator has properly disbursed and paid any | 795 |
amounts to or on behalf of an employee for medical, nurse, and | 796 |
hospital services or medicine for an injury or occupational | 797 |
disease and that injury or occupational disease is subsequently | 798 |
determined to be noncompensable under this chapter or Chapter | 799 |
4121., 4127., or 4131. of the Revised Code, the administrator may | 800 |
request that the employee's third party payer reimburse the | 801 |
administrator for the amount the administrator paid to or on | 802 |
behalf of the employee for medical, nurse, and hospital services | 803 |
or medicine. The employee and the employee's third party payer | 804 |
shall cooperate with the administrator regarding requests for | 805 |
reimbursements under this division, and the third party payer and | 806 |
the administrator may share information as needed to facilitate | 807 |
those requests. The third party payer shall reimburse the | 808 |
administrator in the amount that the administrator disbursed and | 809 |
paid to or on behalf of the employee under this chapter or Chapter | 810 |
4121., 4127., or 4131. of the Revised Code. The administrator | 811 |
shall credit any such amounts received to the surplus fund account | 812 |
created in section 4123.34 of the Revised Code. The administrator | 813 |
shall adopt rules, in accordance with Chapter 119. of the Revised | 814 |
Code, to implement this division. | 815 |
(D) "Subrogation interest" includes past, present, and | 830 |
estimated future payments of compensation, medical benefits, | 831 |
rehabilitation costs, or death benefits, and any other costs or | 832 |
expenses paid to or on behalf of the claimant by the statutory | 833 |
subrogee pursuant to this chapter or Chapter 4121., 4127., or | 834 |
4131. of the Revised Code. | 835 |
(E) "Net amount recovered" means the amount of any award, | 836 |
settlement, compromise, or recovery by a claimant against a third | 837 |
party, minus the attorney's fees, costs, or other expenses | 838 |
incurred by the claimant in securing the award, settlement, | 839 |
compromise, or recovery. "Net amount recovered" does not include | 840 |
any punitive damages that may be awarded by a judge or jury. | 841 |