Ohio Adm.Code 4123 | Ohio Administrative Code 4123 — Bureau of Workers' Compensation

Chapter 4123-1 Notice Procedure

Ohio Adm.Code 4123-1-02 Method of notice of board meetings.

(A) All business transactions of the workers' compensation board shall be conducted at public meetings in accordance with section 121.22 of the Revised Code. A schedule of meetings of the board shall be published in the various newsletters and publications of the bureau of workers' compensation which shall be available to the public. The schedule of meetings shall also be made available to any citizen, group, or organization interested in attending the board meetings in accordance with section 121.22 of the Revised Code.

(B) Any person may determine the time and place of all regularly scheduled meetings and the time, place, and purpose of all special meetings by:

(1) Contacting the bureau of workers' compensation communications department by phone, mail or electronic means, or

(2) Consulting the Ohio bureau of workers' compensation website.

(C) Any representative of the news media may obtain notice of all special meetings by requesting in writing that such notice be provided. A request for such notification shall be addressed to the bureau of workers' compensation communications department.

(1) The request shall provide the name of the individual media representative to be contacted, the individual's mailing address, and a telephone number where the individual can be reached. The bureau shall maintain a list of all representatives of the news media who have requested notice of special meetings pursuant to this section.

(2) In the event of a special meeting not of an emergency nature, the bureau shall notify all media representatives on the list of such meeting by written notice or telephone at least twenty-four hours in advance.

(3) In the event of a special meeting of an emergency nature, the bureau shall notify all media representatives on the list of such meeting by telephone or by notifying the clerk of the state house press room. In such event, however, the notice need not be given twenty-four hours prior to the meeting, but shall be given as soon as possible.

(D) The bureau shall maintain a list of all persons who have requested, in writing, notice of all meetings of the board at which specific subject matters designated by such persons are scheduled to be discussed. Any person may be included on such list.

Last updated May 31, 2023 at 9:45 AM

History

Effective: June 10, 2018
Promulgated Under: 111.15

Ohio Adm.Code 4123-1-03 Bureau internal auditor.

(A) Pursuant to division (J) of section 4121.125 of the Revised Code, the administrator, with the advice and consent of the board, shall employ a chief internal auditor, who shall report findings directly to the board, the workers' compensation audit committee, and the administrator.

(B) The bureau's chief internal auditor shall:

(1) Hold at least a bachelor's degree;

(2) Be either a certified internal auditor, a certified government auditing professional, or a certified public accountant; and,

(3) Have at least five years of internal or external auditing experience.

Last updated May 31, 2023 at 9:46 AM

History

Effective: November 26, 2018
Promulgated Under: 111.15

Chapter 4123-3 Claims Procedure

Ohio Adm.Code 4123-3-01 Office locations; scope of rules.

(A) Offices of the bureau of workers' compensation will be located in cities as the administrator establishes and each office will be open during posted hours of operation, holidays excepted, for the receipt and filing of claim applications or any other documents and for the transaction of any business pertinent to the administration of the workers' compensation law.

(B) Any application, form, or document required to be filed with the bureau but received by the industrial commission or managed care organization (MCO) is considered filed on the date stamped received by the commission or MCO and will be forwarded to the bureau for processing. Any application, form, or document required to be filed with the commission but received by the bureau or MCO is considered filed on the date stamped received by the bureau or MCO and will be forwarded to the appropriate commission office or section for processing.

(C) The rules in this chapter govern claims procedures before the bureau, and include related matters applicable to claims procedures before the industrial commission.

(D) Failure to adhere to the rules of the bureau is a valid ground for refusal by the bureau to grant the relief sought and may result in further action as may be applicable under each case.

(E) All claims will be processed in a consistent and timely manner.

Last updated December 2, 2024 at 8:55 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-02 Forms.

(A) Printed forms for all applications, reports, notices, proofs, etc., necessary for perfecting any claim before the bureau or commission will be furnished without charge by the bureau. Such forms may be obtained online or from any office of the bureau or commission.

(B) Each employer shall make such forms available to employees who sustain industrial injuries or contract occupational diseases.

(C) Any required form or equivalent must include sufficient detail to facilitate the prompt and accurate adjudication of the questions presented.

(D) The bureau will furnish to the public without charge printed forms for use in filing applications for benefits or compensation, or for submitting other necessary proof in any claim before the bureau and the industrial commission.

Last updated December 2, 2024 at 8:55 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-03 Employers' reports of injuries and occupational diseases.

(A) Every employer shall keep a record of all injuries and occupational diseases resulting in seven days or more of total disability or death and report them to the bureau of workers' compensation within one week of acquiring knowledge of such injury or death and within one week after acquiring knowledge of or the diagnosis or death from the occupational disease as set forth in section 4123.28 of the Revised Code.

(B) Public employers and employers contributing to the private fund of the state insurance fund shall make such reports on the application for benefits or equivalent.

(C) Self-insuring employers shall use the application for benefits or equivalent provided by the bureau of workers' compensation to make the report of injury or occupational disease as set forth in section 4123.28 of the Revised Code, within the prescribed time limits set forth. Reports of death due to injury and occupational disease shall be on the application for benefits or equivalent.

(D) Self-insuring employers shall make a similar report on the application for benefits or equivalent in claims for injury, involving seven days or less of lost time, wherein it is apparent that there will be permanent partial disability under division (B) of section 4123.57 of the Revised Code. In such cases involving occupational disease, the report shall be on the application for benefits or equivalent.

(E) In order to assist in determining whether the claimant is entitled to an extension of the statute of limitations as set forth in section 4123.28 of the Revised Code, the bureau shall maintain a record of all injuries and occupational diseases reported by each employer.

(F) Each employer shall give a copy of each report to the employee it concerns or their surviving dependents as set forth in section 4123.28 of the Revised Code.

Last updated December 2, 2024 at 8:55 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-07 Applications for death benefits.

When the death of an employee is the result of a work related injury or occupational disease, the employee's dependents may file an application for death benefits. To be considered a "dependent", a person must be a member of the family of the deceased employee, or bear to the employee the relation of surviving spouse, lineal descendant, ancestor, or brother or sister. An application signed by a person claiming to be a dependent, as described herein, shall be accepted for filing and shall be sufficient to initiate proceedings for workers' compensation benefits and to obtain a ruling on the validity of the claim. If there are no dependents, the application may be filed by the estate of the deceased employee, the attending physician, the funeral director, by a volunteer paying the funeral bill, by a person who authorized the burial and funeral expenses or by the employer, for services rendered because of the injury or occupational disease causing the employee's death.

Last updated October 7, 2024 at 12:02 PM

History

Effective: April 15, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-08 Preparation and filing of applications for compensation and/or benefits.

(A) Preparation and execution of forms.

(1) The "First Report of Injury" form (FROI) or equivalent for applying for payment from the state insurance fund due to an injury, occupational disease, or death may be completed by the employee, employer, medical provider, or other interested party. If someone other than the employee submits a FROI or equivalent, the bureau may contact the employee to attempt to verify that the employee wishes to pursue the application. To accept or deny the validity of the claim, the employer may complete and sign the form at the designated point or may use a separate writing, telephone, or other means of telecommunication.

(2) The FROI for applying for payment from a self-insuring employer shall be completed, signed by the employee, and returned to the self-insuring employer. In situations where there is no prescribed form, a notice in writing shall be given in a manner sufficient to inform that a claim for benefits is being presented.

(3) An injured or disabled employee who is a minor (under eighteen years of age) shall file a claim in his or her own name and right. A report of injury signed by such minor employee is sufficient to initiate proceedings for compensation and/or benefits.

(4) In the event the injured or disabled employee is unable to complete the first report of injury by reason of physical or mental disability, the report may be completed and filed by the employee's spouse, next friend, the guardian of the employee, or the employee's employer.

In claims for death benefits where the dependents are a spouse and one or more minor children, it shall be sufficient for the spouse to make application for benefits on behalf of the spouse and the minor children. In the event a dependent minor child has a guardian of the person other than the spouse of the deceased, such guardian shall execute the report on behalf of such minor child. If there is no spouse surviving, the report on behalf of the dependent minor children, or children who are mentally or physically incapacitated, may be filed by a guardian or next friend of such children.

(5) It is the duty of every employer to assist injured or disabled employees in the preparation and submission of reports for compensation and/or benefits. In the event the employer refuses, neglects, or unduly delays the completion of a report, the report may be filed without the part pertaining to the employer having been completed. The fact of refusal or neglect should be noted upon the report or with it by way of separate letter.

(6) In cases where the death of the employee is not the result of injury or occupational disease, an application for accrued compensation may be made as provided in sections 4123.57 and 4123.60 of the Revised Code.

(7) Application for payment of the balance of a percentage permanent partial disability compensation awarded under division (A) of section 4123.57 of the Revised Code prior to the employee's death may be made by the injured employee's dependents. The application may be filed whether the death was related or unrelated to an industrial injury or occupational disease.

(B) Certification by the employer.

(1) An employer shall accept or reject the validity of a claim filed against its risk within the time provided by sections 4123.511 and 4123.84 of the Revised Code and the rules of the industrial commission and bureau of workers' compensation. If the employer fails to comply with the established time limits, the bureau will take such further action in the claim as provided by section 4123.511 of the Revised Code and the rules of the industrial commission and the bureau.

(2) If the employer accepts or denies the validity of the claim, the employer may sign the report at the designated point and return the requested information to the bureau, or the bureau may obtain the employer's certification or denial of the claim by a separate writing, by telephone, or by other forms of telecommunication.

If the employer denies the validity of the claim, the employer shall state the reasons for rejecting the validity of the claim.

(3) Certification by the employer in state fund cases is not determinative of compensability. Every such claim is subject to administrative review as to compensability.

(4) An employer's certification of a claim may be made by the employer, by an officer of the business entity which is the employer, or by a duly designated representative of the employer. The person certifying a claim for the employer shall indicate in what capacity the person is employed (title). No other person or entity may make such certification. No person may certify his or her own claim, except in cases of a sole proprietor who has obtained coverage as an employee within Chapter 4123. of the Revised Code.

Any first report of injury will be accepted for filing in any office of the bureau, MCO, or industrial commission during working hours, and reports may be filed by mail or reported by telecommunication.

(D) Time limitations within which claims must be filed.

(1) Injury claims applying for compensation and/or benefits shall be in writing or by telecommunication as provided in division (E) of section 4123.84 of the Revised Code, and shall include the specific part or parts of the body alleged to have been injured, the claimant's name and address, and the date of injury. Such claims are forever barred unless notice is filed with the bureau of workers' compensation, MCO or the industrial commission within one year from the date when injured, unless the applicable statute of limitations is extended due to the employer's failure to file a report as set forth in by section 4123.28 of the Revised Code. Except as provided in paragraph (D)(3) of this rule, any claim or application for compensation and/or benefits for an injury to any part or parts of the body not specified in the original claim is barred unless notice of the additional part or parts of the body claimed to have been injured is filed by the claimant with the bureau of workers' compensation, MCO, or the industrial commission within one year of the date when injured.

(2) In self-insuring employers' claims, the time limitation is tolled if the employer has provided treatment by a licensed physician in the employ of the employer or has paid compensation or benefits within the period. "Benefits" means payment by the self-insuring employer to, or on behalf of, an employee for:

(a) A hospital bill;

(b) A medical bill for treatment by a licensed physician, other than a salaried physician in the employ of the self-insuring employer;

(3) The bureau of workers' compensation and the industrial commission have continuing jurisdiction over a claim which meets the provisions of section 4123.84 of the Revised Code, including jurisdiction to award compensation and/or benefits for a condition (or conditions) or disability developing in part or parts of the body not specified pursuant to division (A)(1) of section 4123.84 of the Revised Code, if it is found that the condition (or conditions) or disability was due to and a result of or a residual of the injury to one of the parts of the body set forth in the written notice filed pursuant to division (A)(1) of section 4123.84 of the Revised Code.

(4) Claims for occupational disease arising prior to September 28, 2021 must be filed within two years after the disability begins, or within such longer period as does not exceed six months after diagnosis by a licensed physician, as provided in section 4123.85 of the Revised Code, excepting claims enumerated in paragraph (D)(6) of this rule, or where the applicable statute of limitations is extended due to the employer's failure to file a report as required by section 4123.28 of the Revised Code. The filing limitation of six months after diagnosis, where it applies, can only lengthen, not shorten, the two-year statute of limitations.

(5) Claims for occupational disease arising on or after September 28, 2021 must be filed within one year after the disability begins, or within such longer period as does not exceed six months after diagnosis by a licensed physician, as provided in section 4123.85 of the Revised Code, excepting claims enumerated in paragraph (D)(6) of this rule, or where the applicable statute of limitations is extended due to the employer's failure to file a report as required by section 4123.28 of the Revised Code.

(6) Special statutory provisions (section 4123.68 of the Revised Code) exist as to claims for silicosis, cardiovascular, pulmonary, or respiratory diseases of fire fighters and police officers, coal miners' pneumoconiosis, asbestosis, berylliosis, radiation illness, and all other occupational diseases of the respiratory tract resulting from injurious exposures to dust.

(7) Death claims, alleging that the death is the result of an injury occurring prior to September 29, 2017, must be filed within two years of the death or be forever barred, except as provided in paragraphs (D)(8) and (D)(9) of this rule. Death claims, alleging that the death is the result of an injury occurring on or after September 29, 2017, must be filed within one year of the death or be forever barred.

(8) Where the death is the result of an occupational disease with a date of disease prior to September 28, 2021, the claim must be filed within two years of the death, as provided in section 4123.85 of the Revised Code. Where the death is the result of an occupational disease with a date of disease on or after September 28, 2021, the claim must be filed within one year of the death.

(9) Emergency management claims for injury or death must be filed within one year from the date when injured or from the date of death, or be forever barred. If an injury claim has been filed within the one-year period and the claimant subsequently dies, a death claim must be filed within six months after the death or be forever barred.

(10) Public works relief employees' claims occurring prior to September 29, 2017, must be filed within two years after the date when injured or the date of death, or be forever barred. Public works relief employees' claims occurring on or after September 29, 2017, must be filed within one year after the date when injured or the date of death, or be forever barred.

(11) Militia claims, special contract claims, and apprentice claims are governed by the general time limits applicable to injury and occupational disease claims, as provided by sections 4123.84 and 4123.85 of the Revised Code.

Last updated December 2, 2024 at 8:56 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-09 Procedures in the processing of applications for benefits.

(A) Numbering and recording.

(1) Upon receipt, the bureau will assign a claim number to each initial application for benefits and provide the claim number to the claimant and employer. In cases where a deceased employee has filed, during his or her lifetime, an industrial claim for the injury or disability which is the subject matter of the death claim, the application for death benefits will be assigned the original claim number.

(2) The claim number should be placed on all documents subsequently filed in each claim and the claim number should be given when inquiry is made concerning each claim.

(B) Initial review and processing of new claims.

Immediately after numbering and recording, all new claim applications, except applications of employees of self-insuring employers, will be reviewed and processed by the bureau. "Processing on the question of compensability" means making a determination on the validity of the industrial claim.

(1) Uncontested or undisputed claims.

A "contested or disputed claim," as used herein, is where the employer or the bureau of workers' compensation questions the validity of a claim for compensation or benefits. No claim will be regarded as a contested or a disputed claim requiring a formal (public) hearing, solely by reason of incomplete information, unless every effort has been made to complete the record.

(a) If a state fund claim meets the statutory requirements of compensability, the claims specialist may approve such claim for payment of medical bills and temporary total disability compensation or other appropriate compensation. The approval of the claim will contain the description of the condition or conditions for which the claim is being allowed and part or parts of the body affected.

(b) In the processing of initial applications in state fund claims requesting payment of compensation in addition to medical benefits, the claims specialist may approve temporary total disability compensation over a period not to exceed four weeks, without medical proof in the record, provided that the application has been properly completed and signed, certified by the employer, and was otherwise noncontroversial. If medical proof was submitted with the initial application, the above limitation does not apply. Upon approval of the claim the claimant will be notified in writing that his or her attending physician's report will be necessary for consideration of any additional payment of compensation and an appropriate form will be enclosed, with the necessary instructions, for the claimant's convenience.

(2) Contested or disputed claims.

(a) Contested or disputed claims as well as claims requiring investigation will be referred, immediately after the initial review, to the appropriate office of the bureau from which investigation and determination of issues may be made most expeditiously.

(b) If the bureau or the employer contests the claim application and the claimant is not available for an adjudication due to the claimant's service in the armed services of the United States, the bureau will continue the matter in accordance with the Servicemembers Civil Relief Act until the claimant is available for adjudication of the claim.

(3) Applications for death benefits.

Immediately after numbering and recording, all applications for death benefits will be referred to the appropriate office of the bureau from which investigation and determination of issues may be made most expeditiously. Every effort should be made to complete the investigation within the shortest time possible, depending on the facts and circumstances of each particular case, to enable prompt adjudication of such claims by the bureau.

(4) Contested (disputed) applications for workers' compensation benefits filed by employees of self-insuring employers will be referred to the industrial commission for a hearing.

(1) In every instance the proof shall be of sufficient quantum and probative value to establish the jurisdiction of the bureau to consider the claim and determine the rights of the applicant to an award. "Quantum" means measurable quantity. "Probative" means having a tendency to prove or establish.

(2) Proof may be presented by affidavit, deposition, oral testimony, written statement, document, or other forms.

(3) The burden of proof is upon the claimant (applicant for workers' compensation benefits) to establish each essential element of the claim by preponderance of the evidence. Essential elements include, but will not be limited to:

(a) Establishing that the applicant is one of the persons who under the act have the right to file a claim for workers' compensation benefits;

(b) That the application was filed within the time period as required by law;

(c) That the alleged injury or occupational disease was sustained or contracted in the course of and arising out of employment;

(d) In death claims, that death was the direct and proximate result of an injury sustained or occupational disease contracted in the course of and arising out of employment; the necessary causal relationship between an injury or occupational disease and death may be established by submission of sufficient evidence to show that the injury or occupational disease aggravated or accelerated a pre-existing condition to such an extent that it substantially hastened death;

(e) Any other material issue in the claim, which means a question that must be established in order to determine claimant's right to compensation and/or benefits.

"Preponderance of the evidence" means greater weight of evidence, taking into consideration all the evidence presented. Burden of proof does not necessarily relate to the number of witnesses or quantity of evidence submitted, but to its quality, such as merit, credibility, and weight. The obligation of the claimant is to make proof to the reasonable degree of probability. A mere possibility is conjectural, speculative, and does not meet the required standard.

(4) The bureau or commission may, at any point in the processing of an application for benefits, require the employee to submit to a physical examination or may refer a claim for investigation.

(5) Procedure on employer's request for medical examination of the claimant by a doctor of employer's choice.

The employer may require a medical examination of the employee as provided in section 4123.651 of the Revised Code under the following circumstances:

(a) Such an examination, if requested, shall be in lieu of any rights under paragraph (C)(5)(b) of this rule and in no event will the claimant be examined on the same issue by a physician of the employer's choice more than one time. The exercise of this examination right shall not be allowed to delay the timely payment of benefits or scheduled hearings. Requests for further examinations will be made to the bureau or commission following the provisions of paragraph (C)(5)(b) of this rule. The cost of any examination initiated by the employer shall be paid by the employer including any fee required by the doctor, and the payment of all of the claimant's traveling and meal expenses, in a manner and at the rates as established by the bureau from time to time. If employed, the claimant will also be compensated for any loss of wages arising from the scheduling of an examination.

All reasonable expenses shall be paid by the employer immediately upon receipt of the billing, and the employer shall provide the claimant with a proper form to be completed by the claimant for reimbursement of such expenses.

The employer shall promptly inform the bureau or the commission, as well as the claimant's representative, as to the time and place of the examination, and the questions and information provided to the doctor. A copy of the examination report shall be submitted to the bureau or commission and to the claimant's representative upon the employer's receipt of the report from the doctor.

Emergency treatment does not constitute an examination by the employer for the purposes of this rule. Treatment by a company doctor as the treating physician constitutes an examination for the purposes of this rule. The procedure set forth in paragraph (C)(5)(a) of this rule applies to claims where the date of injury or the date of disability in occupational disease claims occur on or after August 22, 1986.

(b) If, after one medical examination of the claimant under paragraph (C)(5)(a) of this rule, an employer asserts that a medical examination of the claimant by a doctor of the employer's choice is essential in the defense of the claim by the employer, a written request may be filed with the bureau for that purpose. In such request the employer shall state the date of the last examination of the claimant by a doctor of employer's choice on the question pending. If there was no such prior examination, the request must so indicate.

(c) If the claim is pending before the industrial commission or its hearing officers and the question sought to be clarified by such examination is not within the jurisdiction of the bureau (for example: permanent total disability), the request will be referred to the industrial commission or to the appropriate hearing officer, as the case may be, for further consideration.

(d) If the question sought to be clarified by the requested examination is within the bureau's jurisdiction (for example: temporary total disability in otherwise undisputed claim, allowance of additional condition), the bureau will immediately act upon the request.

If, upon a review of the claim file the bureau is of the opinion that the request should be denied for the reason that the claimant has been recently examined by a doctor of the employer's choice, or for any other reason indicating that further examination would not be pertinent to the defense of the claim, based on the facts and circumstances of each particular case, the matter will be referred to the appropriate district hearing officer for further consideration. In cases of temporary total disability, a medical examination performed within the past thirty days is considered "recent." If the question involves additional allowance of claim for an additional condition allegedly causally related to the allowed injury or occupational disease, a medical examination performed within the past sixty to ninety days may be regarded as "recent," depending on the nature and type of the condition and/or disability.

(e) All reasonable expenses incurred by the claimant in submitting to such examination, including any travel expense that the claimant may properly incur, shall be paid by the employer immediately upon receipt of the billing. Payment for traveling expenses shall not require an order of the bureau or commission, unless there is a dispute. The employer shall provide the claimant with a proper form to be completed by the claimant for reimbursement for traveling expenses. In addition, if the claimant sustains lost wages as a result of such examination, the employer shall reimburse the claimant for such lost wages within three weeks from the date of examination. Expenses incurred by the claimant and wages lost by reason of attending such examination are not to be paid in the claim.

(f) The employer shall make arrangements for such examination within fifteen days from the date of receipt of the order of approval. The examination shall be performed not later than within thirty days from the date of the receipt of approval.

The doctor's report shall be filed with the bureau immediately upon its receipt. Failure of the employer to comply with this rule will not delay further action in the claim, unless it is established that the omission was due to causes beyond the employer's control.

(6) Procedure for obtaining the deposition of an examining physician. Authority to allow depositions is within the exclusive jurisdiction of the industrial commission. Any such request, if filed with the bureau, will be referred to the industrial commission for further consideration.

(D) Hearings and orders.

(1) Unless required by law or by the circumstances of the claim, the claim will be adjudicated without a formal hearing.

(2) Disputed or contested claims will be set for a formal (public) hearing on the question of allowance before the district hearing officers. A "disputed or contested claim," as used herein, is where the employer or the claimant questions the decision of the bureau regarding a request for compensation or benefits. No claim shall be regarded as a contested or disputed claim requiring a formal (public) hearing, solely by reason of incomplete information unless every effort has been made to complete the record. In the event the employer or claimant object to the decision of the bureau, such objection shall be made in writing with rationale and supporting evidence, as appropriate.

(3) The administrator or his or her designee may appear at such hearings to represent the interest of the state insurance fund and/or the surplus fund.

(4) The bureau will make payment on orders of the commission, and district or staff hearing officers in accordance with law and rules of the bureau and the industrial commission.

(5) If the administrator or their designee is of the opinion that an emergency exists which requires an immediate hearing of a claim, they may request an emergency hearing, in accordance with rule 4121-3-30 of the Administrative Code. "Emergency," as used herein, means a sudden, generally unexpected occurrence or set of circumstances demanding immediate action.

(E) Representation of claimants and employers before the bureau. Representation of claimants and employers before the bureau is a matter of individual free choice. The bureau does not require representation, nor does it prohibit it. No one other than an attorney at law, authorized to practice in the state of Ohio, shall be permitted to represent claimants for a fee before the bureau.

(F) If the bureau or the parties believe that clarification of issues will facilitate the processing of the claim, the claimant, employer, and their duly authorized representatives, as defined in rule 4123-3-22 of the Administrative Code, will be given an opportunity to provide additional evidence on questions pertaining to the claim pending before the bureau.

The evidence will be made a part of the claim file to be considered by the bureau when the determination is made on the issue pending before the bureau.

Last updated December 2, 2024 at 8:56 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-10 Awards.

(A) Compensation check issuance, delivery and endorsement.

(1) Definition of claimant.

As used in this rule the word "claimant" applies to an employee who sustained an injury or contracted an occupational disease in the course of and arising out of employment, to the dependent of a deceased employee, as well as to any person who was awarded compensation under the Ohio Workers' Compensation Act.

(2) Time limit for issuance.

(a) Any order, finding, or decision of the bureau, the industrial commission, or its hearing officers wherein payment of compensation is to be made will be promptly forwarded to the appropriate department of the bureau charged with the duty of making the payment, or in the case of a self-insuring employer to the personnel of such employer charged with the disbursement of funds in industrial claims.

(b) The initial payment of the bureau in payment of compensation under an order shall be issued within the time limits set forth in division (H) of section 4123.511 of the Revised Code. The payment will include compensation accrued and due the claimant at that time. Further payment of compensation due under that order shall be made by the bureau in biweekly installments. In self-insuring employers' claims payment will be made in accordance with applicable laws and rules.

(3) To whom paid.

(a) Awards of compensation shall be made payable only to the claimant as defined in paragraph (A)(1) of this rule, except in cases of lump sum advancements, or where the claimant is an incompetent person or is a minor awarded a lump sum of compensation, or in the case of attorneys fees as provided in paragraph (A)(7) of this rule.

(b) If the claimant is an incompetent person, payment shall be issued payable and shall be mailed to the claimant's legally appointed guardian upon the receipt of documentary proof establishing the existence of such guardianship.

(c) If the claimant is a minor and was awarded a lump sum of compensation, such sum shall be paid to the claimant's legally appointed guardian or in accordance with section 2111.05 of the Revised Code.

(d) If the bureau or the industrial commission determines it is in the best interest of the claimant that a guardian of the property be appointed to receive the benefits payable, payment shall be withheld until such guardian is appointed.

(4) Delivery of the bureau's payment to claimant and exceptions.

The standard method of delivering payment to a claimant or benefit recipient is by electronic transfer, as provided in paragraph (D) of this rule. Where the bureau issues a check, the bureau's checks payable to a claimant shall be mailed to the claimant's address, as officially recorded in the claim file, except as follows:

(a) The mailing of the bureau's compensation check to a place requested by the claimant in an authorization to receive workers' compensation payment or equivalent, executed in accordance with paragraph (A)(5) of this rule, must be approved by the administrator or the administrator's designee, or by the industrial commission or designee.

(b) Checks for lump sum settlements or lump sum advancements shall be disbursed in accordance with instructions of the bureau or industrial commission, as indicated in the order approving such advancements.

(c) In cases of advancements made by the employer during a period of disability, the bureau's checks shall be delivered in accordance with rule 4123-5-20 of the Administrative Code.

(5) Personal pick-up of the bureau's checks by a claimant or by parties other than a claimant.

(a) Provided approval has been given by a member of the industrial commission or designee, the administrator of the bureau of workers' compensation or the administrator's designee, or a hearing officer, a claimant, an attorney for a claimant, or any other person authorized by a claimant may pick up a compensation check issued by the bureau.

(b) When a claimant authorizes another person to pick up the claimant's compensation check, the authorization constitutes an authorization to receive workers' compensation payment or equivalent. On all types of compensation other than percentage of permanent partial compensation, the authorization must be filed prior to or at the hearing, or prior to the date of payment of the award of compensation, whether the award of compensation was made at a hearing or without a hearing. For authorization to receive compensation checks in connection with permanent partial disability applications and applications for increases thereof, the authorization must be filed with the application, with the agreement of permanent partial disability, with the election, or with the industrial commission at formal hearing or not later than prior to the date of mailing of the findings resulting from the formal hearing.

(c) The warrant will be made payable to the claimant and sent in care of the attorney/representative identified on the authorization to receive workers' compensation payment or equivalent. The warrant shall be mailed to the address that the claimant indicated on the request, or at a place designated by the administrator.

(d) A person authorized to pick up the check at the bureau shall furnish adequate identification and sign a dated receipt verifying acceptance of the check.

(e) In self-insuring employers' claims, the claimant and the employer may agree on check delivery or pick up, such agreement to be based on the same principles as outlined in this rule.

(6) Endorsement of checks and procedure in the event of claimant's death.

(a) Checks payable to a claimant's guardian must be endorsed by said guardian in the guardian's official capacity.

(b) When a claimant dies prior to endorsing a compensation check or accessing an electronic benefit payment, no one has the right to endorse and cash such check or access the electronic benefit funds. Each check payable to a claimant shall bear on the reverse side, immediately above the point specified for endorsement, the standard printed certification explaining the limitations and penalties for false endorsements, as required by the department of administrative services for state warrants and checks.

Checks that cannot be endorsed because the claimant is deceased must be returned to the bureau's benefits payable section, at the address designated by the administrator, by the party handling the claimant's affairs, notifying the bureau of the date of death, if known. Upon receipt of information of claimant's death, payment of compensation shall be terminated and proper entry made in the records of the bureau.

(7) Procedure for a lump sum payment and attorney fees where the claimant is an obligor for child support payments.

(a) If a claimant is entitled to a lump sum payment of one hundred and fifty dollars or greater and the claimant is an obligor for child support payments, prior to issuing the lump sum payment, the bureau shall notify the claimant and the claimant's attorney in writing that the claimant is subject to a support order. The bureau shall hold the lump sum payment for thirty days, pending application by the attorney for attorney fees as provided in paragraph (A)(7)(b) of this rule.

(b) The bureau shall instruct the claimant's attorney in writing to file a copy of the fee agreement signed by the claimant, along with an affidavit signed by the attorney setting forth the amount of the attorney's fee with respect to that lump sum payment award to the claimant and the amount of all necessary expenses, along with documentation of those expenses, incurred by the attorney with respect to obtaining that lump sum award. The attorney shall file the fee agreement and affidavit with the bureau within thirty days after the date the bureau sends the notice under paragraph (A)(7)(a) of this rule.

(i) The attorney shall file a copy of the fee agreement that clearly establishes the fee for the lump sum payment in the claim. The attorney's failure to file a copy of the fee agreement is a reason for the bureau to reject the application.

(ii) The attorney shall file a notarized affidavit in the form provided by the bureau. The attorney may complete the affidavit on the form provided by the bureau or in an affidavit that contains at least all of the elements of the form established by the bureau. The attorney's failure to file an affidavit in the form proscribed by the bureau or failure to obtain a notary signature are reasons for the bureau to reject the application.

(iii) The attorney fee is limited to the fee for obtaining the specific lump sum payment that is the subject of the bureau notice provided in paragraph (A)(7)(a) of this rule. The attorney fee is limited to the written fee agreement of the initial lump sum payment of the award. The bureau will reject a fee application that includes fees from awards other than the subject lump sum payment or that requests a fee from future payments of the award after the lump sum payment.

(iv) If the attorney claims reimbursement for expenses in the affidavit, the expenses shall be limited to the expenses for obtaining the specific lump sum payment that is the subject of the bureau notice provided in paragraph (A)(7)(a) of this rule. The attorney shall provide itemized expenses and documentation to support the expenses. If the attorney fails to provide the required information on expenses, the bureau may reject that portion of the fee application, but process the attorney fee portion of the application.

(v) Where the bureau has paid the attorney fee under paragraph (A)(7)(c) of this rule, the bureau will not honor an authorization to receive workers' compensation payment or equivalent for that award under paragraph (A)(5) of this rule, except in cases of court settlement of the workers' compensation claim.

(vi) Before rejecting an attorney fee affidavit or fee agreement due to noncompliance with any part of this rule, the bureau shall notify the attorney of the noncompliance and provide the attorney an opportunity to submit additional information during the thirty day hold period provided in paragraph (A)(7)(a) of this rule.

(c) Upon receipt of the fee agreement and attorney affidavit, the bureau will review the affidavit as provided in this rule. If the affidavit complies with this rule, the bureau shall deduct from the lump sum payment the amount of the attorney's fee and necessary expenses and pay that amount directly to and solely in the name of the attorney within fourteen days after the fee agreement and attorney affidavit have been filed with the bureau.

(d) After deducting any attorney's fee and necessary expenses, if the lump sum payment is one hundred fifty dollars or more, the bureau shall hold the balance of the lump sum award in accordance with division (A)(11) of section 3121.037 of the Revised Code.

(B) Medical awards.

Medical awards shall be paid by the bureau within the time limits set forth in rule 4123-6-42 of the Administrative Code.

Self-insuring employers shall make payment of compensation and benefits within the time as required by law and rules of the bureau.

(1) It is the duty of the employer to pay, in accordance with the act, the amount of compensation due a claimant whose injury or occupational disease has resulted in more than seven days lost time. Payment shall be made in the manner provided by law and the rules of the bureau.

(2) It is the duty of the employer to pay for necessary medical services rendered by health care providers as a result of an injury or occupational disease for which a claim was recognized by the employer or allowed by the industrial commission.

(3) It is the duty of the employer to pay the amount of compensation and benefits due in a compensable death case, and to make payment to the proper dependents or to such other persons who may be entitled thereto in accordance with the governing statutes and the orders and rules of the bureau. In the event death is the result of a compensable injury or occupational disease, the employer shall also pay the funeral allowance provided by statute at the time of death.

(4) All awards made by self-insuring employers must be at least equal to the amounts specified in the applicable statutes, the rules of the bureau and the industrial commission.

(5) Self-insuring employers shall follow the procedures in paragraph (A)(7) of this rule relating to a lump sum payment and attorney fees where the claimant is an obligor for child support payments.

(D) Electronic payment of compensation and benefits.

(1) For any compensation paid directly to a claimant, the bureau shall either direct deposit funds by electronic transfer into a savings or checking account designated by the payee, or issue to the payee an electronic benefits card.

(a) The bureau will provide to the claimant notice of the types of compensation or payments paid directly to a benefit recipient that are included in the electronic benefits program.

(b) The bureau will provide to the claimant notice of the types of compensation or payments not paid directly to a benefit recipient that are not included in the electronic benefits program. Payments made under an authorization to receive workers' compensation checks are excluded from the electronic benefits program.

(2) The bureau shall notify a benefit recipient of the requirement for electronic payment of benefits and compensation and ask the benefit recipient to designate a financial institution and account to which the bureau shall deposit the benefit recipient's compensation or benefits. If the benefit recipient does not have an account or does not respond, the bureau shall issue the payment by a bureau debit card.

(3) The bureau shall contract with a vendor for the debit cards to allow benefit recipients to receive payment without a monthly maintenance fee and issue the debit card only to the benefit recipient.

(4) The bureau shall provide to a benefit recipient who lives in a foreign country an electronic benefit card.

(5) The bureau shall provide notice of electronic payment delivery on the payment remittance of each paper warrant issued to eligible benefit recipients. The notice shall include the two different payment options and provide the benefit recipient the opportunity to select between the two electronic payment options.

(6) A benefit recipient may request a waiver of the electronic payment delivery of compensation or benefits under this rule for special circumstances due to hardship in establishing a personal checking or savings account or in accepting the bureau debit card. The request for a waiver will be referred to the bureau benefits payable department and may be reviewed by the administrator's designee.

Last updated December 2, 2024 at 8:56 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-11 Reports of payments by self-insuring employers.

(A) During the continuance of temporary total disability, temporary partial disability, or wage loss compensation caused by an injury or occupational disease, the employer shall, at the request of the bureau of workers' compensation or the industrial commission at any time or at the request of the claimant or claimant's representative where the issue of compensation is pending in a workers' compensation hearing or adjudication matter, file a report of compensation payments with the bureau showing the amount and type of compensation paid to such employee during the preceding period. The report shall indicate the date when the first installment of the type of compensation reported was paid.

(B) In the event an injury or occupational disease results in a disability compensable under division (A) or (B) of section 4123.57 of the Revised Code, and an agreement has been entered into between the employee and the employer as to the compensation to be paid for such permanent partial disability, the agreement shall state when the first installment of such compensation is to be paid. Such agreement shall be signed by the employee and employer and filed with the bureau as soon as it has been completed. Such agreement shall be accompanied by a report from the attending physician which indicates the extent of the permanent partial disability sustained.

(C) In cases of compensable death claims, where the employer and the dependents or legal representatives of a deceased employee agree that the death is compensable, and there being no question of apportionment of death benefits, they enter into an agreement in writing as to the benefits which are to be paid; such agreement shall be reported by the employer. It shall indicate the date of the first installment of payment, the weekly rate of death benefits, the period of time over which such benefits will be paid (lifetime or specific dates) and the total amount of benefits in cases where it is known. Such agreement shall be signed by the employer and the dependent, dependents, or legal representatives and be filed with the bureau within one month of the date of execution of the agreement. Such agreement shall include provision for the payment of appropriate funeral, medical, hospital, and other expenses. Subsequent reports of the payment of death benefits shall be filed with the bureau at the request of the bureau or the commission at any time or at the request of the claimant or claimant's representative where the issue of compensation is pending in a workers' compensation hearing or adjudication matter. Should there be a change in death benefits as a result of changes in the dependency status of the recipients, employer's reports shall reflect same.

In cases of compensable death claims, where the employer and the dependents or legal representatives of a deceased employee agree that the death is compensable but where there is a question of apportionment, the self-insuring employer may choose to pay death benefits before a hearing at the industrial commission. The first such payment should indicate to the beneficiaries that because there is a question of apportionment among the surviving spouse, dependent children, or other dependents, the commission must issue an order apportioning the payment; therefore, payments until such order issues are subject to an adjustment in accordance with the apportionment ordered by the commission among the beneficiaries at such time as the apportionment order issues.

In other death claims approved for payment by the industrial commission or its hearing officers, the employer shall report payments in the same general manner as indicated above.

(D) In all claims, the self-insuring employer shall, upon completion of the payment of compensation and benefits, report that fact to the bureau at the request of the bureau or the commission at any time or at the request of the claimant or claimant's representative where the issue of compensation is pending in a workers' compensation hearing or adjudication matter indicating the dates of the payment of the first and last installments of compensation, and the total amount of each type paid, together with the total amounts expended for benefits other than compensation according to type of benefit.

(1) Such report shall be signed by the employer and the employee or his or her dependents or their legal representatives as the circumstances may require.

(2) Upon receipt of such report by the bureau, it shall be examined to determine whether or not the payments made have been in conformity with the provisions of the workers' compensation law. If it is found that the reported payments do conform to the provisions of the workers' compensation law, the same shall be approved by the bureau and the employer advised thereof. If it is found that the reported payments do not conform, the bureau shall notify the employer of that fact indicating the further payments that are to be made. The employer shall make such payments and file a revised report with the bureau.

(3) If, for any reason, it is impossible for the employer to promptly file a report of payments or an agreement as to compensation paid or to be paid, the employer shall immediately report that fact and the reason to the bureau. Failure to do so constitutes sufficient reason for the administrator to take such action as may be indicated.

(E) Where compensation has been ordered paid or where the employee and employer have agreed upon the compensation to be paid, request to the bureau may be made by either the employer, the employee, or the employee's dependents for authorization to pay all or part of the unpaid balance of the award in one or more lump sum payments.

(F) Whenever a self-insured employer that is a professional sports franchise domiciled in Ohio makes payment pursuant to the terms of a contract of hire or a collective bargaining agreement during a period of disability resulting from the injury or occupational disease, the self-insurer shall report such payments on the same basis as required in paragraph (A) of this rule. The total amount of such payments, the period of disability for which those payments were made, and the amount such payments exceed the compensation that was due for that period shall be reported. The amount such payments exceed the compensation payable or, in the event no compensation was payable, the total amounts of such payments, is deemed an advanced payment of compensation and shall be applied to offset future payments of compensation for disability under sections 4123.56 to 4123.58 of the Revised Code. The self-insurer shall report these offsets on the same basis as required in paragraph (A) of this rule. Such offsets apply only in cases where the employee's application for compensation is pending on or after August 22, 1986.

Last updated December 2, 2024 at 8:57 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-14 Procedure in the original adjudication of non-complying employers' claims.

Where the bureau originally adjudicates a claim and determines that the employer is a non-complying employer, the bureau shall note the employer's non-complying employer status in the claim and the bureau order. The bureau shall notify the employer of the filing of the application and the employer's noncompliance, and proceed to secure the employer's obligation to reimburse the bureau for any cost of the claim as provided in rule 4123-14-04 of the Administrative Code.

Last updated December 2, 2024 at 8:57 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-15 Claim procedures subsequent to allowance.

(A) Requests for subsequent actions when a state fund claim has not had activity or a request for further action within a period of time in excess of twenty-four months.

(1) The bureau shall consider a request for subsequent action in a claim in the following situations:

(a) Where the employee requests that the bureau or commission modify or alter an award of compensation or benefits that has been previously granted; or

(b) Where the employee requests that the bureau or commission grant a new award of compensation or to settle the claim; or

(d) Where the claimant dies and there is potential entitlement for accrued benefits or payment of medical bills, or the decedent's dependent is requesting death benefits due to relatedness between the recognized injury and death.

(e) Except for a medical issue relating to a prosthetic device or durable medical equipment as designated by the administrator, the bureau, in consultation with the MCO assigned to the claim, shall issue an order on a medical treatment reimbursement request in a claim which has not had activity or a request for further action within a period of time in excess of twenty-four months as follows:

(i) The MCO shall refer a medical treatment reimbursement request in a claim which has not had activity or a request for further action within a period of time in excess of twenty-four months to the bureau for an order when the request is accompanied by supporting medical evidence dated not more than sixty days prior to the date of the request, or when such evidence is subsequently provided to the MCO upon request (via "Form C-9A" or equivalent). The bureau's order shall address both the causal relationship between the original injury and the current incident precipitating the medical treatment reimbursement request in a claim and the necessity and appropriateness of the requested treatment. The employer or the employee or the representative may appeal the bureau's order to the industrial commission pursuant to section 4123.511 of the Revised Code.

(ii) The MCO may dismiss without prejudice, and without referral to the bureau for an order, a medical treatment reimbursement request in a claim which has not had activity or a request for further action within a period of time in excess of twenty-four months when the request is not accompanied by supporting medical evidence dated not more than sixty days prior to the date of the request and such evidence is not provided to the MCO upon request (via "Form C-9A" or equivalent).

(2) Proof shall conform to the standards set forth in paragraph (C) of rule 4123-3-09 of the Administrative Code and rules 4123-5-18 and 4123-6-20 of the Administrative Code. Medical evidence is required to substantiate:

(a) A request for temporary total disability.

(b) The allowance of a disability or condition not previously considered.

(3) In state fund cases, upon a request for subsequent action under paragraph (A)(1) of this rule, the bureau , upon notification, will inform the parties to the claim of the pending action prior to issuing a decision. Upon request, the bureau will provide a copy of the request and proof to the employer and the claimant, and their representatives, where applicable. Requests in self-insuring employers' cases shall be submitted to the self-insuring employer, which shall accept or refuse the matters sought.

(4) The bureau or commission may require the filing of additional proof or legal citations by either party or may make such investigation or inquiry as appropriate under the circumstances.

(5) A state fund employer shall, upon receipt of notification of the request, notify the bureau of any objection to the granting of the relief requested. Such notification must be filed within the time set forth in the rules of the bureau and industrial commission.

(6) If the request is within the jurisdiction of the bureau and the matter is not contested or disputed, the bureau will adjudicate the request in the usual manner. In all other cases, the request shall be acted upon by the industrial commission's hearing officer or as otherwise in accordance with the rules of the commission, depending on the subject matter.

(7) Failure by the employee to furnish information as specifically requested by the bureau or commission is sufficient reason for the dismissal of the request. If the employer fails to furnish any information requested by the bureau or commission, the request may be adjudicated upon the proof filed.

(B) "Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability" pursuant to division (A) of section 4123.57 of the Revised Code in state fund and self-insured claims.

(1) An "Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability" shall be completed and signed by the applicant or applicant's representative and be filed with the bureau of workers' compensation. An application for an increase in permanent partial disability must be accompanied by substantial evidence of new and changed circumstances which have developed since the time of the hearing on the original or last determination. The bureau shall dismiss an unsigned application. Except where an additional condition has been allowed in the claim and the request is for an increase in permanent partial disability based solely on that additional condition, the bureau shall dismiss a request for an increase in permanent partial disability filed without medical documentation. Whenever the applicant or applicant's representative leaves a question or questions in the application form unanswered, the bureau shall contact the applicant and applicant's representative to obtain the information necessary to process the application. Should the applicant or applicant's representative inform the bureau that the failure to provide the information necessary to process the application is beyond the applicant's control, the bureau shall take appropriate action to obtain such information.

(2) Upon the filing of the application for either of these requests, the application shall be referred to the bureau for review and processing. The bureau shall send notice of the application to the employer and the employer's representative, unless the employer is out of business. The employer shall submit any proof within its possession bearing upon the issue to the bureau within thirty days of the receipt of the claimant's application.

(3) The bureau shall contact each applicant for a determination of the percentage of permanent partial disability to schedule an examination by a physician designated by the bureau. If the applicant fails to respond to the bureau's attempt to schedule the examination or fails to appear for the examination, the bureau may dismiss the application as provided in rule 4123-3-15.1 of the Administrative Code. The examining physician shall file a report of such examination, together with an evaluation of the degree of impairment as a part of the claim file. The bureau shall send a copy of the report of the medical examination to the employee, the employer, and their representatives.

(4) Upon receipt of the examining physician's report, the bureau shall review the medical evidence in the employee's claim file and make a tentative order as the evidence at the time of the making of the order warrants. If the bureau determines there is a conflict of evidence, the bureau shall forward the application, along with the claimant's file, to the industrial commission to set the application for hearing before a district hearing officer.

(5) Where there is no conflict of evidence, the bureau shall enter a tentative order on the request for percentage of permanent partial disability and notify the employee, the employer, and their representatives, in writing, of the tentative order and of the parties' right to request a hearing. Unless the employee, the employer, or their representative notifies the bureau, in writing, of an objection to the tentative order within twenty days after receipt of the notice thereof, the tentative order shall go into effect and the employee shall receive the compensation provided in the order. In no event shall there be a reconsideration of a tentative order issued under this division.

(6) If the employee, the employer, or their representatives timely notify the bureau of an objection to the tentative order, the bureau shall refer the matter to a district hearing officer who shall set the application for hearing. Upon referral to a district hearing officer, the employer may obtain a medical examination of the employee, pursuant to the rules of the industrial commission.

(7) Where the application is for an increase in the percentage of permanent partial disability, no sooner than sixty days from the date of mailing of the application to the employer and the employer's representative, the applicant shall either be examined, or the claim referred for review by a physician designated by the bureau. Such period may be extended or the processing of the application suspended by the bureau for good cause shown. If the bureau has determined the employer is out of business the bureau will not mail the application and may process the application without waiting the sixty day period. The bureau physician shall file a report of such examination or review of the record, together with an evaluation of the degree of impairment, as part of the claim file. Either the employee or the employer may submit additional medical evidence following the examination by the bureau medical section as long as copies of the evidence are submitted to all parties.

(8) After completion of the review or examination by a physician designated by the bureau, the bureau may issue a tentative order based upon the evidence in file. If the bureau determines that there is a conflict in the medical evidence, the bureau shall adopt the recommendation of the medical report of the bureau medical examination or medical review.

(9) The bureau shall enter a tentative order on the request for an increase of permanent partial disability and notify the employee, the employer, and their representatives, in writing, of the nature and amount of any tentative order issued on the application requesting an increase in the percentage of the employee's permanent disability. The employee, the employer, or their representatives may object to the tentative order within twenty days after the receipt of the notice thereof. If no timely objection is made, the tentative order shall go into effect. In no event shall there be a reconsideration of a tentative order issued under this division. If an objection is timely made, the bureau shall refer the matter to a district hearing officer who shall set the application for a hearing in accordance with the rules of the industrial commission. The employer may obtain a medical examination of the employee and submit a defense medical report at any stage of the proceedings up to a hearing before a district officer.

(10) Where an award under division (A) of section 4123.57 of the Revised Code has been made prior to the death of an employee, the bureau shall pay all unpaid installments accrued or to accrue to the surviving spouse, or if there is no surviving spouse, to the dependent children of the employee, and if there are no such children surviving, then to such other dependents as the bureau may determine.

(C) Payment of permanent partial disability pursuant to division (B) of section 4123.57 of the Revised Code (scheduled loss) in state fund and self-insured employer claims.

(1) The bureau or self-insuring employer will determine the payment of scheduled loss for a loss by amputation or for a loss of use upon the motion of a party for such award. To determine the payment of the award, the bureau or self-insuring employer may review the medical evidence in the file, may request additional medical information from the parties, or may refer the claimant for an examination by a physician designated by the bureau or self-insuring employer.

(2) The bureau shall enter an order on or the self-insuring employer shall make a decision on the payment of scheduled loss and shall notify the employee, the employer, and their representatives, in writing, of the order or decision. The parties have a right to appeal the order or contest the decision pursuant to section 4123.511 of the Revised Code.

(3) Upon an order for the payment of scheduled loss for a loss, the bureau or self-insuring employer shall calculate such award pursuant to the statutory schedule of division (B) of section 4123.57 of the Revised Code. The bureau or self-insuring employer shall pay the award to the claimant in weekly payments as provided in division (B) of section 4123.57 of the Revised Code.

(4) Where a scheduled loss has been ordered but not paid prior to the death of an employee, upon application, the award is payable to the surviving spouse, or if there is no surviving spouse, to the dependent children of the employee, and if there are no such children surviving, then to such other dependents as the bureau may determine.

Last updated December 2, 2024 at 8:57 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-15.1 Dismissal of an application for the determination of percentage of permanent partial disability.

(A) This paragraph of this rule applies to any employee's application for a determination of the percentage of permanent partial disability or for an increase of permanent partial disability filed on or after September 29, 2017.

(1) If an employee who files an application for a determination of percentage of permanent partial disability or for an increase of permanent partial disability fails to respond to the bureau's attempt to schedule a medical examination, or fails to attend a medical examination scheduled under section 4123.57 of the Revised Code without notice or explanation, the bureau shall dismiss the application without prejudice. The employee, the employer, or their representative may object to the bureau's tentative order dismissing the application within twenty days after receipt of the notice as provided in section 4123.57 of the Revised Code, and if the employee, the employer, or their representative timely notify the bureau of an objection, the bureau shall refer the matter to a district hearing officer for a hearing.

(a) The bureau shall contact the employee to schedule the employee for an examination on an application for a determination of percentage of permanent partial disability or for an increase of permanent partial disability. The bureau may use a variety of communication methods to contact the employee, such as by telephone, mail, or other methods, but the bureau shall not limit the contact to one method or one attempt if the bureau is not able to contact the employee on the first attempt. If the bureau is unable to contact the employee and the employee is represented, the bureau shall contact the employee's representative for assistance in scheduling the examination. The bureau shall document its contacts in the claim file. If the bureau attempts to contact the employee by mail and the mail is returned undeliverable, the bureau shall attempt to find a correct address for the employee and shall document the attempt in the claim file. If the employee fails to respond to the bureau's attempts to contact the employee to schedule the examination, the bureau shall dismiss the application.

(b) If the bureau schedules the employee for an examination on the employee's application for a determination of the percentage of permanent partial disability or for an increase of permanent partial disability and the employee fails to attend the examination, the bureau shall contact the employee for an explanation why the employee did not attend the examination. If the employee is represented, the bureau shall contact the employee's representative. If the employee provides an explanation for missing the examination, the bureau shall reschedule the employee for an examination. If the employee fails to respond or fails to provide an explanation, the bureau shall dismiss the application.

(2) If the bureau dismisses an employee's application for a determination of percentage of permanent partial disability or for an increase of permanent partial disability under this rule, the employee may refile an application as provided in paragraph (B) of rule 4123-3-15 of the Administrative Code subject to the continuing jurisdiction limitations of section 4123.52 of the Revised Code. A dismissed application does not toll the continuing jurisdiction of the bureau or the industrial commission under section 4123.52 of the Revised Code.

(B) This paragraph of this rule applies to an employee's application for a determination of the percentage of the employee's permanent partial disability or for an increase of permanent partial disability filed under section 4123.57 of the Revised Code that has been suspended pursuant to division (C) of section 4123.53 of the Revised Code as of September 29, 2017.

(1) For an employee's application for a determination of the percentage of the employee's permanent partial disability or for an increase of permanent partial disability filed under section 4123.57 of the Revised Code that has been suspended pursuant to division (C) of section 4123.53 of the Revised Code as of September 29, 2017, the bureau shall send a notice to the employee's last known address informing the employee that the bureau may dismiss the application unless the employee schedules a medical examination with the bureau within thirty days after receiving the notice.

(a) If the employee does not schedule a medical examination with the bureau within thirty days after receiving the notice provided in paragraph (B)(1) of this rule, the bureau may dismiss the application. The employee, the employer, or their representative may object to the bureau's tentative order dismissing the application within twenty days after receipt of the notice as provided in section 4123.57 of the Revised Code, and if the employee, the employer, or their representative timely notify the bureau of an objection, the bureau shall refer the matter to a district hearing officer for a hearing.

(b) For an employee whose application has been suspended who schedules an examination but fails to appear for the examination, the bureau shall follow the same procedure as provided in paragraph (A)(1)(b) of this rule.

(2) If the bureau dismisses an employee's application for a determination of percentage of permanent partial disability or for an increase of permanent partial disability under this rule, the employee may refile the application as provided in paragraph (B) of rule 4123-3-15 of the Administrative Code, subject to the continuing jurisdiction limitations of section 4123.52 of the Revised Code. A dismissed application does not toll the continuing jurisdiction of the bureau or the industrial commission under section 4123.52 of the Revised Code.

Last updated December 2, 2024 at 8:57 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-16 Motions.

(A) Form C-86 motion or its equivalent shall be used to request action from the bureau or commission.

(B) A motion may be submitted by the employee or the employer to seek a determination by the bureau or the commission on any matter not otherwise provided for in this chapter. It is appropriate to file a motion in order to secure allowance of a disability or condition not previously considered in a claim. A motion shall not be used as a substitute for an untimely appeal.

(C) A motion shall fully set forth the question presented together with a succinct statement of the action or relief sought.

(D) A motion shall be accompanied by competent proof conforming to the standards established in paragraph (C) of rule 4123-3-09 of the Administrative Code.

(E) Except in matters not affecting the rights of the opposite party, the applicant filing a motion shall provide a copy of the motion to the opposite party and the copy of the motion filed with the bureau or the commission shall indicate that a copy has been so provided. When in doubt, the applicant shall provide a copy of the motion to the opposite party.

(F) A motion shall bear the signature of the applicant or the applicant's authorized representative.

(G) Failure to comply with the provisions of this rule is sufficient reason for the dismissal of the motion.

(H) Motions will be adjudicated in the same manner as provided in paragraph (A)(7) of rule 4123-3-15 of the Administrative Code, except motions for allowance of a psychiatric disability (paragraph (I) of this rule).

(I) Procedure governing motions for allowance of a psychiatric disability:

(1) A motion requesting that a claim be additionally recognized for a psychiatric or psychological condition shall include a statement, personally signed and dated by the claimant, acknowledging the claimant is aware the motion is being filed to request that the bureau or commission recognize a psychiatric or psychological condition as being a result of the injury for which the claim is allowed.

(2) A motion requesting the recognition of an additional condition of a psychiatric or psychological nature shall be accompanied by supporting evidence consisting of a report by a doctor of medicine (MD), doctor of osteopathic medicine (DO), a clinical psychologist, a licensed professional clinical counselor (LPCC), or a licensed independent social worker (LISW).

(3) The bureau may have the claimant scheduled for an examination by an independent specialist.

(4) If the claimant fails to comply with the bureau's request relating to the motion as provided in paragraphs (I)(1) to (I)(3) of this rule, the bureau will refer the motion to the commission with a recommendation to dismiss the motion.

(5) If there is no conflict in the evidence or the motion is not contested or disputed, the bureau will adjudicate the motion. If there is a conflict in the evidence or the motion is contested or disputed, the bureau will refer the motion to the commission for further consideration.

Last updated December 2, 2024 at 8:58 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-17 Briefs.

(A) Parties may, of their own volition, file briefs with the bureau or commission on legal questions presented in claims.

(B) The bureau or commission may require parties to file briefs on legal questions presented in claims. A time certain shall be fixed for the filing of such briefs allowing a reasonable time for preparation.

(C) In either instance, the submitted briefs shall be legibly typewritten on paper not exceeding eight and one-half inches by eleven inches in size and filed without a protective cover. The party filing a brief shall furnish a copy to the opposite party at the time that the brief is filed with the bureau or the commission. If the brief is directed to a matter before the bureau, the brief shall be filed with the bureau. If the brief is directed to the attention of the commission, the brief shall be filed with the commission unless otherwise directed by the commission.

Last updated October 7, 2024 at 12:02 PM

History

Effective: February 10, 2009
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-18 Appellate procedure.

(A) Administrative appeals.

(1) The right of an administrative appeal is limited to the claimant, the dependents of a deceased worker, the employer, and the administrator, where the administrator or the administrator's representative appeals on behalf of the state insurance fund or the surplus fund.

(2) The named eligible appellants may appeal decisions of district hearing officers or staff hearing officers, in accordance with rule 4121-3-18 of the Administrative Code.

(3) Decisions of district hearing officers are appealable to staff hearing officers. Decisions of the staff hearing officers are appealable to the industrial commission.

(4) Appeal applications shall be signed by the party appealing or by an authorized representative on behalf of such party. The same applies to the administrator when filing an appeal.

(5) Such applications may be filed with any office of the bureau or of the industrial commission.

(6) The same time limits apply to appeals filed from the decision of the staff hearing officers to the industrial commission.

(7) Appellate review and determination of claims being within the exclusive jurisdiction of the industrial commission, the conduct of hearings and other incidental matters are governed by the rules of the industrial commission.

(8) The bureau's legal division shall act as attorney in appeals filed by the bureau on behalf of the state insurance fund; it may also act as a representative of the administrator in appeals filed by the bureau on behalf of the surplus fund. As a party to the proceedings, the bureau's legal divisionis entitled to proper notice of any action taken by the appellate body on appeals filed by the bureau.

(9) The bureau will make payment of an award of compensation in a claim at the earliest time provided in division (H) of section 4123.511 of the Revised Code, except that, in all cases of a determination made under division (A) of section 4123.57 of the Revised Code for percentage permanent partial disability compensation, payment will not be made to the claimant until a final decision on reconsideration allows such compensation.

(10) In all other cases, if the decision of the district hearing officer is appealed by the employer or the administrator, the bureau will withhold medical benefits during the course of appeal to the staff hearing officer, but where the staff hearing officer rules in favor of the claimant, the bureau will pay medical benefits immediately upon the receipt of the order, regardless of whether or not further appeal is taken. In self-insuring employers' claims, payment shall be made in accordance with applicable laws and rules.

(11) Payments of an award of compensation and/or benefits made by the bureau pursuant to a decision of a staff hearing officer will commence immediately upon the bureau's receipt of the order.

(B) Appeals to court.

(1) The claimant or the employer may appeal an order of the industrial commission made under division (E) of section 4123.511 of the Revised Code in any injury or occupational disease case, other than a decision as to the extent of disability, to the court of common pleas of the county in which the injury was inflicted or in which the contract of employment was made if the injury occurred outside the state, or in which the contract of employment was made if the exposure occurred outside the state. If no common pleas court has jurisdiction for the purposes of an appeal by the use of the jurisdictional requirements described in this division, the appellant may use the venue provisions in the Rules of Civil Procedure to vest jurisdiction in a court. If the claim is for an occupational disease, the appeal shall be to the court of common pleas of the county in which the exposure which caused the disease occurred. Like appeal may be taken from an order of a staff hearing officer made under division (D) of section 4123.511 of the Revised Code from which the commission has refused to hear an appeal. Except as otherwise provided in paragraph (B)(2) of this rule, the appellant shall file the notice of appeal with a court of common pleas within sixty days after the date of the receipt of the order appealed from or the date of receipt of the order of the commission refusing to hear an appeal of a staff hearing officer's decision under division (D) of section 4123.511 of the Revised Code. The filing of the notice of the appeal with the court is the only act required to perfect the appeal.

(2) Either the claimant or the employer may file a notice of intent to settle the claim within thirty days after the date of the receipt of the order appealed from or of the order of the commission refusing to hear an appeal of a staff hearing officer's decision. The claimant or employer shall file notice of intent to settle on the appropriate form with the administrator of workers' compensation, and the notice shall be served on the opposing party and the party's representative. The filing of the notice of intent to settle extends the time to file an appeal to one hundred fifty days, unless the opposing party files an objection on the appropriate form within fourteen days after the date of the receipt of the notice of intent to settle. The party shall file the objection with the administrator, and the objection shall be served on the party that filed the notice of intent to settle and the party's representative.

(3) "Notice of Appeal" stating the names of the administrator of workers' compensation, the claimant, and the employer, the number of the claim, the date of the order appealed from, and the fact that the appellant appeals from such order must be filed with the industrial commission and with the court of common pleas within the timeframes provided in paragraphs (B)(1) and (B)(2) of this rule.

(4) Such appeal or any other action filed from a decision of the industrial commission in a claim in which an award of compensation has been made shall not stay the payment of compensation under such award or payment of compensation for subsequent periods of total disability during the pendency of the appeal.

Last updated December 2, 2024 at 8:58 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-20 Additional awards by reason of violations of specific safety requirements.

The determination of awards by reason of violation of specific safety requirements being within the exclusive jurisdiction of the industrial commission, the bureau will refer any such applications filed with the bureau to the industrial commission for further consideration.

Last updated December 2, 2024 at 8:58 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-22 Inspection of claim files.

(A) Authorizations for representation shall be in writing and signed by the authorizing party. When the authorization is on behalf of the employee, it shall be filed on an "Claimant Authorized Representative" form or equivalent. There shall be a separate authorization filed with the bureau for each claim to which the authorization is to extend. When the authorization is on behalf of the employer, a blanket authorization may be filed with the bureau.

(B) An authorization may be cancelled by the filing of a notice to that effect with the bureau or by filing a new authorization by another representative. In either event, the party should notify the former representative of the party's action.

(1) The parties and/or their duly authorized representatives as outlined in paragraphs (A) and (B) of this rule;

(2) Any other person authorized, in writing, by either the employee or the employer; such authorization having been executed within one year prior to its use;

(3) Members of the general assembly when in the course of their duties as such;

(4) The governor, a select committee of the general assembly, a standing committee of the general assembly, the auditor of state, the attorney general, or the designee of any, in the pursuance of any duty imposed by Chapters 4121. and 4123. of the Revised Code.

(5) Duly authorized employees of governmental agencies whose official duties require the information contained in the claim files;

(6) Such other persons as are specifically authorized by a member of the commission or the administrator pursuant to the provisions of section 4123.88 of the Revised Code.

Last updated October 7, 2024 at 12:02 PM

History

Effective: July 1, 2019
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-23 Limitations on the filing of fee bills.

(A) Except as otherwise provided in this rule, fee bills for medical or vocational rehabilitation services rendered in a claim shall be submitted to the bureau or commission for payment within one year of the date on which the service was rendered or one year after the date the services became payable under division (I) of section 4123.511 of the Revised Code, whichever is later, or shall be forever barred.

(B) A self-insuring employer may, but is not required to, negotiate with a provider to accept fee bills from the provider for a time period other than as set forth in paragraph (A) of this rule.

(1) Requests made by the centers for medicare and medicaid services in the United States department of health and human services for reimbursement of conditional payments made pursuant to section 1395y(b)(2) of title 42, United States Code (commonly known as the "Medicare Secondary Payer Act");

(2) Requests made by the Ohio department of medicaid, or by a medical assistance provider to whom the department has assigned its right of recovery for a claim for which it has notified the provider that it intends to recoup its prior payment for a claim, for reimbursement under sections 5160.35 to 5160.43 of the Revised Code for the cost of medical assistance paid on behalf of a medicaid recipient;

(3) Requests made by the department of veterans affairs (VA) pursuant to section 1729 of title 38, United States Code for reimbursement of medical treatment provided to an injured worker in or through any VA provider or facility;

(4) Fee bills resubmitted by the proper servicing provider following MCO or bureau recovery of non-fraudulent overpayment of bills that were initially timely submitted and paid: provided, however, that such fee bills resubmitted more than one year and seven days from the date of the MCO or bureau recovery of the overpayment are forever barred;

(5) Fee bills submitted outside the timeframe set forth in paragraph (A) of this rule due to MCO or bureau error; however, division (A) of section 4123.52 of the Revised Code still applies;

(6) Fee bills submitted outside the timeframe set forth in paragraph (A) of this rule because the fee bills were initially submitted to a patient, different third-party payer, or state or federal program other than medicare, medicaid, or the VA that reimburses for medical or vocational rehabilitation services and that patient, payer, or program has determined it is not responsible for the cost of the services; however, division (A) of section 4123.52 of the Revised Code still applies.

(D) Except in cases involving MCO or bureau error, requests for additional payment on fee bills that were initially timely submitted under this rule shall be submitted within one year and seven days of the adjudication of the initial fee bill by the bureau or shall be forever barred. In cases involving MCO or bureau error, requests for additional payment on fee bills shall be submitted within one year and seven days from the date the provider knew or should have known of an MCO or bureau error impacting payment or shall be forever barred. No medical or vocational rehabilitation provider shall bill a claimant for any request for additional payment that is barred under this paragraph.

(E) Paragraphs (A) to (C) of this rule apply to bills with dates of service on or after July 29, 2011. Paragraph (D) of this rule applies to bills with dates of service on or after September 12, 2011.

Last updated May 1, 2026 at 8:10 AM

History

Effective: May 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-24 Fee controversies.

When a controversy exists between a party and the party's representative concerning fees for services rendered in industrial claims, either the party or the representative may make a written request to the industrial commission to resolve the dispute, the matter being within the exclusive jurisdiction of the industrial commission. The bureau will refer any such request filed with the bureau to the industrial commission for further consideration.

Last updated December 2, 2024 at 8:58 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-25 Application for change of occupation allowance.

(A) Eligibility for a change of occupation allowance.

(1) Where it is found that a change of occupation is medically advisable for an employee suffering from silicosis, coal miners' pneumoconiosis, or asbestosis contracted in the course of employment, but the employee is not totally disabled therefrom, and any other diseases which may be specified by law for which the statutory allowance for change of occupation may be granted, or

(2) Where it is found that a change of occupation is medically advisable for a fire fighter or police officer suffering from a cardiovascular and pulmonary disease contracted in the course of employment, but the employee is not totally disabled therefrom,

(3) Pursuant to the provisions of section 4123.57 of the Revised Code, such employee may file a motion in accordance with paragraph (A) of rule 4123-3-16 of the Administrative Code requesting the approval of the statutory allowance for such change of occupation, in order to decrease substantially further injurious exposure.

(B) This rule is applicable to public employees, employees of employers contributing to the private fund, employees of self-insuring employers, and employees of amenable but non-complying employers.

(C) If there is no conflict in the medical or the matter is not contested or disputed, the bureau will adjudicate the request. If a conflict in the medical exists or the request is contested or disputed, the bureau will refer the request to the commission for further consideration.

(D) To qualify for an award, the employee must establish by appropriate evidence that the employee has discontinued employment or has changed his or her occupation to one in which the exposure is substantially decreased. The fact that the employee continues employment with the same employer will not preclude the granting of the award so long as the employment subsequent to the change is such that the exposure is substantially decreased and the change of occupation is certified by the claimant as permanent.

(E) An award for change of occupation in excess of the initial thirty weeks must be supported by evidence of employment in an occupation in which the exposure is substantially decreased or evidence of reasonable attempts to secure employment in an occupation in which the exposure is substantially decreased.

Last updated December 2, 2024 at 8:59 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-29 Informing the claimant of the right to representation and status of the claim.

(A) Whether a claimant is or is not represented in an industrial claim is a matter of the claimant's free choice. No employee of the bureau or of a self-insuring employer shall directly or indirectly convey any information in derogation of this right.

(B) Upon receipt of a claim, the bureau shall notify the claimant and the employer of the number assigned to the claim and inform the claimant of his or her right to representation or to elect no representation in the processing of the claim. It is the responsibility of the bureau to aid and assist a claimant in the filing of a claim as provided in division (A) of section 4123.511 of the Revised Code.

(C) Upon request, the bureau shall inform the claimant of the status of the claim and of any action necessary to maintain the claim.

Last updated December 2, 2024 at 8:59 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-31 Disabled workers' relief fund: claimant's payments.

(A) On and after August 22, 1986, all persons, without regard to date of injury, who are receiving compensation for permanent and total disability which, when combined with disability benefits received pursuant to the Social Security Act, is less than three hundred forty-two dollars per month adjusted annually as provided in division (B) of section 4123.62 of the Revised Code, are eligible to participate in the disabled workers' relief fund. For purposes of this rule, this amount is the "DWRF qualifying figure."

(B) Each person who has satisfied the requirements of paragraph (A) of this rule shall receive from the disabled workers' relief fund a monthly amount equal to either the difference between the DWRF qualifying figure and such amount as the person is receiving per month as disability benefits from the social security administration or the difference between the DWRF qualifying figure and such amount as the person is receiving under the workers' compensation laws for permanent total disability, whichever calculation results in the lower DWRF payment.

(C) For purposes of this rule, in the case of individuals who have received a commutation of permanent total disability benefits pursuant to section 4123.64 of the Revised Code, payments from the disabled workers' relief fund are calculated as if such commutation had not been made.

Last updated December 2, 2024 at 8:59 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-32 Temporary total examinations.

(A) Pursuant to section 4123.53 of the Revised Code, the bureau of workers' compensation shall schedule an examination, for a date not later than thirty days following the end of the initial ninety-day period of temporary total disability compensation, to determine the employee's continued entitlement to temporary total disability compensation, the employee's rehabilitation potential, and the appropriateness of the employee's medical treatment. The bureau will mail a copy of the bureau's determination to schedule the examination to the employee, employer, and their authorized representatives, except where the bureau has determined the employer is out of business.

(B) If the result of the medical examination is that the employee continues to receive temporary total disability compensation, the bureau shall determine a date for the employee to be scheduled to be reexamined, based upon the recommendation of the medical examiner or other available evidence. If at the date the bureau has determined to schedule the employee to be reexamined the employee is receiving temporary total disability compensation, the bureau shall schedule the employee for the examination. The bureau will continue to determine dates to schedule the employee for subsequent examinations as long as the employee continues to receive temporary total disability compensation.

(C) The bureau, for good cause, may waive the scheduling of the employee's medical examination under section 4123.53 of the Revised Code. "Good cause" is determined at the discretion of the bureau, but generally is for a reason that the medical examination is not feasible, such as the employee's medical instability. The bureau shall contact the employer or the employer's representative if the bureau determines that a waiver of the examination is advisable. If the employer objects to the bureau's waiver of the medical examination, the bureau shall schedule the medical examination. If the employer does not object to the bureau's waiver of the examination, the bureau will notify the employee, employer, and their authorized representatives of the waiver of the examination, except where the bureau has determined the employer is out of business. If the bureau has waived an examination, the bureau shall determine a date for the employee to be scheduled to be reexamined pursuant to paragraph (B) of this rule.

(D) An employer of an employee scheduled for an examination by the bureau under section 4123.53 of the Revised Code may waive the bureau's scheduling of any such examination. The employer shall notify the bureau of its intent to waive the examination, and indicate whether the waiver is temporary or permanent, the reason for the waiver, and, if applicable, a recommended subsequent date upon which the employee should be reevaluated for scheduling the examination if the employee is receiving temporary total disability compensation. The waiver shall indicate the name and title of the person waiving the examination for the employer. The bureau may schedule the examination even if the employer waives the examination where the bureau determines that an examination is necessary. The bureau shall cancel the examination if the bureau had scheduled the examination and agrees with the employer's waiver of the examination.

(E) The bureau shall conduct ninety day examinations for employees of self-insuring employers upon the request of the self-insuring employer. A self-insuring employer may determine that a ninety day examination is not necessary, and in that instance may decide not to request such examination be conducted by the bureau. At the appropriate time thereafter, the self-insuring employer may request that the ninety day examination be conducted. The self-insuring employer shall pay for the ninety day examination, as well as all reasonable expenses associated with the ninety day examination.

(F) Medical examinations scheduled under this rule shall not limit medical examinations provided for in other provisions of Chapter 4121. or Chapter 4123. of the Revised Code.

Last updated December 2, 2024 at 8:59 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-34 Settlement of state fund claims.

(A) The procedures of this rule shall apply to the settlement of state fund injury and occupational disease claims.

(B) The employer or the claimant shall file an application for approval of settlement agreement on the appropriate form with the administrator of workers' compensation. Each application shall include the signature of the claimant and the employer, or their authorized legal representative, except as follows:

(1) A claimant may file an application without an employer's signature in the following situations:

(a) The employer is no longer doing business in Ohio;

(b) The claim no longer is in the employer's industrial accident or occupational disease experience as provided in division (B) of section 4123.34 of the Revised Code and the claimant no longer is employed with that employer; or,

(2) If a claimant files an application without an employer's signature, and the employer still is doing business in this state, the bureau shall send written notice of the application to the employer immediately upon receipt of the application. If the employer fails to respond to the notice within thirty days after the notice is sent, the application need not contain the employer's signature.

(1) Include a list of the claim numbers and body parts affected in all claims filed by the claimant with the administrator of workers' compensation or the industrial commission.

(2) Set forth the reason the proposed full and final settlement is deemed desirable by the claimant and state the amount of the requested settlement.

(D) Settlement may be requested for a portion of a claim, one or more claims, or a combination of claims, provided that the claimant is not required to enter into a settlement agreement for every claim that has been filed with the bureau by the claimant.

(E) The administrator shall utilize whatever methods the administrator determines to be appropriate, consistent with general insurance principles, to evaluate a claim for settlement. When a settlement agreement has been approved by the administrator, a notice of approval shall be sent to the claimant, the employer, and their representatives, informing them of their rights to withdraw consent to the settlement agreement within thirty days. . An employer shall not deny or withdraw consent to a settlement application filed under this section if both of the following apply to the claim that is the subject of the application: the claim is no longer within the date of impact pursuant to the employer's industrial accident or occupational disease experience as provided in division (B) of section 4123.34 of the Revised Code; and, the employee named in the application is no longer employed by the employer. Supporting evidence indicating that the claim remains within in the date of impact or that the claimant continues to be employed with the employer may be filed with the employer's withdrawal of consent. If written notice of the withdrawal of consent is not filed within the thirty day period, the settlement agreement is final. A claimant's refusal to endorse a settlement check issued as a result of an agreement reached pursuant to these procedures does not alter the finality of the settlement. The administrator may reopen a settled claim for purposes of conducting a fraud investigation.

(F) The administrator shall also send the notice of approval to the industrial commission within five days from the date of the bureau order of approval. The staff hearing officer shall determine, within the time set forth in paragraph (E) of this rule, whether the settlement agreement is or is not a gross miscarriage of justice. If the staff hearing officer determines within that time period that the settlement agreement is clearly unfair, the staff hearing officer shall issue an order disapproving the settlement agreement. If the staff hearing officer determines that the settlement agreement is not clearly unfair, or fails to act within the time limits, the settlement agreement is approved.

(G) The effective date of the settlement is the date the notice of approval of settlement agreement is mailed. Once the thirty day waiting period has passed as set forth in paragraphs (E) and (F) of this rule, the agreed settlement shall be final and cannot be appealed to the industrial commission or to court.

(H) When a settlement application is filed in a claim in which an application for violation of specific safety requirement has been granted or is pending, the administrator shall refer the claim to the industrial commission for disposition of the application for violation of the specific safety requirement. If the application for the specific safety requirement has been granted and the employer is no longer doing business, or is otherwise not making the payments required by any award for violation of any specific safety requirement, the administrator may approve a final settlement without referring the claim to the industrial commission, provided the administrator identifies any settlement amounts that may be attributed to the award for violation of specific safety requirement. The administrator need not refer to the industrial commission any claim in which the claimant has voluntarily withdrawn an application for violation of a specific safety requirement, provided no portion of the settlement amount is attributed to any violation of a specific safety requirement.

(I) The administrator may offset settlement amounts due the claimant by overpayments owed by the claimant or, where the claimant is also an employer, unpaid premiums owed by a claimant, as the administrator determines appropriate.

(J) The representative's signature for either the claimant or the employer satisfies the requirements for paragraphs (B) and (C) of this rule.

(K) A settled claim may be used as a defense to a claim for the same or similar conditions. A self-insuring employer shall not settle disabled workers' relief fund liability in state fund claims without the administrator's approval.

(L) An employer or claimant who files a notice of intent to settle authorized under section 4123.512 of the Revised Code shall file on the appropriate form with the administrator of workers' compensation prior to filing an application for approval of settlement agreement. If the opposing party does not object within fourteen days of receipt of the notice, the administrator will proceed with the settlement process under this rule.

Last updated October 7, 2024 at 12:03 PM

History

Effective: October 8, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-35 Employer disability relief.

(A) For the purposes of disability relief under section 4123.343 of the Revised Code, an "employee with a disability" means an employee who is defined as having one or more of the conditions listed in division (A) of section 4123.343 of the Revised Code.

(1) With respect to the condition defined in division (A)(4) of section 4123.343 of the Revised Code, degenerative disc disease, spondylosis, spondylolysis, and spondylolistheses do not constitute evidence of arthritis for purposes of satisfying the statute.

(2) With respect to the condition defined in division (A)(14) of section 4123.343 of the Revised Code, the employee must have inpatient treatment and admission for the psycho-neurotic disability in a recognized medical or mental institution. Outpatient treatment does not satisfy the statutory definition.

(3) With respect to the condition defined in division (A)(25) of section 4123.343 of the Revised Code, an employer is not eligible for disability relief in the same claim in which the employee participated in a rehabilitation program. The employee must suffer a subsequent compensable injury or occupational disease claim, and any rights to disability relief would be in the subsequent claim.

(B) Under division (B) of section 4123.343 of the Revised Code, the administrator specifies the following grounds upon which the administrator may charge claims costs to the statutory surplus fund.

(1) The administrator will consider disability relief under section 4123.343 of the Revised Code only in claims satisfying all of the following prerequisites:

(a) The claimant is an employee with a disability as defined in division (A) of section 4123.343 of the Revised Code and paragraph (A) of this rule.

(b) The employer has filed an application for disability relief while the claim is within the employer's claim experience period, as referred to in division (B) of section 4123.34 of the Revised Code.

(i) For a claim involving a private state fund employer:

(a) If the date of injury is between January first and June thirtieth, the application shall be filed by June thirtieth of the year no more than six years from the year of the date of the injury or occupational disease.

(b) If the date of injury is between July first and December thirty-first, the application shall be filed by June thirtieth of the year no more than seven years from the year of the date of the injury or occupational disease.

(ii) For a claim involving a public employer taxing district employer, the application shall be filed by December thirty-first of the year no more than six years from the year of the date of the injury or occupational disease.

(iii) For a claim involving a private state fund employer or a public employer taxing district employer participating in a retrospective rating plan, the application shall be filed within the time provided in paragraph (B)(1)(b)(i) or (B)(1)(b)(ii) of this rule, as applicable.

(c) The bureau has awarded compensation to the claimant for temporary total disability, disabilities described under division (B) of section 4123.57 of the Revised Code, permanent total disability, or death benefits, or the claimant has received wages from the employer in lieu of compensation.

(2) For an employer granted relief, all or such portion as the administrator determines of the amount that otherwise would be charged to the employer's experience will be deducted from each claim arising from injury or occupational disease to an employee with a disability for the purpose of premium or assessment adjustment, in accordance with the following principles and paragraphs (E), (F), and (G) of this rule:

(a) All amounts deducted from the experience of the employer will be charged to the statutory surplus fund.

(b) The bureau will calculate the amount of the cost of the claim to remain in the employer's experience by applying the complement of the disability relief percentage to the reducible costs contained within the claim cost as limited by the maximum value of a claim chargeable to the employer's experience, as determined by the employer's credibility group under rule 4123-17-05.1 of the Administrative Code.

(i) Temporary total disability;

(ii) Disabilities described under division (B) of section 4123.57 of the Revised Code;

(iii) Permanent total disability;

(iv) Death benefits;

(v) Lump sum settlements under section 4123.65 of the Revised Code or a settlement agreement approved by a court of competent jurisdiction in this state;

(vi) Medical payments; and

(vii) Claims reserves.

(d) If the actual cost of a claim exceeds the maximum value of the claim chargeable to a particular employer's experience, the ratio of the nonreducible costs of the claim to the total cost of the claim will be maintained in the maximum value chargeable to the particular employer's experience, so that when the disability relief percentage is applied, it will be applied only to that portion of the maximum value that is reducible in accordance with division (B) of section 4123.343 of the Revised Code.

(e) The bureau will apply the disability relief in a claim for lump sum settlements as provided in paragraph (B)(2)(c)(v) of this rule as follows:

(i) Where the disability relief determination is made on or after September 29, 2017, the bureau will apply disability relief to a lump sum settlement effective before, on or after September 29, 2017;

(ii) Where the lump sum settlement is effective on or after September 29, 2017, the bureau will apply the disability relief to a disability relief determination made before, on or after September 29, 2017;

(iii) Where both the disability relief determination was made and the lump sum settlement was effective prior to September 29, 2017, the provisions in paragraph (B)(2)(c)(v) of this rule do not apply and the bureau will not apply the disability relief to the lump sum settlement.

(C) The administrator of workers' compensation may delegate the authority granted to the administrator under Chapters 4121. and 4123. of the Revised Code for determining the amount to be charged to the statutory surplus fund in connection with an employer's employees with disabilities. The decision of the administrator's designee is the decision of the administrator.

(1) An employer which seeks a disability relief award must file a complete and timely application and attach copies of all relevant medical evidence which the employer believes the administrator should consider when determining the appropriate award.

(a) The administrator may dismiss without prejudice an incomplete application. The administrator may dismiss without prejudice an application at the employer's request. Within the time limits and provisions of this rule the employer may refile an application that was dismissed without prejudice.

(b) The administrator may deny an application not filed within the employer's experience as provided in division (B) of section 4123.34 of the Revised Code and paragraph (B)(1)(b) of this rule.

(c) The administrator may dismiss an application which fails to meet the provisions of paragraphs (A) and (B) of this rule.

(d) The administrator may dismiss an application if the initial allowance of the claim is being contested before the bureau, industrial commission, or a court of competent jurisdiction at the time the application is filed. Upon a final administrative or judicial determination allowing the claim, the employer may refile an application dismissed under this provision.

(2) The administrator may issue a disability relief order based on a review of the application and any information contained in any relevant claim file or any other relevant bureau or industrial commission records.

(3) The administrator will afford an employer the opportunity for an informal conference if the application meets the provisions of this rule.

(a) If the administrator conducts an informal conference, the administrator will send a notice of conference to the employer and its representative by regular mail or email, setting forth the date, time, and place of the conference.

(b) The administrator will notify the employer by mail or email not less than fourteen days before the date of such conference, unless the employer waives this notice.

(c) At the request of the employer or another party, the administrator may conduct an expedited or an informal telephone conference.

(4) The administrator's decision will be reduced to writing and mailed to all interested parties. The order will state the evidence upon which the administrator based the decision.

(5) The administrator will keep a record of disability relief applications received, conferences scheduled, orders issued with publication dates and any waiver of appeals, and appeals to the industrial commission.

(D) The burden of proof is upon the employer to establish entitlement to the relief under section 4123.343 of the Revised Code by appropriate medical evidence or other evidence as may be indicated

(1) With respect to any credit under division (D)(1) of section 4123.343 of the Revised Code, the administrator will grant full disability relief credit if the employer establishes that the injury or occupational disease would not have occurred but for the employee's pre-existing qualifying condition.

(2) With respect to any credit under division (D)(2) of section 4123.343 of the Revised Code, the administrator will determine the degree of relief to be granted based upon the following:

(a) The degree to which medical evidence or other evidence indicates the pre-existing condition has affected the cost of the claim.

(b) The employer shall establish the relationship between the pre-existing condition and subsequent injury by way of aggravation or delayed recovery by proof on file but the condition need not be recognized by an order of allowance for such condition or aggravation of the condition.

(c) In determining the appropriate per cent of relief in the claim, the administrator will consider the effect of the pre-existing condition on the past claims costs, and also account for the effect of the condition on the anticipated future costs of the claim.

(E) A non-complying employer is not entitled to relief under section 4123.343 of the Revised Code. If the employer had active coverage on the date of the injury but was a non-complying employer on the date of the application for disability relief, the administrator may dismiss the application.

(F) No employer in any rating year may receive credit under section 4123.343 of the Revised Code in an amount greater than the premium it paid.

(G) An order issued by the administrator is appealable under section 4123.511 of the Revised Code.

(1) If the administrator holds an informal conference, the employer and the administrator may agree upon the amount of disability relief in a claim, and the employer may waive its right to appeal.

(2) Upon waiver of the employer's right to an appeal or the expiration of the appeal period, the administrator's order is final, and the bureau will immediately process the award.

(3) If no agreement is reached at the informal conference and the employer files a written appeal within fourteen days of the employer's receipt of the administrator's decision, the administrator will forward the claim file to the industrial commission within seven days of the administrator's receipt of the notice of appeal for a hearing before a district hearing officer.

(4) The employer and the administrator are parties at any hearing conducted by the industrial commission or its hearing officers.

(5) Upon a final industrial commission order which grants disability relief, the bureau will immediately process the award.

(H) Since pursuant to paragraph (D)(2)(c) of this rule the administrator is to consider the effect of the qualifying condition on the past and future costs of the claim in determining disability relief, the employer is not entitled to consideration of a subsequent application for disability relief for a condition in a claim in which the administrator has made a previous determination on the condition, regardless of whether there has been a change in circumstances such as allowance of the condition or payment of compensation. A subsequent application cannot substitute for an appeal of the administrator's order. The administrator will dismiss or deny any subsequent application for an increase in disability relief in a previously determined claim.

Last updated October 7, 2024 at 12:04 PM

History

Effective: April 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-36 Immediate allowance and payment of medical bills in claims.

(A) In accordance with division (A) of section 4123.511 of the Revised Code the administrator has established a program to immediately allow specific medical conditions which have a historical record of being allowed whenever included in a claim and having low medical costs.

The medical conditions the administrator has determined to be included in the program are indicated in the appendix to this rule.

(B) Upon the initial filing of a claim, the administrator will investigate the claim and issue an order on the claim pursuant to section 4123.511 of the Revised Code. For any medical condition identified in the appendix to this rule, however, the administrator may grant immediate allowance of the medical condition and may make immediate payment of the medical bills relating to that condition, regardless of the receipt of the medical reports for that medical condition or the employer's certification of the claim.

(C) The employer retains the right to contest the immediate allowance of a medical condition in a claim under this rule. If the employer appeals the allowance and the claim is disallowed, the payment for the medical treatment provided prior to the date of the disallowance of that claim shall be charged to and paid from the surplus fund created under section 4123.34 of the Revised Code. The administrator will not seek reimbursement of the payment from the claimant or the provider.

View Appendix

Last updated December 2, 2024 at 8:59 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-37 Lump sum advancements.

(A) The administrator of the bureau of workers' compensation, under special circumstances, may commute an award of compensation to a lump sum payment when the administrator determines the advancement is advisable for the purpose of providing the claimant or the surviving spouse financial relief or for furthering the claimant's rehabilitation.

(1) The bureau may grant a lump sum advancement to a claimant only from an award of compensation made pursuant to section 4123.58 of the Revised Code or from division (A) or (B) of section 4123.57 of the Revised Code.

(2) The bureau may grant a lump sum advancement to a surviving spouse only from an award of death benefits made pursuant to section 4123.59 of the Revised Code. However, the advancement cannot exceed the amount of death benefits payable to the surviving spouse over a two-year period.

(3) The bureau will not grant a lump sum advancement to a surviving dependent from an award of compensation made pursuant to division (B) of section 4123.57 of the Revised Code.

(4) The bureau will not grant a lump sum advancement in a claim where the allowance of the award of compensation made pursuant to section 4123.58 of the Revised Code or from division (A) or (B) of section 4123.57 of the Revised Code is on appeal under section 4123.511 of the Revised Code or an appeal to court.

(5) The industrial commission has exclusive jurisdiction over an application for a lump sum advancement for the payment of attorney fees incurred in securing an award. The bureau will refer such applications to the industrial commission to adjudicate.

(B) A claimant or the surviving spouse requests a lump sum advancement by filing a fully completed application with the bureau.

(1)

(a) The claimant or surviving spouse is to provide proof that there are special circumstances for the lump sum advancement and that the lump sum advancement is advisable for the purpose of providing financial relief or for furthering the claimant's rehabilitation.

(b) The bureau may dismiss an application for a lump sum advancement where the claimant or surviving spouse has not provided proof of special circumstances and proof of financial relief or for furthering the claimant's rehabilitation.

(2) The bureau will review the application and utilize whatever methods the bureau determines to be appropriate, consistent with general insurance principles, to evaluate the claim for a lump sum advancement.

(3) For a lump sum advancement from an award of compensation made pursuant to section 4123.58 of the Revised Code or from an award of death benefits pursuant to section 4123.59 of the Revised Code, if the bureau determines the lump sum advancement is advisable, the bureau will calculate the net present value of the lump sum advancement on the remaining compensation payable to the claimant or benefits payable to the spouse. The bureau will determine the amount of the biweekly rate reduction and the terms of such reduction. The administrator will fix a specific time for the reduction of the biweekly rate of compensation to offset the lump sum advancement depending upon the time period the claimant or surviving spouse has selected for the offset of the lump sum advancement, when applicable. Once a claimant or surviving spouse has selected a time period for the offset of the lump sum advancement, the claimant or surviving spouse cannot change the time period. The bureau will include the net present value of the lump sum advancement in determining the reduction of the biweekly rate of compensation.

(4) For a lump sum advancement of an award made pursuant to division (A) or (B) of section 4123.57 of the Revised Code, if the bureau determines the lump sum advancement is advisable, the bureau will calculate the net present value of the lump sum advancement on the remaining weeks of compensation payable to the claimant and in determining the amount to be paid to the claimant for the lump sum advancement.

(5) In determining the net present value of a lump sum advancement, the bureau will use the discount factor as periodically established by the bureau.

(6) The bureau will issue an order approving or disapproving the application. If the bureau approves the application, the order will advise the claimant or surviving spouse of the amount of reduction of compensation and the terms of the lump sum advancement.

(1) No lump sum advancement will be approved that will result in a rate reduction of more than one-third of the biweekly rate of compensation, except where the advancement is for compensation under division (A) or (B) of section 4123.57 of the Revised Code. The bureau will not include an advancement for attorney's fees in accordance with section 4123.06 of the Revised Code in the calculation of the maximum rate reduction limitation.

(2) The bureau may approve no more than two concurrent lump sum advancements in a claim in addition to an advancement for attorney fees that the industrial commission has granted in accordance with section 4123.06 of the Revised Code.

(3) Upon the recoupment of the lump sum advancement in accordance with the terms of the order and agreement, the bureau will remove the rate reduction due to the lump sum advancement and reinstate the claimant's rate of compensation or the surviving spouse's benefits.

(D) The lump sum advancement warrant will include the claimant or the surviving spouse as a payee, except where the warrant is for the payment of attorney's fees in accordance with section 4123.06 of the Revised Code, in which case the attorney will be named as the only payee on the warrant.

Last updated October 7, 2024 at 12:04 PM

History

Effective: September 15, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-3-38 Surplus fund charge of qualified motor vehicle accident claims.

(A) Pursuant to section 4123.932 of the Revised Code and when an employer satisfies all of the requirements of this rule, the bureau shall charge to the surplus fund created under division (B) of section 4123.34 of the Revised Code any compensation and benefits related to a compensable workers' compensation claim based on a motor vehicle accident involving a third party. This rule applies only to claims arising on or after July 1, 2017.

(B) Eligibility requirements.

(1) This rule does not apply to self-insuring employers, state agencies, or a state institution of higher education, including its hospitals.

(2) This rule applies to private state fund employers and public employer taxing district employers that pay premiums into the state insurance fund.

(a) The employer must have had active workers' compensation coverage on the date of injury of the claim.

(b) The employer must be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code.

(c) The employer must be current on the payment schedule of any part-pay agreement into which it has entered for payment of premiums or assessment obligations.

(C) If an employer believes the bureau should charge a claim to the surplus fund under this rule, the employer may file an application with the bureau requesting the bureau determine whether the claim is to be charged to the surplus fund. The bureau will not review or consider charging a claim to the surplus fund under this rule unless the employer files an application in accordance with this rule.

(D) The employer's application to charge a claim to the surplus fund will include all of the following:

(1) Evidence that the claim is based on a motor vehicle accident involving a third party. "Motor vehicle" has the same meaning as in section 4501.01 of the Revised Code.

(2) Evidence that either of the following circumstances apply to the claim:

(a) The third party involved in the motor vehicle accident was issued a citation for violation of any law or ordinance regulating the operation of a motor vehicle arising from the accident on which the claim is based and that any form of insurance maintained by the third party or uninsured or underinsured motorist coverage as described in section 3937.18 of the Revised Code covers damages caused by the motor vehicle accident which gave rise to the claim.

(i) The employer does not need to prove that the third party was convicted of the citation.

(ii) The employer does not need to prove that the insurance accepts complete liability for the motor vehicle accident, but only that the insurance accepts liability for some portion of the accident and pays costs associated therewith.

(b) If there is evidence that the third party was not issued a citation arising from the accident, the employer is to provide evidence that the third party involved in the motor vehicle accident was primarily liable for the accident on which the claim was based and that any form of insurance maintained by the third party or uninsured or underinsured motorist coverage as described in section 3937.18 of the Revised Code covers damages caused by the motor vehicle accident which gave rise to the claim.

(i) "Primarily liable" means that the third party involved in the motor vehicle accident is more than fifty per cent liable for purposes of section 2315.33 of the Revised Code.

(ii) The employer does not need to prove that the insurance accepts complete liability for the motor vehicle accident, but only that the insurance accepts primary liability for the accident and pays costs associated therewith.

(E) Within one hundred eighty days after the bureau receives the employer's application, the bureau shall determine whether the claim shall be charged to the surplus fund under this rule.

(1) If the bureau believes the employer has not provided all of the information necessary for the bureau to make the determination, the bureau will contact the employer for the employer to provide the additional evidence required prior to denying an application.

(2) If the bureau determines that the employer failed to establish that the bureau should charge the claim to the surplus fund under this rule, the bureau will deny the application with an explanation of the reasons for the denial.

(3) If the bureau fails to make a determination within the time required, the application will be deemed approved and the bureau shall charge the claim to the surplus fund.

(F) If the bureau determines that the employer's claim meets the criteria of this rule, or if the application is deemed approved because the bureau failed to make a determination within the time provided for in paragraph (E) of this rule, the bureau shall charge all of the costs of the claim to the surplus fund created under division (B) of section 4123.34 of the Revised Code.

If the bureau previously included the costs of the claim in the calculation of the employer's experience in any prior policy year, the bureau will adjust the employer's experience in the prior policy years the costs of the claim were included.

(G) The bureau's denial of an employer's application to charge a claim to the surplus fund under this rule is appealable to the adjudicating committee under section 4123.291 of the Revised Code.

Last updated December 2, 2024 at 9:00 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Chapter 4123-5 Miscellaneous Provisions

Ohio Adm.Code 4123-5-01 Assignment of duties to the bureau's operational units.

The administrator of workers' compensation may reorganize the work of the bureau of workers' compensation to the extent necessary to achieve the most efficient performance of its functions. The duties of the operational units of the bureau include, but are not limited to the following:

(A) A division responsible for the fiscal and planning function to assist the administrator in maintaining the solvency of the insurance fund, establishing policies and procedures for fiscal management, receiving and disbursing funds from the state insurance fund, and preparing the bureau's budget.

(B) A division responsible for the medical services function to assist the administrator in establishing and maintaining a quality pool of medical and vocational service providers, developing and maintaining quality medical, vocational rehabilitation, and pharmaceutical benefits plans, overseeing managed care services, and ensuring the proper and timely payment of medical bills.

(C) A department responsible for the special investigations function to conduct investigations of alleged workers' compensation fraud and alleged violations of specific safety requirements pursuant to workers' compensation claims.

(D) A division or divisions responsible for the customer service function to assist the administrator in:

(1) Identifying employers subject to the Ohio Workers' Compensation Act;

(2) Conducting periodic reviews of the manual classifications and payroll reports of state fund employers to ensure that employer premium payments have been properly computed and paid;

(3) Developing and making available alternative premium plans to state fund employers;

(4) Managing the claims of claimants in accordance with applicable statutes, rules and policies;

(E) A division responsible for the actuarial function to assist the administrator in ensuring that rates for all employers are calculated based on actuarial principles and standards of practice, ensuring that financial liabilities for compensation and compensation adjustment are calculated based on actuarial principles and standards of practice, and developing and supporting alternative rating options for employers.

(F) A division responsible for the investment function to assist the administrator in the investment and monitoring of assets of the state insurance fund and other funds administrated by the bureau, and in the implementation and monitoring of the bureau investment policy approved by the board of directors.

(G) A division responsible for the internal audit function to conduct reviews of divisions and control systems within the bureau, at appropriate intervals, to determine whether they are effectively carrying out their functions of administration, accounting, safeguarding of bureau assets, and control in accordance with management's instructions, policies, and procedures, and in a manner that is in agreement with both agency objectives and high standards of administrative practice; conduct special examinations at the request of management or the bureau of workers' compensation board of directors audit committee; submit an annual audit plan to the administrator and the audit committee for their review and approval.

Last updated October 7, 2024 at 12:04 PM

History

Effective: December 12, 2019
Promulgated Under: 119.03

Ohio Adm.Code 4123-5-11 Employer's reports must be signed by officer or person in employ of employer.

The bureau of workers' compensation will not accept an employer's report on application for payment of compensation and/or benefits, payroll reports, settlement sheets, and other instruments which employers are required to submit to the bureau unless the document is signed by an officer in the organization of the employer, or a person in the employ of the employer, who is duly authorized to sign such instruments. The person signing such instruments for the employer shall indicate in what capacity the person is employed (title). No instruments purporting to authorize any service organization or any other person to sign such instruments for an employer shall be recognized as granting such authority.

Last updated December 2, 2024 at 9:00 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-5-13 Expenses related to the work-related death of an employee.

(A) The date of death governs the amount of funeral benefits to be paid in a death claim for the funeral expenses of an employee who has died as a result of an allowed work-related industrial injury or occupational disease. In such cases no disbursements shall be made in excess of the amount allowed by law for funeral expenses.

(B) In cases where an attempt was made by the ambulance service, by a physician or at a hospital emergency room to revive the employee and such attempt was in the nature of treatment (e.g. use of oxygen, artificial respiration, injection, medication, electro-shock, etc.), payment for such services and for the use of equipment shall be made in addition to the payment for funeral expenses. The bureau may make payment for exceptional transportation costs in addition to the payment of funeral expenses. (e.g. returning the body of the deceased employee when the death occurred outside the area where the deceased lived.)

Last updated December 2, 2024 at 9:00 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-5-18 Medical proof required for payment of compensation.

(A) Except as provided in paragraph (E) of this rule and paragraph (B)(1)(b) of rule 4123-3-09 of the Administrative Code, no payment of compensation shall be approved by the bureau of workers' compensation in a claim unless supported by a report of a physician duly licensed to render the treatment.

(B) When evaluating the sufficiency of medical proof, the following criteria shall be considered:

(1) The nature and type of injury or occupational disease;

(2) The consistency of the diagnosis with the description of events resulting in the injury or occupational disease, as shown by proof of record;

(3) Whether the disability is based solely on the condition or conditions for which the claim is recognized;

(4) Whether the disability is based on objective symptoms of disability as a direct result of the injury or occupational disease in the respective claim; "objective symptoms" means those signs and indications which are discovered from an examination of the claimant, as distinguished from subjective symptoms which are reported by the claimant;

(5) Whether a reason or reasons for the medical opinion are stated.

(C) Whenever payment of compensation cannot be made due to lack of medical proof, the claimant shall be immediately advised of the necessity to submit appropriate medical proof.

(D) In cases of continued temporary disability as a result of the allowed injury or occupational disease it is the duty of the claimant to submit signed requests for temporary total disability compensation on form C-84 or equivalent and to ensure periodic medical reports on form MEDCO-14 or equivalent, completed in accordance with this rule and rule 4123-6-20 of the Administrative Code, are submitted to support disability and assure regular payment of compensation. Except to correct clerical errors, a previously submitted MEDCO-14 or equivalent cannot be altered, in any manner, and resubmitted to satisfy this rule. The frequency of filing such reports depends on the type and nature of the injury or occupational disease and the degree of disability.

(E) Notwithstanding paragraph (A) of this rule:

(1) During the first six weeks after the date of injury, medical reports on form MEDCO-14 or equivalent completed and signed by a physician, certified nurse practitioner, clinical nurse specialist, or physician assistant who has examined the claimant may be considered sufficient medical proof to support payment or non-payment of disability for no more than six weeks of disability.

(2) For subsequent periods of temporary disability, to be considered sufficient medical proof to support payment or non-payment of disability, medical reports on form MEDCO- 14 or equivalent must be:

(a) Completed and signed by a physician who has examined the claimant, or

(b) Completed by a certified nurse practitioner, clinical nurse specialist, or physician assistant who has examined the claimant and co-signed by a physician who has reviewed medical documentation of the examination of the claimant by the certified nurse practitioner, clinical nurse specialist, or physician assistant.

Last updated December 2, 2024 at 9:00 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-5-20 Payment of compensation when advancements are made during period of disability.

(A) Except for payments made to claimants under a contract of hire or under a collective bargaining agreement by an employer that is a professional sports franchise domiciled in Ohio, whenever a claimant and the employer advise the bureau of workers' compensation in writing that wages or sick leave were paid or advancements were made solely for the purpose of assisting the claimant in obtaining necessary maintenance and care during a period not to exceed twelve weeks following an injury sustained or occupational disease contracted by the claimant in the course of and arising out of employment, particularly while a claim for compensation is being acted upon by the bureau, and the claimant and employer had mutually agreed that the employer is to be reimbursed, at least to the extent of any compensation paid to the claimant over the same period in which the wages were paid or the advancements made, the bureau shall issue warrants in payment of compensation awarded for a period not to exceed twelve weeks commencing from the date of such an injury or beginning of disability, which warrants are to be mailed to the claimant in care of the employer with instructions that the warrants are to be endorsed personally by the claimant. The bureau will not honor the agreement unless the written notice of the agreement is signed by the employer and claimant and filed with the bureau within thirty days of the beginning date of payment of wages, sick leave, or advancement. Failure to comply otherwise with the terms of this rule may result in the bureau's refusal to honor the terms of the agreement between the employer and the claimant. Within thirty days of the end date of payment of wages, sick leave, or advancement, the employer or claimant shall provide written notice to the bureau. The warrants to be sent in care of the employer are not to be in payment of compensation for disability in excess of a period of twelve weeks closely following the date of injury or beginning of disability, unless under special circumstances the bureau authorizes the sending of warrants in payment of compensation for disability beyond the twelve weeks in care of the employer.

(B) Whenever an employer that is a professional sports franchise domiciled in Ohio makes payment pursuant to the terms of a contract of hire or a collective bargaining agreement during a period of disability resulting from the injury or occupational disease, the aggregate amount of such payments are deemed an advanced payment. Upon the filing of proof of such payments, compensation payments under sections 4123.56 to 4123.58 of the Revised Code shall be reimbursed by the bureau directly to the employer if it is a state fund employer unless payment has been made to the claimant prior to the bureau's receipt of the employer's proof of an advanced payment. Self-insured employers shall apply the aggregate amount of advanced payments to a claimant to offset that claimant's future payments of compensation under section 4123.56 to 4123.58 of the Revised Code. Employer reimbursements and offsets apply only where the employee's application for compensation is pending on or after August 22, 1986.

(C) Where a claimant is entitled to vacation with pay, payment of wages for a vacation period during the period of temporary disability resulting from injury or occupational disease shall not be deemed an advancement nor shall such payment be applied to offset any temporary total compensation payable for that period of time.

If the employer and claimant agree in writing, supplemental sick leave benefits may be paid in addition to temporary total compensation, and payment of the supplemental sick leave benefits shall not be deemed an advancement nor shall such payment be applied to offset any temporary total compensation payable for that period of time.

Where claimants are paid a regular salary during the period of disability on any other basis, sick leave, payment of compensation for temporary disability cannot be paid so long as such regular salary or wages are paid, unless the claimant and the employer notify the bureau in writing pursuant to paragraph (A) of this rule.

Last updated December 2, 2024 at 9:01 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-5-21 Abatement of claims.

(A) When a claimant dies, action on any application filed by the claimant, and pending before the bureau of workers' compensation or the industrial commission at the time of their death, is abated by claimant's death.

(B) Abatement of action, as described in paragraph (A) of this rule, does not apply to payment for medical and hospital treatment, for medicine, nursing, and other health care services rendered as a result of the injury or occupational disease for which the claim was allowed during the deceased claimant's lifetime, provided that the respective bills were timely filed with the industrial commission and the bureau.

Last updated December 2, 2024 at 9:01 AM

History

Effective: December 1, 2024
Promulgated Under: 119.03

Chapter 4123-6 Health Partnership Program

Ohio Adm.Code 4123-6-01 Definitions.

As used in this chapter:

(A) "Authorization" or "prior authorization" means:

Notification that a specific treatment, service, or equipment is medically necessary for the diagnosis or treatment of an allowed condition.

(B) "Bureau certified provider" means:

A provider who is approved by the bureau for participation in the health partnership program (HPP) pursuant to this chapter of Administrative Code.

A process by which the bureau approves a provider or managed care organization (MCO) for participation in the HPP.

(D) "Credentialing" or "recredentialing" means:

A process by which the bureau validates or reviews the completed and signed application of a provider for certification or recertification.

(E) "Dispute resolution" means:

Procedures for the resolution of medical disputes prior to filing an appeal under section 4123.511 of the Revised Code.

(F) "Emergency" means:

Medical services that are required for the immediate diagnosis and treatment of a condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or that are immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency, but is necessary to determine whether an emergency exists.

(G) "Employee" means:

As used in the rules of this chapter, the term "employee" includes the terms "injured worker" and "claimant" and all employees of employers covered under HPP.

(H) "Health care provider" or "provider" means:

A physician or practitioner, or any person, firm, corporation, limited liability corporation, partnership, association, agency, institution, or other legal entity licensed, certified, or approved by a professional standard-setting body or by medicare or medicaid to provide medical services or supplies to an injured worker, including a qualified vocational rehabilitation provider.

(I) "Health partnership program" or "HPP" means:

The bureau of workers' compensation's comprehensive managed care program under the direction of the chief of medical services as provided in sections 4121.44 and 4121.441 of the Revised Code.

(J) "Hospital" means:

An institution that provides facilities for surgical and medical diagnosis and treatment of bed patients under the supervision of staff physicians and furnishes twenty-four hour-a-day care by registered nurses.

(1) For the purposes of this chapter relating to hospitals, "inpatient" means:

An injured worker is considered to be an inpatient when he or she has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. An injured worker is considered an inpatient if there is a formal order for admission from the physician. The determination of an inpatient stay is not based upon the number of hours involved. If it later develops during the uninterrupted stay that the injured worker is discharged, transferred to another inpatient unit within the hospital, transferred to another hospital, transferred to another state psychiatric facility or expires and does not actually use a bed overnight, the order from the attending physician addressing the type of encounter will define the status of the stay.

(2) For the purposes of this chapter relating to hospitals, "outpatient" means:

The injured worker is not receiving inpatient care, as "inpatient" is defined in paragraph (J)(1) of this rule, but receives outpatient services at a hospital. An outpatient encounter cannot exceed seventy-two hours of uninterrupted duration.

(K) "Injury" means:

For the purposes of the rules of this chapter of the Administrative Code only, an injury as defined in division (C) of section 4123.01 of the Revised Code or an occupational disease as defined in division (F) of section 4123.01 of the Revised Code.

(L) "Managed care organization" or "MCO" means:

A vendor as defined under section 4121.44 of the Revised Code who has contracted with the bureau to provide medical management and cost containment services as provided in sections 4121.44 and 4121.441 of the Revised Code. As used in these rules, a managed care organization is not a health care provider.

(M) "Medically necessary" means:

Services which are reasonably necessary for the diagnosis or treatment of disease, illness, and injury, and meet accepted guidelines of medical practice. A medically necessary service must be reasonably related to the illness or injury for which it is performed regarding type, intensity, and duration of service and setting of treatment.

(N) "Medication" means:

The same as drug as defined by division (E) of section 4729.01 of the Revised Code.

(O) "Non-bureau certified provider" means:

A provider who is not approved by the bureau for participation in the HPP, or whose certification has lapsed and has not been reinstated pursuant to rule 4123-6-02.4 of the Administrative Code.

(P) "Physician" means:

(1)

(a) A doctor of medicine, doctor of osteopathic medicine or surgery, or doctor of podiatric medicine who holds a current, valid certificate of licensure to practice medicine or surgery, osteopathic medicine or surgery, or podiatry under Chapter 4731. of the Revised Code;

(b) A doctor of chiropractic who holds a current, valid certificate of licensure to practice chiropractic under Chapter 4734. of the Revised Code;

(c) A doctor of mechanotherapy who holds a current, valid certificate of licensure to practice mechanotherapy under Chapter 4731. of the Revised Code and who was licensed prior to November 3, 1985;

(d) A psychologist who holds a current, valid certificate of licensure to practice psychology under Chapter 4732. of the Revised Code; or

(e) A dentist who holds a current, valid certificate of licensure to practice dentistry under Chapter 4715. of the Revised Code.

(2) A physician licensed pursuant to the equivalent law of another state shall qualify as a physician under this rule.

(Q) "Physician of record" or "attending physician" means:

Pursuant to Chapters 4121. and 4123. of the Revised Code, the authorized physician chosen by the employee to direct treatment.

(R) "Practitioner" means:

A physician, or a physical therapist, occupational therapist, optometrist, or any other person currently licensed and duly authorized to practice within his or her respective health care field.

(S) "Provider certification application and agreement" means:

A bureau form providers complete that requests background information and documentation necessary for certification and which, if completed and signed by the provider and approved by the bureau, constitutes a written, contractual agreement between the bureau and the provider.

(T) "Provider outcome measurement" means:

A medical management analysis tool used by the bureau or MCO which at a minimum, utilizes line item detail from a medical bill and employee specific information including, but not limited to, demographics, diagnosis allowances, return to work and remain at work statistics, and other data regarding treatment, to evaluate a health care provider on the basis of cost, utilization and treatment outcomes efficiency and compliance with bureau requirements.

(U) "Qualified health plan" or "QHP" means:

A health care plan sponsored by an employer or a group of employers which meets the standards for qualification under section 4121.442 of the Revised Code and is certified as a qualified health care plan with the bureau.

(V) "Recertification application and agreement" means:

A bureau form certified providers complete as part of the provider recertification process that requests background information and documentation necessary for recertification and which, if completed and signed by the provider and approved by the bureau, constitutes a written, contractual agreement between the bureau and the provider.

(W) "Remain at work services" means:

Services to support an injured worker in continued employment where the injured worker is experiencing difficulties performing a job as a result of conditions related to an allowed medical only claim.

(X) "Return to work services" means:

Services to support an injured worker in returning to employment where the injured worker is experiencing difficulty as a result of conditions related to an allowed lost time claim.

(Y) "Transitional work" means:

A work-site program that provides an individualized interim step in the recovery of an injured worker with job restrictions resulting from the allowed conditions in the claim. Developed in conjunction with the employer and the injured worker, or with others as needed, including, but not limited to the collective bargaining agent (where applicable), the physician of record, rehabilitation professionals, and the MCO, a transitional work program assists the injured worker in progressively performing the duties of a targeted job..

(Z) "Treatment guidelines" means:

Guidelines of medical practice, developed through consensus of practitioner representatives, that assist a practitioner and a patient in making decisions about appropriate health care for specific medical conditions.

(AA) "Urgent care facility" means:

A facility where ambulatory care is provided outside a hospital emergency department and is available on a walk in, non-appointment basis.

(BB) "Utilization review" means:

The assessment of an employee's medical care by the MCO. This assessment typically considers medical necessity, the appropriateness of the place of care, level of care, and the duration, frequency or quality of services provided in relation to the allowed condition being treated.

Last updated June 30, 2026 at 1:16 PM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-01.1 Applicability of medical rules.

Unless specifically stated otherwise, the rules of this chapter governing payment of medical services and supplies shall apply to payments to health care providers in all claims for work related injuries or occupational diseases before the bureau, self-insuring employers, MCOs, QHPs, and the industrial commission.

However, nothing in these rules shall inhibit or diminish the commission's right to establish adjudicatory policy under Chapters 4121., 4123., 4127., and 4131. of the Revised Code, or otherwise prevent the full adjudication of claims properly before the commission or its hearing officers.

Last updated September 9, 2025 at 11:29 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-01.2 Provisional treatment reimbursement approval -- pilot program.

Notwithstanding any provision to the contrary in any other rule of the bureau, the administrator may, for purposes of a pilot program, allow one or more managed care organizations to authorize medical treatment reimbursement requests for the first sixty days from the initial allowance of an identified at-risk claim for any conditions within the same body part or parts as the conditions initially allowed in the claim, and presumed to be causally related to the same industrial injury or occupational disease, without disclaimer, during such time as the conditions for which treatment reimbursement is authorized but which are not yet allowed are being considered for allowance or being adjudicated.

The operation of the pilot program authorized under this rule does not impair in any manner the right of an employer to appeal a claim, additional allowance, or medical treatment reimbursement determination under section 4123.511 of the Revised Code or rule 4123-6-16 of the Administrative Code.

The pilot program authorized under this rule may be implemented for a period not to exceed three years; provided, however, that the administrator may terminate the pilot program early at the administrator's discretion.

Last updated November 4, 2025 at 2:09 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02 Provider access to the HPP - generally.

(A) The bureau is authorized to certify a provider who wishes to participate in the HPP. The bureau is authorized to recertify providers as determined by the bureau. The bureau may, but is not required to, recertify providers on a staggered basis, in order of the provider's initial certification date or such other criteria as the bureau determines appropriate.

(B) A provider shall be certified or recertified by the bureau to treat injured workers if the provider is a direct service provider; meets and maintains credentialing criteria under rule 4123-6-02.2 of the Administrative Code; meets and maintains all other applicable criteria under the workers' compensation statutes and rules; and completes and signs a provider application and agreement or recertification application and agreement with the bureau.

Last updated November 4, 2025 at 2:09 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.2 Provider access to the HPP - provider certification criteria.

(A) The bureau will establish minimum criteria for provider certification. Providers must meet all licensing, certification, or accreditation requirements necessary to provide services in Ohio. A provider licensed, certified, or accredited pursuant to the equivalent law of another state qualifies as a provider under this rule in that state. However, a provider is ineligible to participate in the health partnership program if:

(1) The state of Ohio has denied the provider's application for a professional license or the provider's professional license in Ohio is under revocation or suspension; or

(2) The provider's professional license is subject to disciplinary restrictions that affect the provider's ability to treat patients or that compromise patient care.

(B) The minimum criteria for a provider, where applicable based upon the type of provider, are as follows. The provider shall:

(1) Be currently licensed to practice, as applicable, without disciplinary restrictions that affect the provider's ability to treat patients or that compromise patient care.

(2) Meet other general certification criteria for the specific provider type, as provided in paragraph (C) of this rule.

(3) Not be currently excluded from participation in medicare or Ohio medicaid for cause.

(4) Not be currently ineligible to participate in the health partnership program due to the provider having been convicted of or pleaded guilty to a criminal offense as set forth in the appendix to this rule.

(5) Attest to and maintain professional malpractice and liability insurance, and provide proof of such coverage to BWC upon request.

(6) Provide documentation of the provider's malpractice history for the previous five years.

(7) Not have any outstanding provider overpayment or other indebtedness to the bureau which has been certified to the attorney general for collection.

(8) Maintain workers' compensation coverage to the extent required under Ohio law or the equivalent law of another state, as applicable, and provide proof of such coverage to BWC upon request.

(9) Not have been excluded or removed from participation in other health plans for cause.

(10) Not have lost hospital privileges for cause.

(1) Adult day care facility: Ohio department of aging PASSPORT adult day care provider agreement.

(2) Alcohol and drug counseling clinic: certified by Ohio department of mental health and addiction services.

(3) Ambulance, ambulette, or air ambulance service: license from Ohio state board of emergency medical, fire, and transportation services if private; approved for medicare if government/public.

(4) Ambulatory surgical center: license from Ohio department of health and approved for medicare.

(5) Anesthesiologist assistant: license from Ohio state medical board.

(6) Athletic trainer: license from Ohio occupational therapy, physical therapy, and athletic trainers board.

(7) Audiologist: license from Ohio state speech and hearing professionals board.

(8) Certified nurse practitioner: license from Ohio board of nursing and certified by American nurses credentialing center or other certifying agency approved by the Ohio board of nursing.

(9) Certified registered nurse anesthetist (CRNA): license from Ohio board of nursing and certified by national council on certification of nurse anesthetists or other certifying agency approved by the Ohio board of nursing.

(10) Certified shoe retailer: certified or accredited by American board for certification in orthotics, prosthetics and pedorthics or board of certification/accreditation.

(11) Chiropractic physician (D.C.): license from Ohio state chiropractic board.

(12) Clinical nurse specialist: license from Ohio board of nursing and certified by American nurses credentialing center or other certifying agency approved by the Ohio board of nursing.

(13) Comprehensive pain management services program: (free standing) commission on accreditation of rehabilitation facilities CARF accreditation; (hospital based) CARF or joint commission accreditation.

(14) Dentist: license from Ohio state dental board.

(15) Dialysis center: license from Ohio department of health and approved for medicare.

(16) Durable medical equipment supplier (excludes orthotics, prosthetics and pedorthics): approved for medicare and state of Ohio board of pharmacy home medical equipment certificate of registration.

(17) Employment specialist:

(a)

(i) Certification for American board of vocational experts (ABVE), certified rehabilitation counselor (CRC), certified case manager (CCM), certified employment support professional (CESP), certification for individual placement and support (CIPS), global career development facilitator (GCDF), associate certified coach (ACC), professional certified coach (PCC), master certified coach (MCC), certified disability management specialist (CDMS), or CARF accreditation for employment and community services in job development or employment supports; or

(ii) Evidence of completion of three or more courses, seminars or workshops prior to application for certification, totaling a minimum of eighty hours and approved by the bureau or by an entity offering a certification referenced in paragraph (C)(17)(a)(i) of this rule, in at least two of the following domain areas: job development, job placement, and career and lifestyle development; vocational consultation and services for employers; professional roles and practices, ethics, and utilization of community resources; or

(iii) Evidence of bureau reimbursement to the provider for job placement, job development, job seeking skills training, job club, and/or job coaching services to injured workers for dates of service beginning not less than eighteen months prior to April 1, 2014. However, if the provider has been certified pursuant to this provision and the provider's certification subsequently lapses, the provider must thereafter meet the criteria of paragraph (B)(17)(a)(i) or (B)(17)(a)(ii) of this rule for certification or recertification.

(b) Employment specialists certified pursuant to paragraph (C)(17)(a)(ii) or (C)(17)(a)(iii) of this rule must complete thirty hours of continuing education, including three hours of ethics, every three years to maintain certification under this rule.

(18) Ergonomist: certification for certified professional ergonomist (CPE), certified human factors professional (CHFP), associate ergonomics professional (AEP), associate human factors professional (AHFP), certified ergonomics associate (CEA), certified safety professional (CSP) with "ergonomics specialist" designation, certified industrial ergonomist (CIE), certified industrial hygienist (CIH), assistive technology practitioner (ATP), or rehabilitation engineering technologist (RET).

(19) Hearing aid dealer: license from Ohio state speech and hearing professionals board.

(20) Home health agency: license from Ohio department of health, and approved for medicare or accredited by a deeming organization approved by the centers for medicare and medicaid services.

(21) Hospice: license from Ohio department of health, and approved for medicare.

(22) Hospital: license from Ohio department of health, and approved for medicare or obtained CARF accreditation for rehabilitation hospitals. The following facility types are eligible to be credentialed and certified as hospitals: short-term general and specialty hospitals; long-term care hospitals; rehabilitation hospitals; and psychiatric hospitals.

(23) Independent diagnostic testing facility (IDTF): approved for medicare.

(24) Laboratory: valid clinical laboratory improvement amendments (CLIA) certificate.

(25) Licensed professional clinical counselor (LPCC) or licensed professional counselor (LPC): license from Ohio counselor, social worker, and marriage and family therapist board.

(26) Licensed social worker (LSW) or licensed independent social worker (LISW): license from Ohio counselor, social worker, and marriage and family therapist board.

(27) Massage therapist: license from Ohio state medical board.

(28) Non-physician acupuncturist: license to practice acupuncture or certificate to practice as an oriental medicine practitioner from Ohio state medical board.

(29) Nursing home: license from Ohio department of health or approved for medicare.

(30) Ocularist: license from Ohio state vision professionals board.

(31) Occupational rehabilitation-comprehensive programs (work hardening): CARF accreditation.

(32) Occupational therapist: license from Ohio occupational therapy, physical therapy, and athletic trainers board.

(33) Optician: license from Ohio state vision professionals board.

(34) Optometrist: license from Ohio state vision professionals board.

(35) Orthotist, prosthetist or pedorthist: license from Ohio occupational therapy, physical therapy, and athletic trainers board.

(36) Physical therapist: license from Ohio occupational therapy, physical therapy, and athletic trainers board.

(37) Physician (M.D. or D.O.): license from Ohio state medical board.

(38) Physician assistant: certified by national commission on certification of physician assistants and license from Ohio state medical board.

(39) Podiatric physician (D.P.M.): license from Ohio state medical board.

(40) Psychologist: license from Ohio state board of psychology.

(41) Radiology services (free-standing) registration from the Ohio department of health and approved for medicare.

(42) Residential care/assisted living facility: license from Ohio department of health.

(43) Sleep laboratory: certified by the American academy of sleep medicine and approved for medicare.

(44) Speech-language pathologist: license from Ohio state speech and hearing professionals board.

(45) Traumatic brain injury (TBI) program: CARF accreditation for brain injury services (acute or post-acute).

(46) Urgent care facility (free standing): approved for medicare.

(47) Vocational rehabilitation case managers: certification for ABVE, occupational health nursing (COHN(S)), CRC, CDMS, certified vocational evaluator (CVE), certified rehabilitation nurse (CRRN), or CCM.

(48) Vocational rehabilitation case management interns:

(a) Vocational rehabilitation case management may be provided by a bureau-certified intern. An intern is a non-credentialed individual who provides vocational case management services and is supervised by a credentialed vocational case manager, as identified in paragraph (C)(47) of this rule.

(b) To become eligible for bureau certification and provide service as an intern, the intern must:

(i) Enroll with the bureau as an intern.

(ii) Qualify to take one of the examinations to become credentialed, as identified in paragraph (C)(47) of this rule.

(d) Vocational rehabilitation case management interns cannot be recertified for additional four-year periods.

View Appendix

Last updated November 4, 2025 at 2:10 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.3 Provider access to the HPP - provider application and certification criteria.

(A) The bureau shall make available to each provider a provider certification application and agreement or recertification application and agreement, as applicable, which shall require the provider to furnish documentation as provided in rule 4123-6-02.2 of the Administrative Code.

(B) The provider application and agreement or recertification application and agreement shall require the provider to make statements that the provider is without impairments that would interfere with the provider's ability to practice or that would jeopardize a patient's health, and a statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit. The provider shall provide to the bureau any additional documentation requested and shall permit the bureau to conduct a review of the provider's practice or facility. The provider shall notify the bureau within thirty days of any change in the provider's ownership as reported on the application and agreement, or status regarding any of the credentialing criteria of paragraph (B) or (C) of rule 4123-6-02.2 of the Administrative Code.

(C) The bureau shall review the application and agreement and all documentation submitted by the provider. The bureau may cross-check data with other governmental agencies or licensing bodies. The bureau may refer provider certification and malpractice issues to the bureau's stakeholders health care quality assurance advisory committee for review as provided under rule 4123-6-22 of the Administrative Code.

(D) By signing the provider application and agreement or recertification application and agreement, the provider agrees to, and the bureau may refuse to certify or recertify or may decertify a provider for failure to:

(1) Provide health services that are applicable to a work related injury, and not to substantially engage in the practice of experimental modalities of treatment.

(2) Acknowledge and treat injured workers in accordance with bureau recognized treatment guidelines.

(3) Acknowledge and treat injured workers in accordance with the vocational rehabilitation hierarchy.

(4) Provide adequate on-call coverage for patients.

(5) Utilize bureau certified providers when making referrals to other providers.

(6) Timely schedule and treat injured workers to facilitate a safe and prompt return to work.

(7) Release information from the national practitioner data bank or the federation of state licensing boards. The bureau may submit a report to the appropriate state licensing board or data bank as required in the event the provider is decertified.

(8) Practice in a managed care environment and adhere to MCO and bureau procedures and requirements concerning provider compliance, outcome measurement data, peer review, quality assurance, utilization review, bill submission, and dispute resolution.

(9) Adhere to the bureau's confidentiality and sensitive data requirements, and use information obtained from the bureau by means of electronic account access for the sole purpose of facilitating treatment and no other purpose, including but not limited to engaging in advertising or solicitation directed to injured workers.

(10) Maintain professionalism, integrity, and civility in the provision of services in the HPP, including in all written and oral communications with the bureau, the industrial commission, the MCO, injured workers, employers, and their representatives.

(11) Comply with the workers' compensation statutes and rules and the terms of the provider application and agreement or recertification application and agreement.

(E) Upon review and determination by the bureau that the provider has met bureau credentialing requirements, the bureau shall certify or recertify the provider as a bureau certified provider.

(F) The bureau may enter into an addendum to a physician's provider certification application and agreement or recertification application and agreement, offering appropriate performance incentives to enhance physician proficiency in patient care and navigation of the Ohio workers' compensation system, to physicians who agree to:

(1) Perform enhanced duties as the treatment team leader in the care of injured workers, as set forth in the addendum, and

(2) Enhanced provider outcome measurement.

Last updated November 4, 2025 at 2:09 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.4 Provider access to the HPP - provider recertification.

(A) The bureau shall initiate the recertification process by sending certified providers notice and a recertification application and agreement, which must be completed, signed, and submitted to the bureau if the provider wishes to be considered for recertification.

(B) Except as otherwise provided in paragraph (E) of this rule, if the bureau receives a completed and signed recertification application and agreement from a provider, the provider's certification shall remain in effect until the bureau issues a final order approving or denying the provider's application for recertification.

(C) If the bureau does not receive a completed and signed recertification application and agreement from the provider within sixty days from the date of the notice sent in accordance with paragraph (A) of this rule, the bureau shall send a second notice to the provider stating that the provider has thirty days from the date of the second notice to complete, sign, and submit the recertification application and agreement to the bureau if the provider wishes to be considered for recertification.

(D) If the bureau does not receive a completed and signed recertification application and agreement from the provider within thirty days from the date of the second notice sent in accordance with paragraph (C) of this rule, the provider's certification shall lapse. Such lapse of certification is not an adjudication order and is not subject to appeal pursuant to rule 4123-6-17 of the Administrative Code.

(E) If the bureau receives a completed and signed recertification application and agreement from a provider after the provider's certification has lapsed pursuant to paragraph (D) of this rule, the provider's certification shall remain lapsed until the bureau issues a final order approving or denying the provider's application for recertification.

(F) All recertification applications and agreements are subject to review as provided in rule 4123-6-02.3 of the Administrative Code.

Last updated November 4, 2025 at 2:10 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.5 Provider access to the HPP - provider not certified.

(A) A provider not certified or recertified shall submit any information missing from the provider application and agreement or recertification application and agreement upon request, within thirty days of notice by the bureau. The bureau may deny certification or recertification if the provider fails to submit the requested information.

(B) The administrator of the bureau of workers' compensation, pursuant to rule 4123-6-17 of the Administrative Code, may refuse to certify or recertify or may decertify a provider where the provider has failed to comply with the workers' compensation statutes or rules, or the terms of the provider application and agreement or recertification application and agreement.

(C) Notwithstanding paragraph (B) of this rule, the administrator may immediately revoke or suspend the certification and terminate the enrollment of a provider other than a hospital, in accordance with section 4121.443 of the Revised Code.

(D) The administrator may impose disciplinary sanctions upon a provider where the provider has failed to comply with the workers' compensation statutes or rules governing providers or the terms of the provider application and agreement or recertification application and agreement. In imposing a disciplinary sanction against a provider the administrator may consider, but is not limited to, suspending all reimbursements to a provider.

Last updated November 4, 2025 at 2:10 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.6 Provider access to the HPP -- selection by an MCO.

(A) The bureau shall maintain a public list of bureau certified providers. The bureau shall make the list of bureau certified providers available through the bureau's website.

(B) An MCO may, but is not required to, retain a panel of bureau certified providers. A bureau certified provider is eligible to participate on an MCO's provider panel. A bureau certified provider may participate in a single MCO panel or may participate in more than one MCO panel.

(C) A provider identified by an MCO for temporary privileges in its panel of providers that is not a bureau certified provider shall 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.

(E) The MCO shall include in its panel or its arrangements with providers a substantial number of the medical, professional, and pharmacy providers currently being utilized by employees. An MCO may limit the number of providers on its MCO provider panel or with whom they enter into arrangements, but must do so based upon objective data approved by the bureau, such as reasonable access to care, community needs, the potential number of injured workers the MCO may be expected to service, and other performance criteria, without discrimination by provider type.

(F) A bureau certified provider must follow the medical management and return to work management approaches of the MCO medically managing an employee's claim, whether or not the provider is on the MCO's provider panel or has an arrangement with the MCO. MCO guidelines may not be more restrictive for a non-panel provider than for an MCO panel provider.

Last updated November 4, 2025 at 2:10 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.7 Provider access to the HPP - provider decertification procedures.

(A) Except as otherwise provided in paragraph (C) of this rule, the administrator of the bureau of workers' compensation will follow the procedures set forth in this rule to terminate the enrollment of and decertify a non-facility provider who has failed to comply with a workers' compensation statute or rule.

(1) If the bureau determines a provider has committed three or more reported violations of the same workers' compensation statute or rule in a six month period, or five or more reported violations of any workers' compensation statute or rule in a six month period, the bureau will serve written notice of the violations to the provider.

(2) If the bureau determines the provider has committed two or more subsequent reported violations of any workers' compensation statute or rule for which the provider previously received notice pursuant to paragraph (A)(1) of this rule, and the subsequent violations occurred any time within the six month period following the calendar month in which the provider received notice pursuant to paragraph (A)(1) of this rule, the bureau will serve written notice of the violations to the provider, which will include a thirty day period within which the provider must submit and implement a correction plan signed by the provider. The bureau will enter the correction plan into the provider's certification file and will document that the provider is "under correction plan" during the six month period following the calendar month in which the provider's thirty day implementation period expires.

(3) If the bureau determines the provider has committed two or more subsequent reported violations of the same workers' compensation statute or rule for which the provider previously received notice pursuant to paragraph (A)(2) of this rule and submitted a correction plan satisfactory to the bureau, and the subsequent violations occurred any time within the six month period following the calendar month in which the provider's thirty day implementation period provided in the notice sent pursuant to paragraph (A)(2) of this rule expires, the bureau will serve written notice of the violations to the provider, which will include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(4) If the bureau determines a provider who has twice received written notice pursuant to paragraph (A)(1) of this rule for violation of the same workers' compensation statute or rule has committed two subsequent reported violations of the same workers' compensation statute or rule within eighteen months of the date written notification was first sent to the provider by the bureau pursuant to paragraph (A) of this rule, the bureau will serve written notice of the violations to the provider, which will include a thirty day period within which the provider must submit and implement a correction plan signed by the provider. The bureau will enter the correction plan into the provider's certification file and will document that the provider is "under correction plan" during the six month period following the calendar month in which the provider's thirty day implementation period expires.

(5) If the provider fails to submit a correction plan within the thirty day implementation period specified in paragraph (A)(2) or (A)(4) of this rule satisfactory to the bureau, which satisfaction shall not be unreasonably withheld, the bureau will serve written notice of the failure to the provider, which will include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(6) The bureau may, in its discretion, consider mitigating circumstances in its application of the procedures set forth in paragraphs (A)(1) to (A)(5) of this rule with regard to an individual provider. Mitigating circumstances may include, but are not limited to:

(a) The violations related to the provision of emergency treatment;

(b) At the time the violations occurred, the provider was not aware a workers' compensation claim was involved;

(d) The violations were due to bureau or MCO error;

(e) The provider billed the bureau for goods or services in fewer than five workers' compensation claims in the twelve months prior to the violations;

(f) Other documented justification as deemed sufficient by the bureau.

(7) The bureau will serve all notices to the provider pursuant to this rule in accordance with section 119.05 of the Revised Code.

(B) Providers whose enrollment is terminated and who are decertified pursuant to paragraphs (A)(2) to (A)(5) of this rule are eligible to apply for and be considered for recertification and reenrollment at any time after two years from the date of the final administrative or judicial order of enrollment termination and decertification.

(C) The procedures set forth in paragraphs (A)(1) to (A)(7) of this rule do not apply to, and the administrator may proceed directly to enrollment termination and/or decertification of a provider for, the following:

(1) Violation of the minimum provider certification criteria set forth in rule 4123-6-02.2 of the Administrative Code.

(2) Acts of misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit on the provider's provider application and agreement or recertification application and agreement.

(3) Acts involving breach of the bureau's confidentiality and sensitive data requirements, including but not limited to failure to maintain the confidentiality of injured worker medical or claim information.

(4) Acts involving misuse of information obtained from the bureau by means of electronic account access for a purpose other than facilitating treatment, including but not limited to engaging in advertising or solicitation directed to injured workers.

(5) Acts involving advertising or solicitation directed to injured workers in violation of rule 4123-6-02.9 of the Administrative Code.

(6) Acts of intentional misrepresentation, misstatement, or omission of a relevant fact or other acts involving false, fraudulent, deceptive, or misleading information on reports, information, and/or documentation submitted by the provider, the provider's employees, or the provider's agents to the bureau, industrial commission, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation claim.

(7) Upon peer review recommendation of the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the Administrative Code, the bureau of workers' compensation pharmacy and therapeutics (P&T) committee pursuant to rule 4123-6-21.2 of the Administrative Code, or other peer review committee established by the bureau.

(8) Revocation or suspension in accordance with section 4121.443 of the Revised Code.

Last updated November 3, 2025 at 7:37 AM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.8 Provider requirement to notify of injury.

(A) HPP: Within one business day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease in accordance with either paragraph (A)(1) or (A)(2) of this rule.

(1) A provider may report an injury to the MCO responsible for medical management of the employee's treatment. When reporting the injury to the MCO, the provider shall do so in accordance with procedures established by the bureau.

(2) A provider may report an injury to the bureau through the bureau's website pursuant to rule 4125-1-02 of the Administrative Code.

(B) QHP: Within one business day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease to the QHP or employer.

(C) Self-insuring employer (non-QHP): Within one business day of initial treatment or initial visit of an injured worker, a provider must report the employee's injury or occupational disease to the self-insuring employer.

Last updated June 30, 2026 at 1:16 PM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.9 Provider access to the HPP - provider marketing.

(A) No bureau certified or enrolled provider shall engage in any advertising or solicitation directed to injured workers which is false, fraudulent, deceptive, or misleading.

(B) No bureau certified or enrolled provider shall hire, arrange for, or allow any other individual or entity to engage in any advertising or solicitation directed to injured workers on behalf of the provider which is false, fraudulent, deceptive, or misleading.

(C) No bureau certified or enrolled provider shall pay, allow, or give, or offer to pay, allow, or give, any consideration, money, or other thing of value to an injured worker, or to any other person, firm, or corporation (including but not limited to free or discounted examinations, treatment, or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any goods or services for which payment may be made by the bureau, MCO, QHP, or self-insuring employer under Chapter 4121., 4123., 4127., or 4131. of the Revised Code.

(D) A bureau certified provider that violates this rule may be subject to termination of enrollment, decertification, or disciplinary sanctions pursuant to the rules of this chapter of the Administrative Code.

Last updated June 30, 2026 at 1:16 PM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.21 Provider access to the HPP - non-certified provider enrollment.

(A) The bureau may enroll non-certified providers eligible under rule 4123-6-06.2 or 4123-6-10 of the Administrative Code or division (N) of section 4121.44 of the Revised Code to receive reimbursement for goods and services provided to injured workers, and for this purpose may require such non-certified providers to complete and sign an enrollment application as the bureau deems appropriate, provided such non-certified providers meet the minimum qualifications for their provider category as set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code. The provider shall notify the bureau within thirty days of any change in the provider's ownership as reported on the enrollment application.

(B) Persons or entities who do not fall within the provider categories set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code are not eligible for certification as providers. The bureau may enroll such persons or entities to receive reimbursement for goods and services provided to injured workers, and for this purpose may require such persons or entities to complete and sign an enrollment application as the bureau deems appropriate.

(C) The certification of providers who fall within the provider categories set forth in paragraph (C) of rule 4123-6-02.2 of the Administrative Code may lapse, and the provider shall be enrolled with the bureau only, if the provider has had no billing activity with the bureau for a period of eighteen months or longer while certified. If the provider submits a bill while the provider's certification is lapsed pursuant to this paragraph, the provider may apply for recertification. However, the provider's certification shall remain lapsed until the bureau issues a final order approving or denying the provider's application for recertification.

(D) The enrollment of a non-certified provider, person, or entity pursuant to paragraph (A), (B), or (C) of this rule may expire if the non-certified provider, person, or entity has had no billing activity with the bureau for a period of eighteen months or longer while enrolled as a non-certified provider.

Last updated November 4, 2025 at 2:10 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.22 Provider access to the HPP - ambulatory surgical center arthroplasty center requirements.

(A) To be eligible for participation in the HPP as an ambulatory surgical center arthroplasty center, an ambulatory surgical center must:

(1) Be certified as an ambulatory surgical center under paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(2) Have a formal joint replacement program which has been in place for at least one year prior to the date of application, and have performed a minimum of ten arthroplasty procedures prior to the date of application.

(3) Have a physician credentialing criteria policy which includes, at a minimum:

(a) A statement confirming any surgeon performing the service for injured workers is board certified in a related surgery specialty;

(b) A statement confirming any surgeon performing this service for injured workers has performed the procedure at the facility within one year prior to the date of application;

(c) A statement confirming any surgeon performing the service for injured workers has admitting privileges at a hospital within thirty miles of the facility or otherwise closest hospital;

(d) The facility recredentials surgeons at regular intervals.

(4) Have a patient selection criteria policy for injured workers consistent with applicable standards of care which includes, at a minimum:

(a) The patient is American society of anesthesiologists (ASA) physical status I (normal healthy patient) or II (patients with mild systemic disease);

(b) The patient is under sixty-five years of age;

(d) The patient has no co-morbid conditions that would be likely to affect surgical outcome;

(e) The patient has one or more individuals to assist with immediate post-surgical recovery care (home support).

(5) Report quality data measures to the centers for medicare and medicaid services (CMS) under the ambulatory surgical center quality reporting (ASCQR) program.

(6) Have an established protocol for tracking and reporting the following Ohio association of ambulatory surgery center (OAASC) quality data measures:

(a) Number of extended stays past midnight;

(b) Number of unexpected complications;

(i) Vomiting which does not respond to treatment;

(ii) Severe pain not responding to treatment;

(iii) Excessive bleeding necessitating a return to surgery or transfer;

(iv) Cardiac or respiratory arrest;

(i) Medication errors;

(ii) Medical device errors;

(iii) Unintentional retained foreign body;

(d) Post discharge complications;

(i) Infections (thirty days post-operative; implants up to one year);

(ii) Emergency room visit within forty-eight hours for related issue;

(7) List on its application the specific procedure(s) it is requesting bureau certification to perform and receive reimbursement for under rule 4123-6-37.3 of the Administrative Code as an ambulatory surgical center arthroplasty center.

(B) The bureau is authorized to recredential and recertify a facility to participate in the HPP as an ambulatory surgical center arthroplasty center in accordance with rule 4123-6-02 of the Administrative Code.

(C) The administrator may decertify, or refuse to certify or recertify the facility as an ambulatory surgical center arthroplasty center, in accordance with rule 4123-6-17 of the Administrative Code and Chapter 119. of the Revised Code:

(1) If the facility has failed to meet or maintain any of the criteria for bureau certification as an ambulatory surgical center arthroplasty center set forth in paragraph (A) of this rule;

(2) Upon the recommendation of the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) or other peer review committee established by the bureau that injured worker safety would be compromised by the continued participation of the facility as an ambulatory surgical center arthroplasty center in the HPP; or

(3) As otherwise provided by this chapter of the Administrative Code.

Last updated June 30, 2026 at 1:16 PM

History

Effective: April 15, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-02.51 Provider access to the HPP -- Denial of provider, entity or MCO enrollment or certification based on criminal conviction or civil action.

(A) The administrator may refuse to certify or recertify, or may decertify from participation in the HPP, any MCO that:

(1) Is owned, directly or indirectly, by an individual or entity that has a felony conviction in any jurisdiction, a conviction under a federal controlled substance act, a misdemeanor conviction for an act involving dishonesty, fraud, or misrepresentation, a conviction for a misdemeanor committed in the course of practice, or a felony or misdemeanor conviction involving dishonesty, fraud, or misrepresentation related to any compensation or benefits payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code.

(2) Has one or more owners, shareholders, members, partners, managing employees, officers or directors, who have a conviction as described in paragraph (A)(1) of this rule; and including any MCO that is no longer so described because of a transfer of ownership or interest to an immediate family member or a member of the person's household in anticipation of or following a conviction as described in paragraph (A)(1) of this rule.

(3) Is owned directly, or indirectly, by an individual or entity who has engaged in specific conduct which demonstrates financial irresponsibility. Such conduct shall include, but not be limited to:

(a) Specific examples of insolvency of businesses owned or controlled by the individual or entity;

(b) Specific examples of failures to pay debts or judgments;

(c) Specific examples of activity which has defrauded any person, entity or organization, regardless of whether such activity has resulted in criminal prosecution;

(d) Any finding of fraud in a civil or administrative proceeding related to any compensation or benefits payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code or the equivalent laws of another state.

(B) The administrator may refuse to enroll, certify or recertify, or may terminate enrollment or decertify from participation in the HPP, any provider or entity that:

(1) Is owned, directly or indirectly, by an individual or entity that has been convicted of or pleaded guilty to a criminal offense as set forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The provider or entity is ineligible for enrollment, certification, or recertification for the same period of ineligibility provided in the appendix to rule 4123-6-02.2 of the Administrative Code for the criminal offense.

(2) Has one or more owners, shareholders, members, partners, managing employees, officers or directors who have a conviction or plea of guilty to a criminal offense as set forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The provider or entity is ineligible for enrollment, certification, or recertification for the same period of ineligibility provided in the appendix to rule 4123-6-02.2 of the Administrative Code for the criminal offense.

(3) It is owned directly, or indirectly, by an individual or entity who has engaged in specific conduct which demonstrates financial irresponsibility as described in paragraph (A)(3) of this rule.

(1) "Entity" means any sole proprietorship, partnership, corporation, professional association, limited liability company or any other business organization doing business in this or any other state.

(2) "Immediate family member" means a person's spouse; natural or adoptive parent; child or sibling, stepparent, stepchild, stepbrother or stepsister; father-, mother-, daughter-, son-, brother- or sister-in-law; grandparent or grandchild; or spouse of a grandparent or grandchild.

(3) "Managing employee" means an individual (including a general manager, office manager, business manager, administrator or director) who exercises operational or managerial control over the provider, entity or MCO or part thereof, or directly or indirectly conducts the day-to-day operations of the provider, entity or MCO or part thereof, or is involved in the billing functions of the provider, entity or MCO or part thereof.

(4) "Member of household" means, with respect to a person, any individual with whom they are sharing a common abode.

(5) "Owned directly or indirectly" means having an interest that includes ownership, as an individual or through any other entity or entities, of five per cent or more in the provider, entity or MCO at issue.

(D) Notwithstanding and in addition to the provisions set forth in this rule, pursuant to division (C)(1) of section 4121.444 of the Revised Code the administrator may terminate any agreement between the bureau and a person or a health care provider or managed care organization or its owner and cease reimbursement to, decertify and terminate the enrollment of that person, provider, organization, or owner for services rendered if any of the following apply:

(1) The person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization is convicted of or pleads guilty to a violation of sections 2913.48 or 2923.31 to 2923.36 of the Revised Code or any other criminal offense related to the delivery of or billing for health care benefits.

(2) There exists an entry of judgment against the person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization and proof of the specific intent of the person, health care provider, managed care organization, or owner to defraud, in a civil action brought pursuant to section 4121.444 of the Revised Code.

(3) There exists an entry of judgment against the person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization in a civil action brought pursuant to sections 2923.31 to 2923.36 of the Revised Code.

(E) No person, health care provider, or managed care organization that has had its agreement with and reimbursement from the bureau terminated by the administrator pursuant to division (C)(1) of section 4121.444 of the Revised Code, or an owner, officer, authorized agent, associate, manager, or employee of that person, health care provider, or managed care organization shall do either of the following:

(1) Directly provide services to any other bureau provider or have an ownership interest, as an individual or through any other entity or entities, of five per cent or more in a provider of services that furnishes services to any other bureau provider;

(2) Arrange for, render, or order services for claimants during the period that the agreement of the person, health care provider, managed care organization, or its owner is terminated as described in division (C)(1) of section 4121.444 of the Revised Code;

(F) The administrator shall not terminate the agreement or reimbursement if the person, health care provider, managed care organization, or owner demonstrates that the person, provider, organization, or owner did not directly or indirectly sanction the action of the authorized agent, associate, manager, or employee that resulted in the conviction, plea of guilty, or entry of judgment as described in division (C)(1) of section 4121.444 of the Revised Code.

(G) Nothing in division (C) of section 4121.444 of the Revised Code prohibits an owner, officer, authorized agent, associate, manager, or employee of a person, health care provider, or managed care organization from entering into an agreement with the bureau if the provider, organization, owner, officer, authorized agent, associate, manager, or employee demonstrates absence of knowledge of the action of the person, health care provider, or managed care organization with which that individual or organization was formerly associated that resulted in a conviction, plea of guilty, or entry of judgment as described in division (C)(1) of section 4121.444 of the Revised Code.

(H) Actions taken by the administrator pursuant to this rule shall be subject to rule 4123-6-17 of the Administrative Code.

Last updated November 4, 2025 at 2:10 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-03.2 MCO participation in the HPP -- MCO application for certification or recertification.

(A) Upon request, the bureau shall send the MCO an application for certification which the MCO may complete and submit to the bureau.

(B) The application submitted to the bureau by the MCO shall include a list of bureau certified providers in its provider panel and/or bureau certified providers with which the MCO has arrangements.

(C) Regardless of whether the MCO elects to retain a provider panel or enters into provider arrangements, the application submitted to the bureau by the MCO shall include the following:

(1) A description of the MCO's health care provider panel or provider arrangements, including a substantial number of the medical, health care professional and pharmacy providers currently being utilized by injured workers. The provider panel or provider arrangements shall cover the geographic area in which the MCO plans to compete, and may include out-of-state providers.

(2) A description of how the MCO's provider panel or provider arrangements will provide timely, geographically convenient access to a full range of medical services and supplies for injured workers, including access to specialized services.

(3) A description of the MCO's process and methodology for credentialing providers in the MCO's provider panel, if applicable, and the MCO's process and methodology for assisting non-bureau certified providers in the MCO's provider panel or with which the MCO has provider arrangements in applying for bureau provider credentialing and certification.

(4) A description of the MCO's process and methodology for payment of providers in the MCO's provider panel or under a provider arrangement.

(5) A description of the MCO's policies and procedures for sanctioning and terminating providers in the MCO's panel, if applicable, and a description of the MCO's methodology to notify the bureau, employers and employees of any changes in the MCO's provider panel or provider arrangements.

(6) A description of the MCO's methodology for distributing provider panel and provider arrangement directories and directory updates to employers and employees.

(D) The application for certification submitted to the bureau by the MCO shall include, at a minimum, the following information and provisions:

(1) A statement that the application is without misrepresentation, misstatement, or omission of a relevant fact or other representations involving dishonesty, fraud, or deceit.

(2) A description of the geographic area of the state of Ohio for which the MCO wishes to be certified by the bureau. The minimum geographic area is a county. The bureau shall certify MCO participation on a county basis. The MCO may apply for coverage in more than one county or statewide.

(3) A description of the MCO that includes, but is not limited to, a profile that includes a disclosure statement regarding the MCO's organizational structure, including subsidiary, parent and affiliate relationships, together with historical and current data. The MCO must identify its principals; provide the MCO's date of incorporation or formation of partnership, or limited liability company, or business trust; provide any trade names or fictitious names the MCO is, or has been, doing business under; provide the number of years the MCO has operated in Ohio; identify other states in which the MCO is doing business or has done business; provide a table of organization with the number of employees; and identify any banking relationships, including all account information with any financial institutions.

(4) A description of the MCO's business continuity plan.

(5) A description of the bureau approved treatment guidelines used by the MCO, including a description of how the MCO shall implement the treatment guidelines.

(6) A description of the MCO's utilization review process.

(7) A description of the MCO's quality assurance/improvement standards program and process, including the use of satisfaction surveys.

(8) A description of the MCO's medical dispute resolution process that meets the requirements of rule 4123-6-16 of the Administrative Code.

(9) A description of the MCO's administrative and bill payment grievance processes.

(10) A description of the MCO's information system platforms, capabilities and capacities; a description of the MCO's system for reporting necessary data elements, including but not limited to those required for performance measurements; and the MCO's measures in place to ensure data security, including back-up systems.

(11) A description of the MCO's medical case management policies and procedures.

(12) A description of the MCO's policies and procedures regarding the protection of confidential and sensitive records.

(13) A description of the MCO's policies and procedures regarding retention of information.

(14) A description of the MCO's provider relations and education program.

(15) A description of the MCO'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.

(16) A description of the MCO's provider bill payment processes including, but not limited to, clinical editing software (including review criteria, process and methodology).

(17) Attestation of intent to obtain and maintain insurance coverage as required by the MCO contract, with proof of such coverage to be submitted to the bureau prior to execution of the contract, and current workers' compensation coverage.

(18) Attestation of intent to obtain and maintain professional accreditations as required by the MCO contract, with proof of such accreditations to be submitted to the bureau prior to execution of the contract.

(19) A description of any and all individuals and entities the MCO is affiliated with (including, but not limited to, a subcontractor or subcontractee, vendor or vendee, joint venture or other arrangement), and a copy of the MCO's contract or agreement with each individual or entity. For purposes of this rule, "affiliated with the MCO" shall have the same meaning as defined in paragraph (B) of rule 4123-6-03.9 of the Administrative Code.

(20) Other descriptions and requirements as contained in divisions (F)(1) to (F)(10) of section 4121.44 of the Revised Code.

(E) For MCO recertification, prior to the expiration of an MCO's certification, the bureau shall send the certified MCO an application for recertification, which must be completed and returned to the bureau. The MCO must be able to provide proof of delivery of the completed application to the bureau upon request. The application for recertification may be amended from time to time at the bureau's discretion.

(F) The bureau shall review the application for certification or recertification submitted by the MCO. The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.

(G) During the bureau's review of the application for certification or recertification, the MCO shall provide to the bureau any additional documentation requested and shall permit the bureau, upon request and with reasonable notice given, to conduct an onsite review of the MCO.

(H) An MCO may cure any defects in its application for certification or recertification within thirty days of notice by the bureau of such defect in its application.

(I) The bureau may require that the application be accompanied by an application fee, which shall not exceed the amount sufficient to cover the cost of processing the application.

(J) The bureau shall hold as confidential and proprietary information contained in an MCO's application for certification or recertification, and other information furnished to the bureau by an MCO for purposes of obtaining certification or to comply with performance and auditing requirements established by the administrator, in accordance with divisions (H)(1) and (H)(2) of section 4121.44 of the Revised Code.

(K) The bureau shall not accept or approve any application for certification or recertification in which the MCO proposes to subcontract or outsource medical case management services, other than as part of the MCO's business continuity plan as described in paragraph (D)(4) of this rule and approved by the bureau. However, an MCO may subcontract onsite or out-of-state medical case management services with the prior approval of the bureau, provided such services are conducted under the supervision of the MCO.

Last updated February 1, 2022 at 9:30 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-03.4 MCO participation in the HPP - MCO certification.

(A) Upon review by and satisfactory to the bureau that the managed care organization has met bureau certification standards, the bureau shall certify an MCO as eligible to contract with the bureau to provide medical management and cost containment services for injured workers and employers.

(B) MCO certification by the bureau shall be for a period of two years.

(C) The bureau may certify any number of MCOs for each county or statewide. Upon approval by the bureau, an MCO may expand its coverage area after the first year of certification and every year thereafter.

(D) The bureau shall maintain a current list of all bureau certified MCOs. The list shall include the name and address of each MCO and the counties in which the MCO is certified.

(E) An MCO may apply to the bureau for recertification beyond the first two years of certification.

Last updated September 9, 2025 at 11:30 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-03.7 MCO participation in the HPP - bureau's authority to decertify, to refuse to certify or recertify an MCO.

(A) Should the administrator determine that sufficient evidence exists that an MCO has failed to maintain any of the requirements set forth in division (F) of section 4121.44 of the Revised Code, or to reasonably comply with or to perform in accordance with the terms of a contract between the bureau and the MCO entered into pursuant to division (B)(4) of section 4121.44 of the Revised Code, or has violated a rule adopted under section 4121.441 of the Revised Code, the administrator has the authority to decertify or refuse to certify or recertify an MCO, in accordance with rule 4123-6-17 of the Administrative Code and Chapter 119. of the Revised Code.

(B) Upon a final order of the administrator to decertify or refuse to recertify an MCO, employees and employers shall not receive services from such MCO pursuant to the HPP.

(C) Upon a final order of the administrator to decertify or refuse to recertify an MCO, any obligation of a provider to provide services under the HPP pursuant to a contract or agreement with such MCO shall be null and void.

Last updated November 4, 2025 at 2:10 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-03.9 MCO participation in the HPP - MCO disclosure of relationship.

(A) If an MCO is affiliated with another individual, corporation, or entity that has had or contemplates activities of any nature with the Ohio workers' compensation system including but not limited to third party administrators, medical or vocational rehabilitation providers, alternate employer organizations, professional employer organizations, and/or transitional work developers:

(1) To the extent such relationship creates or presents either the opportunity for a conflict of interest or preferential treatment or the appearance of a conflict of interest or preferential treatment for the managed care organization and/or the other individual, corporation, or entity, the MCO shall provide to the bureau a written description of the resolution of such opportunity for or the appearance of a conflict of interest satisfactory to the bureau; and shall disclose the potential conflict of interest and its resolution to the employers and injured workers assigned to the MCO.

(2) The MCO and the other affiliated corporation or entity shall implement complete separation of functions, offices, systems, and staff. Complete separation of staff shall include, but not be limited to, medical and vocational rehabilitation case management staff and marketing staff.

(B) For purposes of this rule, an individual, corporation, or entity is "affiliated with an MCO" when it:

(1) Owns, is owned by, or is under common ownership with an MCO, directly or indirectly through one or more intermediaries;

(2) Controls, is controlled by, or is under common control with an MCO, directly or indirectly through one or more intermediaries;

(3) Has a contractual or other business arrangement with an MCO;

(4) Has one or more owners, shareholders, partners, members, officers, directors or other persons who exercise operational or managerial control in common with the MCO.

Last updated November 4, 2025 at 2:10 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-03.10 Conflict of interest.

No individual who is an officer or employee of an MCO shall represent a claimant or employer in any matter before the industrial commission, the bureau of workers' compensation, or a court of competent jurisdiction.

Last updated September 9, 2025 at 11:30 AM

History

Effective: February 1, 2010
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-04.3 MCO scope of services - MCO medical management and claims management assistance.

(A) The MCO, in conjunction with the employer, injured worker, attending physician, and the bureau claims personnel assigned to the claim, shall provide medical management and cost containment services that facilitate the provision of high-quality, cost-effective medical care focused on minimizing the physical, emotional, and financial impact of a work related injury or illness and as appropriate, promotes a safe and timely return to work.

(B) The MCO shall educate employees and employers regarding access to and use of medical services for work related injuries or illnesses, and assist the bureau in educating employers and providers, whether in state or out of state, as to bureau rules, policies and initiatives.

(C) The MCO shall comply with bureau procedures for reporting injuries to the bureau and employers, and instruct the provider to forward to the MCO and the bureau, in accordance with rule 4123-6-15 of the Administrative Code, all necessary data to effectuate medical and claims management.

(D) The MCO shall review all bills submitted to it for payment by a provider consistent with the MCO's previous treatment reimbursement determination regarding the service billed, the MCO's utilization standards, the criteria set forth in rule 4123-6-25 of the Administrative Code, applicable industry standards, and the requirements of the MCO contract. The MCO shall have in place and operating a grievance hearing procedure allowing a provider, employer, or injured worker to grieve a disputed bill payment.

(E) The MCO shall refer a medical treatment reimbursement request in an inactive claim to the bureau, with the MCO's recommendation, for a determination of both the causal relationship between the original injury and the current incident precipitating the treatment request and the necessity and appropriateness of the requested treatment as provided in rule 4123-3-15 of the Administrative Code.

(F) An MCO shall provide medical management and return to work management services in a claim as long as the employer remains assigned to the MCO, regardless of the date of injury of the claim, except claims assumed by the bureau pursuant to rule 4123-6-04.6 of the Administrative Code. In cases where an injured worker has multiple claims with different employers, each claim remains with the associated employer and is managed by that employer's current MCO.

Last updated November 4, 2025 at 2:11 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-04.5 MCO scope of services - bureau claims management.

(A) Upon receipt of notification of a workers' compensation claim, the bureau shall assign a claim number and shall notify the injured worker, employer and MCO of that claim number. The bureau shall determine the compensability of the claim and the allowed conditions of the claim pursuant to the provisions of section 4123.511 of the Revised Code. The bureau will notify all parties and the MCO of the allowed conditions in the claim.

(B) Upon referral from an MCO of a medical treatment reimbursement request in an inactive claim, after considering the MCO's recommendation the bureau will determine, as provided in rule 4123-3-15 of the Administrative Code, both the causal relationship between the original injury and the current incident precipitating a medical treatment reimbursement request and the necessity and appropriateness of the requested treatment. The bureau will notify all parties and the MCO of its determination.

The employer, injured worker, or representative may appeal the bureau's order to the industrial commission pursuant to section 4123.511 of the Revised Code.

(C) The bureau shall not make medical payments in a disallowed claim or for conditions not allowed in a claim until permitted to do so under the provisions of section 4123.511, 4123.512, or 4123.66 of the Revised Code or except as provided by the rules of this chapter or Chapter 4123-18 of the Administrative Code. The bureau shall notify all parties and the MCO when a claim or conditions are allowed or disallowed and indicate whether treatment rendered therefore may or may not be paid.

(D) During the adjudication process, the provider may continue to render or the MCO may continue to manage medical services on behalf of the employee, but the bureau shall not pay for medical services in a disallowed claim or for disallowed conditions. If the claim or condition is disputed, the MCO shall inform the employee and the provider that the services provided may not be covered by workers' compensation and may be the responsibility of the employee.

Last updated September 9, 2025 at 11:30 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-04.6 Return to work assessment.

(A) The bureau may perform a return-to-work assessment of an injured worker who has eight or more days of lost time due to a work related injury and who has not returned to work within an acceptable timeframe as determined by the bureau.

(B) The assessment may include, but is not limited to, the medical case management goals, identification of barriers, return to work plan, medical stability and vocational status of the claim.

(C) All findings and conclusions of the assessment and all recommendations for addressing deficiencies shall be documented in writing to the MCO assigned to the claim. The assigned MCO shall have five business days from receipt of the bureau's findings to initiate or complete the recommended action steps identified by the bureau or propose alternative action steps acceptable to the bureau.

(D) If the assigned MCO does not carry out the recommended action steps or if the MCO fails to propose an acceptable alternative course of action to resolve the return-to-work barriers, the bureau may assume the medical and vocational rehabilitation management of the claim.

Last updated September 9, 2025 at 11:30 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-05.2 Employer access to the HPP - employer enrollment and selection of MCO.

(A) An employer may select any bureau certified MCO that has contracted with the bureau, and has not been placed at capacity pursuant to the MCO contract, during an open enrollment period as provided in this rule. The bureau shall develop a process for verifying an employer's MCO selection.

(B) The bureau shall select an MCO for a state fund employer that fails to select an MCO, as necessary.

(C) If an MCO merges into or is acquired by another MCO, the bureau shall assign the employers formerly assigned to that MCO to the surviving MCO.

(D) If the administrator decertifies an MCO or terminates any agreement or contract between the bureau and an MCO, the bureau shall randomly assign the employers formerly assigned to the decertified or terminated MCO to all remaining, eligible MCOs.

(E) Selection of an MCO by an employer or selection by the bureau shall be until the next open enrollment period. At the bureau's discretion or upon the employer's request, the bureau may reassign an employer from the MCO if the bureau determines that the reassignment is in the best interest of both the employer and the MCO.

(F) Once the MCO has been selected by either the employer or the bureau, the employer shall notify all employees of the selection.

(G) The bureau shall establish an open enrollment period during which time an employer may change its selection of an MCO at least once every two years, but no more than once in a year. The administrator may waive the open enrollment period during a state of emergency or disaster declared by the governor of Ohio or the president of the United States. During an open enrollment period, an employer may:

(1) Select a new MCO; or

(2) Continue with the employer's current MCO. In such case, the employer is not required to notify the bureau during the open enrollment period.

(H) The bureau shall maintain and make available to employers electronically the list of all MCOs contracting with the bureau, and shall provide adequate notice to employers in writing of the deadline for new MCO selection.

(I) An MCO may not refuse to accept an employer that has selected it or has been assigned to it by the bureau, unless the MCO has placed itself at capacity pursuant to the MCO contract.

Last updated September 9, 2025 at 11:31 AM

History

Effective: August 6, 2020
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-05.3 Employer access to the HPP - certain solicitation practices by MCOs prohibited.

(A) An MCO, any individual, corporation, or entity affiliated with the MCO as defined in rule 4123-6-03.9 of the Administrative Code, or any other individual, corporation, or entity acting on behalf of an MCO or for the benefit of an MCO, shall not:

(1) Pay, allow, or give, or offer to pay, allow, or give, to any prospective employer or to any other person, firm, or corporation not an employee or agent of the MCO, either directly or indirectly, as an inducement to or in return for an employer's selection of the MCO, any rebate, premium, or kickback, or any special favor or advantage, or any other valuable consideration or inducement not provided for under Chapter 4123-6 of the Administrative Code.

(2) Pay, allow, or give, or offer to pay, allow, or give any commission, consideration, money, or other thing of value to any person, firm, or corporation not an employee or agent of the MCO for soliciting, negotiating, procuring, placing, writing, renewing, forwarding, or transmitting to the bureau an employer's selection of the MCO.

(B) Notwithstanding paragraph (A) of this rule, the MCO may reimburse to a trade or business association certain expenses in accordance with the following:

(1) The trade or business association meets the criteria for being a sponsoring organization for group rating pursuant to section 4123.29 of the Revised Code and rules 4123-17-61 to 4123-17-68 of the Administrative Code.

(2) The MCO may reimburse to the trade or business association only its actual and reasonable expenses incurred in educating its member employers on bureau and MCO medical management and cost containment services and related rules, policies, and processes.

(3) The MCO may reimburse to the trade or business association only its actual and reasonable expenses incurred in marketing the MCO to its member employers, subject to the limits set forth in paragraph (B)(4) of this rule.

(4) The reimbursement of a trade or business association's actual and reasonable expenses incurred in marketing the MCO to its member employers during a calendar year cannot exceed sixteen one-hundredths of one per cent of the premium of those employers that are members of the trade or business association and that have selected the MCO.

(5) The MCO and the trade or business association shall keep accurate records of all marketing and education services provided to its member employers for a period of four years from the date of performance of any such service and provide the bureau with access to such records within a reasonable time after a request for audit of such records by the bureau.

(C) Except as provided in paragraph (B) of this rule, no person, firm, or corporation not an employee or agent of the MCO shall knowingly receive any payment, commission, rebate, premium or kickback, or any other valuable consideration or thing of value described in paragraph (A) of this rule.

(D) For purposes of this rule, "affiliated with an MCO" has the same meaning as in paragraph (B) of rule 4123-6-03.9 of the Administrative Code.

(E) Agent of the MCO.

(1) For purposes of this rule, "agent" of the MCO means:

(a) An insurance agent or broker contracted by the MCO and licensed by the Ohio department of insurance pursuant to Title XXXIX of the Revised Code;

(b) A corporation or entity contracted by the MCO to conduct non-telephonic marketing that has not had and does not contemplate having activities of any nature with the Ohio workers' compensation system so as to create a conflict of interest or the appearance of a conflict of interest under rule 4123-6-03.9 of the Administrative Code;

(c) A telemarketer or telemarketing firm contracted by the MCO who has obtained a certificate of registration from the Ohio attorney general in accordance with Chapter 4719. of the Revised Code.

(2) "Agent" of the MCO does not include the following:

(a) A third party administrator, group rating sponsor, business or trade association;

(b) An individual, corporation, or entity affiliated with the MCO that has had or contemplates having activities with the Ohio workers' compensation system so as to create a conflict of interest or the appearance of a conflict of interest under rule 4123-6-03.9 of the Administrative Code.

Last updated September 9, 2025 at 11:38 AM

History

Effective: April 15, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-05.4 Employer access to the HPP; payment for referrals prohibited.

(A) An MCO shall not solicit, receive, or accept any payment, commission, consideration, money, or other thing of value, including, but not limited to any rebate, premium, or kickback, as an inducement to or in return for the MCO's referral of employers to any sponsoring organization or group for the purpose of participating in a group experience rating program authorized under section 4123.29 of the Revised Code and rules 4123-17-61 to 4123-17-68 of the Administrative Code.

(B) An MCO shall not solicit, receive, or accept any payment, commission, consideration, money, or other thing of value, including but not limited to any rebate, premium, or kickback, as an inducement to or in return for the MCO's referral of employers to any individual or entity for the provision of any goods or services.

(C) An MCO shall not solicit, receive, or accept any payment, commission, consideration, money, or other thing of value, including but not limited to any rebate, premium, or kickback, as an inducement to or in return for the MCO's referral of injured workers to any provider for the provision of any goods or services.

(D) An MCO that violates this rule may be subject to decertification and/or termination of its contract pursuant to the rules of this chapter of the Administrative Code.

Last updated September 9, 2025 at 11:38 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-06.2 Employee access to the HPP - employee choice of provider.

(A) HPP.

(1) Except as provided in paragraph (A)(2) of this rule, an injured worker may seek medical care for a work related injury from:

(a) A bureau certified provider; or

(b) A non-bureau certified provider, subject to an employee's payment responsibilities as delineated in this paragraph.

(2) Except in cases of emergency, injured workers may not seek medical care for work related injuries from themselves or an immediate family member. Injured workers may not select as physician of record, themselves or an immediate family member. The MCO, bureau, employer, and industrial commission shall not reimburse treatment to injured workers delivered, rendered or directly supervised by the injured worker or an immediate family member. "Immediate family member" shall have the same meaning as in paragraph (C)(2) of rule 4123-6-02.51 of the Administrative Code.

(3) At the time of an injury, the injured worker 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 injured worker may, but is not required to, seek medical care from that provider or providers. The MCO shall not discriminate against any category of health care provider when referring the injured worker to a provider.

(4) If the injured worker seeks medical care from a provider, the injured worker shall inform the provider of the injured worker's MCO and/or employer. The provider shall then report the work related injury in accordance with rule 4123-6-02.8 of the Administrative Code.

(a) If the provider is a non-bureau certified provider, the MCO shall inform the provider that the care for the first visit will be compensated by the MCO if the claim and the treated conditions are subsequently allowed and that, unless otherwise permitted by paragraph (A)(5)(a) or (A)(5)(b) of this rule, no further treatment will be authorized.

(b) If the provider is a non-bureau certified provider, the provider shall inform the injured worker upon the initial or emergency treatment that the provider is not a participant in the HPP and that payment will not be made by the bureau, MCO, or employer for the cost of further treatment after the initial or emergency treatment

(5) An injured worker may continue treatment with a non-bureau certified provider under two circumstances:

(a) The MCO has determined that the treatment to be provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and has authorized the non-bureau certified provider to continue to provide the treatment, or

(b) The injured worker may continue to treat with the non-bureau certified provider, but at the injured worker's own expense without recourse against the bureau, MCO, or employer.

(6) Notwithstanding any other provision of this rule, if the injured worker's date of injury is prior to October 20, 1993 and the injured worker's physician of record is a non-bureau certified provider, the injured worker 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 injured worker changes the physician of record for any reason, the injured worker shall select a bureau certified provider as physician of record. If the injured worker 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.

(B) QHP.

(1) An injured worker of an employer that participates in a QHP has freedom of choice of providers within the QHP network of providers established by the employer's QHP. If the injured worker's date of injury is prior to the establishment of the employer's QHP, and the injured worker's physician of record is not a provider on the panel of the QHP when established, the injured worker 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 injured worker shall select a QHP panel provider as the physician of record.

(2) An injured worker 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 injured worker'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

(3) Notwithstanding the provisions contained in paragraph (B)(2) of this rule, an injured worker 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.

(4) Medical management of all injured workers' claims, whether medical services are provided within or without the QHP network of providers, shall be provided by the employer's QHP.

(5) A provider certified to participate in the HPP shall be eligible to participate in and to treat injured workers under the QHP system.

(1) In claims with a date of injury on or after November 2, 1959, injured workers 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.

(3) Once an injured worker of a self-insuring employer goes to a physician for treatment other than on an emergency basis, the injured worker is deemed to have made a choice of physician and the injured worker 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.

Last updated February 1, 2022 at 9:31 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-07 Services and supplies never covered.

The following services and supplies are never covered by, and shall not be authorized or reimbursed by, the bureau or MCO:

(A) Services and supplies that are never covered pursuant to other bureau statutes or rules.

(B) The following services and supplies, which are never considered to be durable medical equipment by the bureau:

(1) Home furniture including, but not limited to:

(a) Reclining chairs (except for the seat lift mechanism portion of a reclining chair);

(b) Non-hospital beds (such as a water bed, adjust-a-sleep adjustable bed, craftmatic adjustable bed, electropedic adjustable bed, simmons beautyrest adjustable bed);

(c) Hospital bed mattresses larger than a standard (eighty inches long, thirty-six inches wide) size, except for bariatric hospital bed mattresses.

(2) Home exercise equipment, including but not limited to such equipment as treadmills and exercise bikes;

(3) Home whirlpools, including built-in whirlpools and pumps, portable hydrotherapy pools, jacuzzi tubs, portable saunas and spas, non-portable hot tubs or whirlpools, and therasaunas.

(4) Unsupervised physical reconditioning programs, except when the criteria have been met for an injured worker who is participating in a vocational rehabilitation or remain at work program.

(D) Prescription smoking deterrent drugs outside an approved smoking cessation program, except when dispensed while the injured worker is admitted to a hospital during an approved inpatient admission or during the course of an outpatient visit in a hospital.

(E) Drug screening of injured workers performed by employers or performed in the emergency room at the time of injury at the request of the employer.

(F) Platelet-rich plasma (PRP) injections.

Last updated October 1, 2026 at 9:09 AM

History

Effective: October 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-08 Bureau fee schedule.

(A) Pursuant to division (A)(1)(h) of section 4121.441 of the Revised Code, the administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, develops, maintains, and publishes a provider fee schedule for the various types of billing codes. The administrator hereby adopts the professional provider fee schedule indicated in the appendix to this rule.

(B) Whether the MCO has elected to retain a provider panel or not, an MCO may contract with providers. The MCO shall provide an MCO fee schedule to each provider that contracts with the MCO, describing the method of payment, and make the MCO fee schedule available to the bureau as part of its application for certification. The bureau will maintain the MCO fee schedule as proprietary information.

View Appendix

Last updated May 1, 2026 at 8:10 AM

History

Effective: May 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-10 Payment to providers.

(A) HPP.

(1) The MCO shall accumulate medical records and bills for services rendered to injured workers for provider services and submit the bills electronically to the bureau for payment in a bureau approved format, utilizing billing policies, including but not limited to clinical editing, as set forth in the MCO contract. The MCO shall submit a bill to the bureau within seven business days of its receipt of a valid, complete bill from the provider.

(2) For a provider in the MCO's panel or with whom the MCO has entered into an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau fee schedule, the MCO contracted fee, or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(3) For a bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(4) For a non-bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider for initial or emergency treatment, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(5) For a non-bureau certified provider who is not in the MCO's panel or with whom the MCO does not have an arrangement, other than a hospital, the bureau shall electronically transfer to the MCO for payment to the provider for subsequent treatment after the initial or emergency treatment, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee, only under the following circumstances:

(a) Where the treatment provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and the MCO has authorized the treatment pursuant to rule 4123-6-06.2 of the Administrative Code, or

(b) Where the treatment provided by the non bureau certified provider is reasonably available through a like bureau certified provider, the non-bureau certified provider may only be reimbursed for the treatment if the provider becomes bureau certified. If the provider refuses or fails to become bureau certified, the treatment shall not be reimbursed.

(6) For hospital services, the bureau shall electronically transfer to the MCO for payment to the hospital, in accordance with rule 4123-6-14 of the Administrative Code, either the lesser of the applicable amount pursuant to rule 4123-6-37.1 (inpatient) or 4123-6-37.2 (outpatient) of the Administrative Code or the MCO contracted fee, or, if applicable under paragraph (A)(7) of this rule, the MCO negotiated fee.

(7) The MCO shall have authority to negotiate fees with providers, either by contract or on a case-by-case basis, in the following circumstances:

(a) As permitted under rule 4123-6-08 of the Administrative Code (including the appendix to the rule);

(b) As permitted under rule 4123-6-37.1, 4123-6-37.2 or 4123-6-37.3 of the Administrative Code;

(d) With non-bureau certified providers outside the state, where the treatment provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider;

(e) With bureau certified providers and non-bureau certified providers within the state, where unusual circumstances justify payment above BWC's maximum allowable rate for the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) level II and level III coded services/supplies, and such circumstances are documented and approved by the bureau.

(8) The bureau shall not pay for missed appointments or procedures. If the provider customarily charges for missed appointments or procedures, the provider shall inform the injured worker upon the initial or emergency treatment that the provider charges for missed appointments or procedures and that such charges are the responsibility of the injured worker. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider for the actual conditions treated. A provider shall not transmit to the MCO or bureau any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.

(B) QHP.

(1) Within each QHP, all payments shall be in accordance with consistent billing and payment policies and practices established by the QHP and consistent with the provisions contained in paragraph (L)(5) of rule 4123-19-03 of the Administrative Code.

(2) With the exception that no financial arrangement between an employer or QHP and a provider shall incentivize a reduction in the quality of medical care received by an injured worker, an employer or QHP may pay a QHP panel provider a rate that is the same, is above or, if negotiated with the provider in accordance with rule 4123-6-46 of the Administrative Code, is below the rates set forth in the applicable provider fee schedule rules developed by the bureau. Nothing in the rules pertaining to the QHP system shall be construed to inhibit employers or QHPs and providers in their efforts to privately negotiate a payment rate.

(3) An employer or QHP shall pay a bureau certified non-QHP panel provider other than a hospital the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(4) An employer or QHP shall pay a bureau certified non-QHP panel hospital the applicable amount under rule 4123-6-37.1 (inpatient) or 4123-6-37.2 (outpatient) of the Administrative Code, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(5) Employers' financial arrangements with company-based providers remain intact and services provided by company based providers need not be billed separately through QHP arrangements.

(6) An employer in the QHP system shall authorize and pay for initial or emergency medical treatment for an injury or occupational disease that is an allowed claim or condition provided by a non-bureau certified provider as follows:

(a) The employer shall pay a non-bureau certified provider only for initial or emergency treatment of an injured worker for a workers' compensation injury, unless the QHP specifically authorizes further treatment. A non-bureau certified provider shall inform the injured worker that the provider is not a participant in the QHP and that the injured worker may be responsible for the cost of further treatment after the initial or emergency treatment, unless payment for further treatment is specifically authorized by the QHP. The injured worker may continue to obtain treatment from the non-bureau certified provider, but the payment for the treatment shall be the injured worker's sole responsibility, except as provided in this paragraph.

(b) An employer or QHP shall pay a non-bureau certified provider that provides initial or emergency medical treatment or further medical treatment that has been specifically authorized by the QHP, other than a hospital, the lesser of the bureau fee schedule or the charges billed by the provider for the allowed services rendered, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(7) An employer or QHP shall pay a non-bureau certified hospital that provides initial or emergency medical treatment or further medical treatment that has been specifically authorized by the QHP the applicable amount under rule 4123-6-37.1 (inpatient) or 4123-6-37.2 (outpatient) of the Administrative Code, unless an alternate payment arrangement is negotiated between an employer or QHP and the provider in accordance with rule 4123-6-46 of the Administrative Code.

(8) The employer or QHP shall not pay for missed appointments or procedures. If the provider customarily charges for missed appointments or procedures, the provider shall inform the injured worker upon the initial or emergency treatment that the provider charges for missed appointments or procedures and that such charges are the responsibility of the injured worker. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider for the actual conditions treated. A provider shall not transmit to the employer or QHP any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.

(1) Payment for medical services and supplies by self-insuring employers shall be equal to or greater than the fee schedule established by the bureau in state fund claims, unless otherwise negotiated with the provider in accordance with rule 4123-6-46 of the Administrative Code. All payments by the self-insuring employer shall be consistent with the provisions contained in paragraph (L)(5) of rule 4123-19-03 of the Administrative Code.

(2) The self-insuring employer shall not pay for missed appointments or procedures. If the provider customarily charges for missed appointments or procedures, the provider shall inform the injured worker upon the initial or emergency treatment that the provider charges for missed appointments or procedures and that such charges are the responsibility of the injured worker. Bills must only contain descriptions of services that have been actually delivered, rendered, or directly supervised by the provider for the actual conditions treated. A provider shall not transmit to the self-insuring employer any bill containing false or misleading information that would cause a provider to receive payment for services that the provider is not entitled to receive.

(D) Provider duty to report overpayment. A provider that has identified an overpayment must report and return the overpayment to the bureau, QHP or self-insuring employer within sixty days of identifying the overpayment. Providers must exercise reasonable diligence to identify and quantify overpayments.

Last updated November 4, 2025 at 2:11 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-14 MCO bill submission to bureau.

(A) The bureau shall review all bills received from the MCO pursuant to paragraph (A)(1) of rule 4123-6-10 of the Administrative Code for payment eligibility. The bureau's review may include, but not be limited to, verification of the following:

(1) The services were delivered, rendered, or directly supervised by providers who meet bureau credentialing and licensing criteria;

(2) The bills conform to the bureau's billing and reimbursement manual in effect on the billed date(s) of service.

(B) The bureau shall electronically transfer funds to the MCO for allowed payments after receipt of a proper invoice and after a final adjudication permitting payment for the bill. Upon receipt of funds from the bureau, the MCO shall pay the provider within seven days or less. The MCO shall pay to providers at least the amount electronically transferred by the bureau to the MCO for reimbursement of provider services.

(C) A provider that bills an MCO for services in expectation of payment from the MCO is responsible for the accuracy of all billing data and information the provider transmits to the MCO. The MCO is responsible for the accuracy of translating billing data received from the provider and the accuracy of transmitting billing data to the bureau that results in payment to the MCO or to the provider.

Last updated September 9, 2025 at 11:39 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-14.1 Records to be retained by MCO.

(A) An MCO shall retain records received from providers and subcontractors that are utilized by the MCO to perform its medical management functions, to substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers, and to develop electronic billings to the bureau.

(1) The MCO shall retain records relating to a claim so long as the industrial commission and bureau of workers' compensation have continuing jurisdiction over the claim pursuant to section 4123.52 of the Revised Code.

(2) The MCO shall also create, maintain, and retain records documenting transactions with the injured worker, providers, and subcontractors that do not relate to a specific claim, including but not limited to monthly bank statements, monthly bank records (e.g., deposit slips), account reconciliations and all supporting documentation (e.g., monthly check registers, outstanding check lists, voided transactions), and general and subsidiary ledger accounting records for a period of seven years from the date of the transaction.

(B) The failure of an MCO to create, maintain, and retain such records shall be sufficient cause for the bureau to deny payment for goods or services, or for performance fees, or for declaring overpaid previous payments made to the MCO, and may be cause for decertification.

(C) As used in this rule, "records" includes, but is not limited to, "record" and "electronic record" as defined in rule 4125-1-02 of the Administrative Code.

Last updated September 9, 2025 at 11:39 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-15 Confidentiality of records.

(A) Subject to sections 2317.02, 4123.27, and 4123.88 of the Revised Code, certain employer premium, payroll, and claim file information is confidential and exempt from the general open records laws of Ohio, as set forth in section 149.43 of the Revised Code.

(B) In the course of medical management in the HPP, some confidential information may be provided by the bureau to the MCO, and/or exchanged among the bureau, the MCO, the employer and its representative, the injured worker and the injured worker's representative, the provider, and the provider's employees and agents. All such parties receiving and/or exchanging confidential information for use in the HPP shall ensure transmission of confidential information through secured methods approved by the bureau, including but not limited to encryption, password protection, facsimile, and other secure methods.

(C) All parties receiving and/or exchanging confidential information for use in the HPP shall not use such confidential information for any use other than to perform duties required by the HPP, and shall prevent such information from further disclosure or use by unauthorized persons. MCOs shall not release any confidential information, other than in accordance with rule 4123-3-22 of the Administrative Code, to any third parties (including, but not limited to, parent, subsidiary, or affiliate companies, or subcontractors of the MCO) without the express prior written authorization of the bureau.

(D) MCOs shall comply with, and shall assist the bureau in complying with, all disclosure, notification or other requirements contained in sections 1347.12, 1349.19, 1349.191 and 1349.192 of the Revised Code, as may be applicable, in the event computerized data that includes personal information, obtained by the MCO for use in the HPP, is or reasonably is believed to have been accessed and acquired by an unauthorized person and the access and acquisition by the unauthorized person causes, or reasonably is believed will cause a material risk of identity theft or other fraud.

(E) MCOs shall comply with all electronic data security measures as may be required by Ohio law, Ohio department of administrative services or other state agency directive, executive order of the governor of Ohio, and/or the MCO contract.

Last updated September 9, 2025 at 11:39 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-16 Alternative dispute resolution for HPP medical issues.

(A) Pursuant to division (A)(1) of section 4121.441 of the Revised Code, this rule provides procedures for an alternative dispute resolution (ADR) process for medical disputes between an employer, an injured worker, or a provider and an MCO arising from the MCO's decision regarding a medical treatment reimbursement request (on form C-9 or equivalent). An injured worker or employer must exhaust the ADR procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code on an MCO's decision regarding a medical treatment reimbursement request.

(B) Within fourteen days of receipt of an MCO decision, an injured worker, employer, or provider may dispute the decision in writing (on form C-11 or equivalent) to the MCO. The written medical dispute must contain, at a minimum, the following elements:

(1) Injured worker name.

(2) Injured worker claim number.

(3) Date of initial medical treatment reimbursement request in dispute.

(4) Specific issue(s) in dispute, including description, frequency/duration, beginning/ending dates, and type of treatment/service/body part.

(5) Name of party making written appeal request.

(6) Signature of party making written appeal request or the party's authorized representative.

Written medical disputes that do not contain the minimum elements set forth in this paragraph may be dismissed by the MCO or bureau.

(C) Upon receipt of a written medical dispute, the MCO will initiate the ADR process, which consists of one independent level of professional review ("peer review") as follows:

(1) If an individual health care provider eligible to be physician of record would be providing the services requested in the dispute, the peer review is to be conducted by an individual or individuals licensed pursuant to the same section of the Revised Code as the health care provider who would be providing the services requested.

(2) Notwithstanding paragraph (C)(1) of this rule, if the MCO has already obtained one or more peer reviews during previous disputes involving the same treatment, the MCO may obtain a different perspective review from a licensed physician who falls outside the peer review criteria set forth in paragraph (C)(1) of this rule.

(3) If an individual health care provider not eligible to be physician of record would be providing the services requested in the dispute, peer review is to be conducted by an individual or individuals eligible to be physician of record whose scope of practice includes the services requested.

(4) If the MCO receives a dispute where the requested treatment is the same as a previous treatment request for which the MCO conducted a peer review, and the previous treatment request was ultimately denied based on the peer review, the MCO may use the previous peer review as the peer review under this paragraph, provided the peer review was conducted within six months of the current request and there are no new or changed circumstances in the injured worker's condition documented in the claim file.

(5) The MCO will submit a copy of the peer review to the bureau, and the bureau will provide the parties to the claim access to the peer review electronically.

(D) If, upon consideration of additional evidence or after agreement with the party that submitted the written medical dispute, the MCO reverses the decision under dispute or otherwise resolves the dispute to the satisfaction of the party, the MCO may issue a new decision and dismiss the dispute.

(E) The MCO will complete the ADR process and submit its recommended ADR decision to the bureau electronically within twenty-one days of the MCO's receipt of the written medical dispute, unless the injured worker is scheduled for an independent medical examination under paragraph (I) of this rule.

(F) Within two business days after receipt of a recommended ADR decision from the MCO, the bureau will publish and mail to all parties a final order, which may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. The provider and the MCO may not file an appeal of the bureau order.

(G) Notwithstanding paragraph (C) of this rule, the MCO may pend a written medical dispute under the following circumstances:

(1) If the MCO receives a written medical dispute involving a medical treatment reimbursement request that is the same as a previous treatment request for which the MCO conducted a peer review, and the previous treatment request is pending before the bureau or industrial commission, the MCO may pend the new dispute until the previous treatment request has been resolved. Once the previous treatment request has been resolved, the MCO will resume the ADR process.

(2) If the MCO receives a written medical dispute involving a medical treatment reimbursement request that is dependent upon the outcome of an additional condition request pending before the bureau or industrial commission, the MCO may pend the dispute until the earlier of the final administrative or judicial decision or the industrial commission staff hearing officer decision on the request for the additional condition, at which time the MCO will resume the ADR process.

(H) Notwithstanding paragraph (C) of this rule, an MCO may submit its recommended ADR decision to the bureau electronically without obtaining a peer review under the following circumstances:

(1) The MCO receives a written medical dispute involving a medical treatment reimbursement request relating to the delivery of medical services that have been approved by the MCO pursuant to standard treatment guidelines, pathways, or presumptive authorization guidelines.

(2) The MCO receives a written medical dispute involving a medical treatment reimbursement request clearly relating to the delivery of medical services for a condition that is not allowed in the claim, and the issue of the allowance of the additional condition is not pending before the bureau or industrial commission.

(I) Either the MCO or the bureau may schedule an independent medical examination (IME) of the injured worker to assist in the ADR process under this rule.

(1) An ADR IME will be limited to issues relating to medical treatment disputes, and will not include extent of disability issues. An ADR IME will not be conducted at the request of an employer and does not substitute for an examination permitted under section 4123.651 of the Revised Code.

(2) If an ADR IME is scheduled under this rule, the parties, and their representatives, if any, will be promptly notified as to the time and place of the examination, and the questions and information provided to the doctor. The injured worker will be reimbursed for travel expenses in accordance with rule 4123-6-40 of the Administrative Code.

(3) The scheduling of an ADR IME will toll the MCO's time frame for completing the ADR process, and in such cases the MCO will submit its recommended ADR decision to the bureau electronically within seven days after receipt of the independent medical examination report.

(4) If an injured worker refuses to attend an IME to assist in the ADR process, the MCO will refer the issue to the bureau, and the injured worker's right to benefits may be suspended during the period of refusal.

Last updated September 9, 2025 at 11:39 AM

History

Effective: June 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-16.1 HPP medical treatment guidelines.

In reviewing medical treatment reimbursement requests pursuant to rule 4123-6-16.2 of the Administrative Code and conducting independent reviews of medical disputes pursuant to rule 4123-6-16 of the Administrative Code, the MCO and the bureau shall refer to treatment guidelines adopted by the bureau. In the event of a conflict between these guidelines and any provision of this chapter of the Administrative Code, the provisions contained in the Administrative Code shall control.

Last updated September 9, 2025 at 11:39 AM

History

Effective: February 1, 2010
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-16.2 Medical treatment reimbursement requests.

(A) Medical treatment reimbursement requests (on form C-9 or equivalent) must be submitted by a provider eligible to submit such requests to the MCO responsible for medical management of the claim prior to initiating any non-emergency treatment.

The following provider types are eligible to submit medical treatment reimbursement requests to the MCO:

(1) A physician as defined in rule 4123-6-01 of the Administrative Code;

(2) The following non-physician practitioner types:

(a) Advanced practice nurses;

(b) Physician assistants;

(d) Occupational therapists;

(e) Optometrists;

(f) Audiologists;

(g) Licensed independent social workers;

(h) Licensed professional clinical counselors;

(i) Licensed prosthetists.

(B) Medical treatment reimbursement requests are evaluated by the MCO using the following three-part test (all parts must be met to authorize treatment reimbursement):

(1) The requested services are reasonably related to the industrial injury (allowed conditions);

(2) The requested services are reasonably necessary for treatment of the industrial injury (allowed conditions);

(3) The costs of the services are medically reasonable.

(C) For informational purposes, the bureau may require the provider to include on the medical treatment reimbursement request the applicable codes, from the edition of the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) in effect on the date of the request, for the procedures or services being requested.

However, review of the request is directed to the treatment being requested, and is not to be construed as approving or denying payment for the specific codes listed by the provider.

(D) Medical treatment reimbursement requests in inactive claims are processed in accordance with rule 4123-3-15 of the Administrative Code.

(E) Medical treatment reimbursement requests submitted by a physical therapist or occupational therapist must be accompanied by a prescription as required in paragraph (B) of rule 4123-6-30 of the Administrative Code, and approval of such requests is valid for no longer than thirty days unless the approval specifies a longer period and such longer period is supported by the prescription.

(F) Medical treatment reimbursement requests submitted by a prosthetist must be accompanied by a prescription from the physician of record or other approved treating provider licensed to practice medicine or osteopathic medicine.

(G) Approval of all medical treatment reimbursement requests is valid for no longer than six months unless the approval specifies a longer period.

(H) The MCO may dismiss without prejudice medical treatment reimbursement requests under the following circumstances:

(1) The request has been submitted by a provider who is not enrolled with the bureau and who refuses to become enrolled, or who is enrolled but non-certified and is ineligible for payment as a non-certified provider under rule 4123-6-06.2 or 4123-6-10 of the Administrative Code or division (N) of section 4121.44 of the Revised Code.

(2) The request is not accompanied by supporting medical documentation that the submitting provider has examined the injured worker within thirty days prior to the request, or that the injured worker requested a visit with the provider, and such evidence is not provided to the MCO upon request (through form C-9A or equivalent).

(3) The request duplicates a previous request that has been denied in a final administrative or judicial determination where the new request is not accompanied by supporting medical documentation of new and changed circumstances impacting treatment, and such evidence is not provided to the MCO upon request (through form C-9A or equivalent).

(4) The underlying claim has been settled, and the dates of service requested are on or after the effective date of the settlement. If the request includes both dates of service on or after the effective date of the settlement and dates of services prior to the effective date of the settlement, the MCO may dismiss without prejudice only that portion of the request relating to dates of service on or after the effective date of the settlement.

(5) The underlying claim has been disallowed or dismissed in its entirety, or the only allowances in the underlying claim are for substantial aggravation of a pre-existing condition, and the conditions have been determined in a final administrative or judicial determination to be in a non-payable status.

(6) The services or supplies being requested are never covered by the bureau pursuant to other bureau statutes or rules.

(7) Unless otherwise provided in this chapter of the Administrative Code, the MCO has requested from the submitting provider (through form C-9A or equivalent) supporting medical documentation necessary to the MCO's evaluation and determination, and such documentation is not provided to the MCO.

(8) A fee bill for the service was not submitted to the bureau or commission within the applicable time frame as set forth in rule 4123-3-23 of the Administrative Code.

(I) If the MCO determines that any approved medical treatment reimbursement request is not medically indicated or necessary, is not producing the desired outcomes, or the injured worker is not responding, the MCO may notify the parties of its decision to discontinue payment of approved treatment that has not already been rendered.

This decision is subject to alternative dispute resolution pursuant to rule 4123-6-16 of the Administrative Code.

(J) Notwithstanding any other provision of this rule, the bureau may reserve the authority to authorize or prior authorize reimbursement for services including, but not limited to, return to work management services pursuant to paragraph (D) of rule 4123-6-04.6 of the Administrative Code, caregiver services, and home and vehicle modifications.

Last updated September 9, 2025 at 11:40 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-16.3 Reimbursement of retroactive medical treatment reimbursement requests.

(A) Except as otherwise provided in paragraph (D) of this rule, medical treatment reimbursement requests submitted retroactively to the MCO responsible for medical management of claim by a provider eligible to submit such requests, without just cause, for non-emergency treatment delivered, rendered, or directly supervised by the provider shall, if approved, be reimbursed at seventy-five per cent of the applicable fee schedule amount, provider may not balance bill the injured worker for the difference in amount.

(B) For purposes of this rule, "just cause" includes, but is not limited to:

(1) The treatment requested was emergency treatment;

(2) The provider was not aware that services were for a workers' compensation claim;

(3) The provider was non-bureau certified and had no established relationship with the injured worker;

(4) The provider was initially bureau certified within six months prior to the treatment request;

(5) The treatment requested was for a pending claim allowance or additional allowance with the bureau or industrial commission;

(6) The treatment provided was within the bureau's presumptive authorization guidelines, or does not require prior authorization per the bureau's provider billing and reimbursement manual;

(7) The treatment request was submitted retroactively due to bureau or MCO error;

(8) Other documented justification as deemed sufficient by the bureau.

(C) Determinations that an approved medical treatment reimbursement request shall be reimbursed at seventy-five per cent of the applicable fee schedule amount pursuant to paragraph (A) of this rule shall be subject to the grievance hearing procedure for disputed bill payments provided by rule 4123-6-04.3 of the Administrative Code.

(D) Retroactive medical treatment reimbursement requests submitted within seven calendar days of the initiation of treatment or prior to the date of the physician of record or eligible treating provider's next encounter with the injured worker, whichever is earlier, shall not be subject to payment reduction under paragraph (A) of this rule.

Last updated September 9, 2025 at 11:40 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-17 Bureau refusal to certify or recertify, action to decertify a provider or MCO - standards and procedures for adjudication hearings.

(A) The administrator of the bureau of workers' compensation may refuse to certify or recertify or may decertify a provider, MCO, or QHP as provided in this chapter.

(B) The bureau will monitor and may investigate a provider, MCO, or QHP, and may participate with other state or federal agencies or law enforcement authorities in gathering evidence for such matters.

(C) Prior to the administrator issuing an adjudication order on the matter, the administrator will afford the provider, MCO, or QHP an opportunity for a hearing by serving written notice to the provider, MCO or QHP in accordance with Chapter 119. of the Revised Code. The notice will include a statement informing the provider, MCO, or QHP that if the bureau does not receive a request for a hearing within thirty days of the time of the service of the written notice, the administrator may proceed with an adjudication order concerning the provider, MCO, or QHP.

(D) If no timely request for a public hearing is made by the provider, MCO, or QHP, the administrator may issue an adjudication order concerning the provider, MCO, or QHP.

(E) If the provider, MCO, or QHP files a timely request for a hearing, the bureau will schedule the hearing in accordance with sections 119.07 and 119.09 of the Revised Code. The hearing will be held at the bureau central office in Columbus, but if requested by the provider, MCO, or QHP, the bureau may hold the hearing in the bureau office closest to the place of business of the provider, MCO, or QHP.

(F) Conduct of hearing.

(1) The hearing will be conducted in accordance with Chapter 119. of the Revised Code. The administrator may conduct the hearing personally or may delegate the hearing to a referee, who will be an attorney at law. The referee may be from the bureau's legal division or an attorney employed by the administrator especially for such purpose. The bureau has the burden of proof to establish, by a preponderance of the evidence, cause for suspending or revoking the certification of a provider, MCO, or QHP.

(G) Should the provider, MCO, or QHP be adversely affected by the order of the administrator, the provider, MCO, or QHP may file a notice of appeal of the decision in accordance with section 119.12 of the Revised Code.

(H) Any adjudicating order of the administrator to decertify, or to refuse to recertify a provider, MCO, or QHP shall include a clear indication of the beginning date of such action.

Last updated September 9, 2025 at 11:40 AM

History

Effective: April 15, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-18 Data gathering and reporting.

(A) Pursuant to division (L) of section 4121.44 of the Revised Code and division (A)(1)(f) of section 4121.441 of the Revised Code, the administrator shall require employees, employers, providers, MCOs, and plans that participate in the workers' compensation system to report data to be used by the administrator to:

(1) Measure and perform comparison analyses of costs, quality, appropriateness of medical care, and effectiveness of medical care delivered by all components of the workers' compensation system.

(2) Compile data to support activities of the MCOs and to measure the outcomes and savings of the HPP.

(3) Publish and report compiled data on the measures of outcomes and savings of the HPP to the governor, the speaker of the house of representatives, and the president of the senate with the annual report prepared under division (F)(3) of section 4121.12 of the Revised Code.

(B) The administrator shall compile at least annually and make available electronically to each employer a report that summarizes the performance of each MCO.

Last updated September 9, 2025 at 11:40 AM

History

Effective: April 1, 2021
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-19 Remain at work services.

(A) The bureau shall take measures and make expenditures, as it deems necessary, to aid injured workers who have sustained compensable injuries or contracted occupational diseases to remain at work.

(B) Remain at work services.

(1) An injured worker is eligible to receive remain at work services when:

(a) The injury results in a medical only claim which is certified by the employer or is allowed pursuant to a bureau or industrial commission order or a lost time claim with eight or more days of lost time due to a work related injury which is certified by the employer or is allowed pursuant to a bureau or industrial commission order, but the injured worker is not receiving and has not been awarded temporary total compensation or salary continuation in the claim; and,

(b) It is documented by the employer, the injured worker, or the physician of record that the injured worker is experiencing problems that are work-related and result from the allowed conditions in the claim.

(2) Services provided shall be charged to the employer's risk.

(3) The MCO shall determine the need for remain at work services.

(4) Within five business days of completion of services, the MCO shall submit a final report to the bureau.

(5) The bureau may audit the MCO's utilization of remain at work services.

(1) Remain at work services may include ergonomic study, functional capacity evaluation, job analysis, physical therapy (on site), occupational therapy (on site), physical reconditioning, transitional work, gradual return to work, on the job training, short term training, job modification, tools and equipment, and remain at work case management.

(2) The bureau will not reimburse an employer for remain at work services that are provided by the employer (e.g., transitional work, on the job training, gradual return to work).

(3) Remain at work services shall cease upon the occurrence of any of the following:

(a) A bureau, industrial commission or court order subsequently disallowing the claim.

(b) The claim changes to a lost time claim with eight or more days of lost time due to a work related injury and the injured worker receives temporary total compensation or salary continuation in the claim.

(4) A claim that changes to a lost time claim with eight or more days of lost time due to a work related injury may be referred for vocational rehabilitation services as provided under Chapter 4123-18 of the Administrative Code if the injured worker is receiving or has been awarded temporary total compensation or salary continuation in the claim.

Last updated September 9, 2025 at 11:40 AM

History

Effective: November 13, 2015
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-20 Obligation to submit medical documentation and reports.

(A) A provider is responsible for the accuracy and legibility of all reports, information, and documentation submitted by the provider, the provider's employees, or the provider's agents to the bureau, industrial commission, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation claim. The provider, the provider's employees, and the provider's agents shall not submit or cause or allow to be submitted to the bureau, industrial commission, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer any report, information, and documentation containing false, fraudulent, deceptive, or misleading information.

(B) Physician's medical reports of work ability.

(1) Physicians treating injured workers shall complete, sign, and submit to the MCO a physician's report of work ability on form MEDCO-14 or equivalent upon every injured worker encounter, unless:

(a) The injured worker has been awarded compensation for permanent total disability;

(b) The injured worker returns to work without restrictions within seven days of the injury; or

(c) The injured worker is seeing the treating physician after the treating physician has submitted a MEDCO-14 or equivalent releasing the injured worker to return to the former position of employment without restrictions.

(2) The physician's report of work ability must include at a minimum the following:

(a) The date of the report;

(b) The date of the last examination;

(c) The "International Classification of Disease" diagnosis code(s) recognized in the claim for all conditions and all parts of the body being treated that are affecting the length of disability, including a primary diagnosis code, with a narrative description identifying the condition(s) and specific area(s) of the body being treated;

(d) Any reason(s) why recovery has been delayed;

(e) The date temporary total disability began;

(f) The current physical capabilities of the injured worker;

(g) An estimated or actual return to work date;

(h) An indication of need for vocational rehabilitation;

(i) Objective findings; and

(j) Clinical findings supporting the information in this rule.

(1) Upon allowance of a claim by the bureau, industrial commission, or self-insuring employer, the physician of record and other providers treating the injured worker shall provide and continue to update a treatment plan to the MCO, QHP, or self-insuring employer according to the format or information requirements designated by the bureau. A treatment plan should include at least the following:

(a) Details of the frequency, duration, and expected outcomes of medical interventions, treatments, and procedures;

(b) The estimated return to work date; and

(2) Modifications should be made to the initial treatment plan as treatment is extended, changed, completed, added, deleted or canceled. The modification should describe the current prognosis for the injured worker, progress to date, and expected treatment outcomes.

(3) Treatment plans should be updated when significant changes occur in the claim that impact claims management. Changes include:

(a) Additional allowance;

(b) Re-activation;

(d) Return to modified or alternative work;

(e) Maximum medical improvement;

(f) Rehabilitation;

(g) A new injury while receiving treatment in the claim.

(D) Supplemental reports or other bureau forms from the attending physician and other providers may be requested by the bureau, industrial commission, employer, MCO, QHP, or by the injured worker or representative. These reports shall be used to determine the appropriateness of a benefit, bill payment, or allowance.

(E) In accepting a workers' compensation case, a provider assumes the obligation to provide to the bureau, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer, upon written request or facsimile thereof and within five business days, all medical, psychological, psychiatric, or vocational documentation relating causally or historically to physical or mental injuries relevant to the claim required by the bureau, MCO, QHP, or self-insuring employer, and necessary for the injured worker to obtain medical services, benefits or compensation.

(F) Independent medical examinations.

(1) A provider performing an independent medical examination of an injured worker shall create, maintain, and retain sufficient records, papers, books, and documents in such form to fully substantiate the accuracy of the resulting report submitted to the bureau, industrial commission, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation claim. The provider, the provider's employees, and the provider's agents shall keep such records in accordance with rule 4123-6-45.1 of the Administrative Code, and such records shall be subject to audit pursuant to rule 4123-6-45 of the Administrative Code.

(2) A provider performing an independent medical examination of an injured worker shall keep confidential all information obtained in the performance of the independent medical examination, including but not limited to knowledge of the contents of confidential records of the bureau, industrial commission, injured worker, employer, or their representatives, MCO, QHP, or self-insuring employer. The provider, the provider's employees, and the provider's agents shall maintain the confidentiality of such records in accordance with all applicable state and federal statutes and rules, including but not limited to rules 4123-6-15 and 4123-6-72 of the Administrative Code.

Last updated November 4, 2025 at 2:11 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-20.1 Access to medical documentation.

(A) The purpose of this rule is to provide parties to a workers' compensation claim reasonable access to and reasonable charges for medical records necessary for the administration of the claim.

(B) Except as provided in this rule, a medical provider shall not assess a fee or charge the bureau, industrial commission, MCO, QHP, self-insuring employer, injured worker, employer, or their representatives for the costs of completing any bureau form or providing any documentation requested pursuant to rule 4123-6-20 of the Administrative Code.

(1) The bureau shall provide authorized parties to the claim access to all filed medical records without charge through secure electronic access.

(2) Where the bureau has provided access to medical records electronically and a party requests copies of such medical records, the bureau may charge a fee for the copies in accordance with the Ohio public records laws.

(3) Where a provider has filed copies of medical records with the bureau or MCO and the bureau has provided access to such medical records electronically or the provider has filed copies of medical records with the self-insuring employer, if a party requests such medical records of the provider, the provider may charge a fee for the copies. The provider's fee shall not exceed the amount allowable under sections 3701.741 and 3701.742 of the Revised Code.

(1) A claimant shall promptly provide a current signed release of medical information, records, and reports relative to the issues necessary for the administration of the claim when requested by the employer. The employer shall immediately provide copies of all medical information, records, and reports to the bureau and to the claimant or the claimant's representative upon request;

(2) Medical information, records, and reports shall be related causally or historically to physical, psychological, or psychiatric injuries relevant to the claimant's workers' compensation claim.

Last updated November 4, 2025 at 2:11 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-21 Payment for outpatient medication.

(A) Except as otherwise provided in rule 4123-6-21.6 of the Administrative Code, medication must be for the treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission. The bureau may deny a drug or therapeutic class of drugs as not being reasonably related to or medically necessary for treatment of the allowed conditions in a claim.

(B) Medication may be prescribed by any treating provider authorized by law to prescribe such medication; however, reimbursement for medication shall be denied under the following circumstances:

(1) Reimbursement for prescriptions written by providers who are not enrolled with the bureau and who refuse to become enrolled shall be denied.

(2) Reimbursement for prescriptions written by providers who are enrolled but non-certified shall be denied, except in the following situations:

(a) The prescription is written by a non-bureau certified provider during initial or emergency treatment of the injured worker if the injured worker's claim and treated conditions are subsequently allowed or payment is permitted under rule 4123-6-21.6 of the Administrative Code.

(b) The prescription is written by a non-bureau certified provider who is outside the state or within the state where no or an inadequate number of bureau certified providers exist and the managed care organization (MCO) has determined that the treatment to be provided by the non-bureau certified provider is not reasonably available through a like bureau certified provider and has authorized the non-bureau certified provider to continue to provide the treatment.

(c) The prescription is written by a non-bureau certified provider for an injured worker with a date of injury prior to October 20, 1993, the provider was the injured worker's physician of record prior to October 20, 1993, and the injured worker has continued treatment with that non-bureau-certified provider.

(C) Drugs covered are limited to those that are approved for human use in the United States by the food and drug administration (FDA) and that are dispensed by a registered pharmacist from an enrolled pharmacy provider.

(D) The bureau may require prior authorization of certain drugs or therapeutic classes of drugs, drugs above a certain cost threshold, drugs submitted outside a certain time frame from the date of injury or the last prescription submitted, or drugs being prescribed for a condition or in a manner not approved by the FDA. The bureau will publish a list of all such drugs or therapeutic classes of drugs, cost thresholds, or time frames for which prior authorization is required.

(E) The bureau may reimburse opioid prescriptions used to treat a work related injury or occupational disease only if the prescriber follows current best medical practices, as outlined in rules 4731-11-13 and 4731-11-14 of the Administrative Code and this rule.

A prescriber's failure to comply with these rules may be subject to peer review by the bureau of workers' compensation pharmacy and therapeutics (P&T) committee pursuant to rule 4123-6-21.2 of the Administrative Code, the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the Administrative Code, or other peer review committee established by the bureau, and subject to decertification pursuant to rule 4123-6-02.7 of the Administrative Code.

(F) Prescriptions for compounded drug products:

(1) Prior authorization may be required for reimbursement of compounded sterile drug products.

(2) Reimbursement for non-sterile compounded prescriptions will be denied, except when a commercially available formulary product becomes unavailable (listed on the "Food & Drug Administration Drug Shortages List," or "American Society of Health-System Pharmacists Drug Shortages List"). In such cases:

(a) A prior authorization request for reimbursement for non-sterile compounded prescriptions must be submitted; and

(b) Approval for reimbursement of non-sterile compounded prescriptions will be for an initial period of thirty days with subsequent approvals contingent upon commercial product availability. Not more than one prescription for a non-sterile compounded prescription will be approved for reimbursement in any thirty day period.

(G) Drugs which fall into one of the following categories may be approved by an MCO as part of a comprehensive treatment plan submitted by the physician of record or treating physician and reimbursed by the MCO or by the bureau's pharmacy benefit manager (PBM):

(1) Drugs for the treatment of obesity;

(2) Drugs for the treatment of infertility;

(3) Non-compounded parenteral drugs not intended for self-administration;

(4) Drugs used to aid in smoking cessation;

(5) Drugs dispensed to an injured worker while the injured worker is admitted to a hospital during an approved inpatient admission or during the course of an outpatient visit in a hospital.

(6) Home infusion services.

(H) Payment for medications to pharmacy providers shall include both a product cost component and a dispensing fee component.

(1) Except as provided in this paragraph, the product cost component shall be the lesser of the following: the provider's billed charge, the maximum allowable cost, if applicable, or the average wholesale price (AWP) of the commonly stocked package size minus fifteen per cent.

(a) For repackaged brand name medications, the product cost component shall be calculated using the AWP of the original labeler.

(b) For compounded prescriptions, the product cost component shall be limited to the lesser of the maximum allowable cost, if applicable, for each ingredient, or the AWP of the commonly stocked package size minus fifteen per cent for each ingredient.

(2) Only pharmacy providers are eligible to receive a dispensing fee component. Unless a different dispensing fee is required by law for the state in which the pharmacy is located for prescriptions filled outside of Ohio, the dispensing fee component will be paid as follows:

(a) For non-compounded prescriptions, the dispensing fee component shall be three dollars and fifty cents.

(b) For sterile and non-sterile compounded prescriptions, the dispensing fee component shall be based on the time necessary to compound, as follows:

(i) One to four minutes: fifteen dollars;

(ii) Five to fourteen minutes: twenty-five dollars;

(iii) Fifteen to twenty-nine minutes: thirty-five dollars;

(iv) Thirty to fifty-nine minutes: fifty dollars;

(v) Sixty or more minutes: seventy-five dollars.

(I) The pharmacy provider is required to bill medication at their usual and customary charge. Pharmacy providers are required to submit for billing the NDC number of the stock bottle from which the dispensed medication is obtained. Drugs may be dispensed in unit dose packaging, but the NDC number of the closest comparable bulk package listed in the bureau or the bureau's PBM's payment system must be used for billing purposes. The pharmacy provider shall:

(1) Include prescriber information within bills submitted electronically to the bureau or the bureau's pharmacy benefits manager for payment. The prescriber information must include the national provider identifier (NPI);

(2) Not pay, allow, or give, or offer to pay, allow, or give, any consideration, money, or other thing of value to an injured worker, or to any other person, firm, or corporation (including but not limited to free or discounted medications or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any medications or other goods or services for which payment may be made by the bureau, the bureau's PBM, or an MCO under Chapter 4121., 4123., 4127., or 4131. of the Revised Code;

(3) Comply with all applicable billing instructions contained in the bureau's provider billing and reimbursement manual in effect on the billed date(s) of service.

(J) The bureau may establish a maximum allowable cost (MAC) for single source medications and multi-source medications which are pharmaceutically and therapeutically equivalent. Pharmaceutically and therapeutically equivalent means the medications contain identical doses of the active ingredient and have the same biological effects as determined by the FDA publication "Approved Drug Products With Therapeutic Equivalence Evaluations" in effect on the billed date(s) of service. The methodology used to determine the MAC shall be determined by the bureau. The bureau may utilize the MAC list of a vendor or develop its own MAC list.

(K) Injured workers who request a brand name drug or whose physician specifies a brand name drug designated by "dispense as written" on the prescription for a medication for which pharmaceutically and therapeutically equivalent medication exist, as defined in paragraph (J) of this rule, shall be liable for the product cost difference between the AWP of the dispensed brand name drug minus fifteen per cent and the established maximum allowable cost price of the drug product. However, the bureau may approve reimbursement of the dispensed brand name drug in accordance with paragraph (H) of this rule if the following circumstances are met:

(1) The injured worker has a documented, systemic allergic reaction as a result of taking the generic equivalent ; or

(2) The injured worker has not achieved the intended therapeutic benefit after a reasonable trial or an unacceptable adverse event has occurred as a result of taking the generic equivalent.

(L) The bureau may adopt the following dispensing limitations:

(1) Supply limitations for drugs which represent the maximum number of days supply that may be dispensed at any one time for a single prescription.

(2) Quantity limitations which represent the largest number of units per drug that may be dispensed at any one time for a single prescription.

(3) Refills of drugs not scheduled by the DEA requested before eighty per cent of the days' supply has been utilized will be denied.

(4) Refills of drugs scheduled by the DEA requested before ninety per cent of the days' supply has been utilized will be denied.

(5) The bureau may override dispensing limitations for the following reasons with supporting documentation:

(a) The pharmacy is submitting an early refill for a shortened days' supply to support medication synchronization;

(b) The injured worker is traveling and will be unable to refill medications during that time;

(d) An emergency or disaster is declared by the president of the United States or the governor of the state in which the injured worker is located.

(e) Medical necessity and appropriateness have been determined by the bureau through the prior authorization process.

(M) Except as otherwise provided in paragraph (G) of this rule, outpatient medications shall be billed to and reimbursed through the bureau's pharmacy benefits manager. Pharmacy providers must submit bills for medication by an on-line point-of-service authorization terminal or a host-to-host link with the bureau's PBM'S established bill processing system as a condition of provider enrollment or reimbursement. Submission by paper will not be accepted by the bureau or the bureau's PBM. The bureau shall not reimburse any third-party pharmacy biller that submits pharmacy bills on behalf of a pharmacy provider or that has purchased pharmacy bills from a pharmacy provider for subsequent submission to the bureau for payment.

(N) A claimant may request outpatient medication reimbursement in accordance with rule 4123-6-26 of the Administrative Code using form C-17, "Request for Injured Worker Outpatient Medication Reimbursement," or equivalent. Claimant reimbursement may be limited to the following situations:

(1) Claimants whose medication is not payable under division (I) of section 4123.511 of the Revised Code on the date of service, but later becomes payable;

(2) Emergency situations where an enrolled pharmacy provider is not available;

(3) Claimants who reside out of the country.

(O) A "pharmacy provider" designation and provider number can be obtained by a provider who meets all the following criteria:

(1) Has a valid "terminal distributor of dangerous drugs" as defined in section 4729.01 of the Revised Code if located within Ohio; or an equivalent state license if located outside of Ohio;

(2) Has a valid DEA number if applicable; and

(3) Has a licensed registered pharmacist in full and actual charge of a pharmacy.

All state and federal laws and regulations relating to the practice of pharmacy and the dispensing of medication by a duly licensed pharmacist must be observed.

(P) The bureau may contract with a PBM to perform drug utilization review and on-line bill processing, maintain a pharmacy provider network and prior authorization program for medications, and provide management reports. The bureau or its vendor may also contract rebate agreements with drug manufacturers. The bureau may utilize other services or established procedures of the PBM which may enable the bureau to control costs and utilization and detect fraud.

(Q) The bureau may identify circumstances under which it may consider reimbursement for pharmacist professional services (also known as cognitive services) when payment for such services results in a measurable, positive outcome. The bureau shall be responsible for developing the criteria which will be used to assess the compensability of billed pharmacist professional services. The bureau shall be responsible for developing the structure of the reporting of the measurable outcomes used to justify the payment of pharmacist professional services, which may include reimbursement for the dispensing fee component. The amount that could be reimbursed for pharmacist professional services shall be determined by the bureau.

(R) The bureau shall retain a registered pharmacist licensed in the state of Ohio to act as the full-time pharmacy program director to assist the bureau in the review of drug bills. The pharmacy program director may assist the bureau in determining the appropriateness, eligibility, and reasonableness of compensation payments for drug services.

Last updated February 17, 2026 at 8:00 AM

History

Effective: February 16, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-21.1 Payment for outpatient medication by self-insuring employer.

(A) Medication must be for treatment of a work related injury or occupational disease in a claim either allowed by an order of the bureau or the industrial commission, or recognized by a self-insuring employer.

(B) Any treating provider authorized by law to prescribe medication may prescribe such medication.

(C) Drugs covered in self-insuring employer claims are limited to those that are approved for human use in the United States by the food and drug administration (FDA) and that are dispensed by a registered pharmacist from a pharmacy provider.

(D) A self-insuring employer may approve and reimburse for various drugs as a part of a comprehensive treatment plan submitted by the physician of record or a treating physician when reasonably related to and medically necessary for treatment of the allowed conditions in the claim, provided that such approval and reimbursement shall not constitute the recognition of any additional conditions in the claim even if such drugs are used to treat conditions that have not been allowed in the claim.

(E) Payment for medications to pharmacy providers shall include both a product cost component and a dispensing fee component.

(1) Except as provided in this paragraph, the product cost component shall be the lesser of the following, unless the self-insuring employer has negotiated a payment rate with the pharmacy provider pursuant to rule 4123-6-46 of the Administrative Code: the provider's billed charge, the maximum allowable cost established under paragraph (N) of this rule, if applicable, or the average wholesale price (AWP) of the commonly stocked package size minus fifteen per cent.

(a) For repackaged brand name medications, the product cost component shall be calculated using the AWP of the original labeler.

(b) For compounded prescriptions, the product cost component shall be limited to the lesser of the maximum allowable cost, if applicable, for each ingredient or the AWP of the commonly stocked package size minus fifteen per cent for each ingredient.

(c) The maximum product cost component reimbursement for any one non-sterile compounded prescription will be one hundred dollars.

(2) Only pharmacy providers are eligible to receive a dispensing fee component. Unless the self-insuring employer has negotiated a payment rate with the pharmacy provider pursuant to rule 4123-6-46 of the Administrative Code or a different dispensing fee is required by law for the state in which the pharmacy is located for prescriptions filled outside of Ohio, the dispensing fee component will be paid as follows:

(a) For non-compounded prescriptions, the dispensing fee component shall be three dollars and fifty cents.

(b) For sterile and non-sterile compounded prescriptions, the dispensing fee component shall be based on the time necessary to compound, as follows:

(i) One to four minutes: fifteen dollars;

(ii) Five to fourteen minutes: twenty-five dollars;

(iii) Fifteen to twenty-nine minutes: thirty-five dollars;

(iv) Thirty to fifty-nine minutes: fifty dollars;

(v) Sixty or more minutes: seventy-five dollars.

(F) The pharmacy provider is required to bill medication at their usual and customary charge. Pharmacy providers are required to submit for billing the national drug code (NDC) number of the stock bottle from which the dispensed medication is obtained. Drugs may be dispensed in unit dose packaging, but the NDC number of the closest comparable bulk package listed in the bureau or vendor payment system must be used for billing purposes.

(G) The pharmacy provider shall:

(1) Include prescriber information within bills submitted electronically to the self-insuring employer or its vendor for payment. The prescriber information must include the national provider identifier (NPI);

(2) Not pay, allow, or give, or offer to pay, allow, or give, any consideration, money, or other thing of value to an injured worker, of to any other person, firm, or corporation (including but not limited to free or discounted medications or other goods or services) as an inducement to or in return for the injured worker ordering or receiving from the provider any medications or other goods or services for which payment may be made by the self-insuring employer or its vendor or QHP under Chapter 4121., 4123., 4127., or 4131. of the Revised Code;

(3) Comply with all applicable billing instructions contained in the bureau's provider billing and reimbursement manual in effect on the billed date(s) of service.

(H) Claimant reimbursement for medications shall be in accordance with rule 4123-6-26 of the Administrative Code and shall at least be equal to the bureau's established rate for the medication, unless the self-insuring employer has negotiated a payment rate with the pharmacy provider utilized by the claimant pursuant to rule 4123-6-46 of the Administrative Code, in which case the claimant reimbursement shall be at least the rate negotiated with the provider. Requests for reimbursement must be paid within thirty days of receipt of the request.

(I) Self-insuring employers must obtain a drug utilization review from a physician before terminating payment for current medications, as follows:

(1) Except as otherwise provided in paragraph (I)(7) of this rule, before terminating payment for current medications, the self-insuring employer shall notify all parties to the claim (including authorized representatives) and the prescribing physician, in writing, that a physician drug review is being performed, or has been performed, regarding the necessity and appropriateness of the continued use of current medications (by therapeutic drug class).

(2) The written notice shall inform all parties to the claim (including authorized representatives) and the prescribing physician that they have twenty-one days from receipt of the notice to provide additional information and/or medical documentation to justify the need for continued use of the medications (by therapeutic drug class).

(3) The self-insuring employer shall provide all medically related information regarding the medications to an independent physician reviewer for review and opinion as to the necessity or appropriateness of the medications. If the self-insuring employer has obtained an independent physician reviewer's report prior to sending the notice required by paragraph (I)(1) of this rule and subsequently receives additional information and/or medical documentation pursuant to paragraph (I)(2) of this rule, the self-insuring employer shall provide the additional information and/or medical documentation to the independent physician reviewer and obtain an addendum. The independent physician reviewer's report (and addendum, if applicable) shall address the medical rationale, necessity and appropriateness of the drug treatment in the control of symptoms associated with the allowed conditions in the claim.

(4) When the independent physician reviewer's report (and addendum, if applicable) indicates the drug treatment is not medically necessary or appropriate for treatment or in the control of symptoms associated with the allowed conditions in the claim, the self-insuring employer may terminate reimbursement for the medications (by therapeutic drug class) effective as of the date of receipt of the independent physician reviewer's report, or addendum if one is obtained, or in the case that a drug is in a therapeutic class that requires a "weaning-off" period, in accordance with the tapering schedules set forth in the appendix to rule 4123-6-21.5 of the Administrative Code or such other date as agreed to by the prescribing physician and self-insuring employer.

(5) In the event the self-insuring employer terminates reimbursement for the medications as set forth in paragraph (I)(4) of this rule, the self-insuring employer or its authorized representative shall provide all parties to the claim (including authorized representatives) and the prescribing physician with a copy of the independent physician reviewer's report (and addendum, if applicable) and the self-insuring employer shall notify the injured worker and the injured worker's representative in writing of its decision to terminate. The employer's notification to the injured worker and injured worker's representative shall indicate that the injured worker has the right to request a hearing before the industrial commission.

(6) In the event there is a dispute as to whether the drug treatment is medically necessary or appropriate for treatment of the symptoms associated with the allowed conditions in the claim, the disputed matter shall be adjudicated in accordance with paragraph (L)(5) of rule 4123-19-03 of the Administrative Code.

(7) The self-insuring employer may terminate current medications that have been removed from the bureau's outpatient medication formulary set forth in the appendix to rule 4123-6-21.3 of the Administrative Code without obtaining a physician drug review. However, the tapering schedules set forth in rule 4123-6-21.5 of the Administrative Code would apply.

(J) Self-insuring employers may deny initial requests for a drug or therapeutic class of drugs as not being reasonably related to or medically necessary for the treatment of the allowed conditions in a claim.

(K) Self-insuring employers may contract with a pharmacy benefits manager PBM. A self-insuring employer utilizing a PBM may require pharmacy providers to submit bills for medication by an on-line point-of-service authorization terminal or a host-to-host link with the pharmacy benefits manager's established bill processing system as a condition of reimbursement, and may refuse submission by paper. Self-insuring employers utilizing a PBM may refuse to reimburse any third-party pharmacy biller that submits pharmacy bills on behalf of a pharmacy provider or that has purchased pharmacy bills from a pharmacy provider for subsequent submission to the self-insuring employer for payment.

(L) Self-insuring employers utilizing a PBM may require prior authorization of drugs or therapeutic classes of drugs which appear on the bureau's published list of drugs or therapeutic classes of drugs for which prior authorization is required. Notwithstanding rule 4123-19-03 of the Administrative Code, the self-insuring employer shall approve or deny a prior authorization request within three business days of the request.

(M) Self-insuring employers utilizing a PBM may apply the following dispensing limitations, adopted by the bureau, to medications approved and reimbursed by the self-insuring employer:

(1) Supply limitations for drugs which represent the maximum number of days supply that may be dispensed at any one time for a single prescription.

(2) Quantity limitations which represent the largest number of units per drug that may be dispensed at any one time for a single prescription.

(3) Requests submitted that exceed either the days supply limit or maximum quantity limit shall be denied; provided, however, that the pharmacy provider may still fill the prescription up to the days supply limit or maximum quantity limit, as applicable.

(4) Refills of drugs not scheduled by the DEA requested before eighty per cent of the days' supply has been utilized will be denied.

(5) Refills of drugs scheduled by the DEA requested before ninety per cent of the days' supply has been utilized will be denied.

(6) The self-insured employer may override denials for the following reasons with supporting documentation:

(a) The pharmacy is submitting an early refill for a shortened days supply to support medication synchronization;

(b) The injured worker is traveling and will be unable to refill medications during that time;

(d) An emergency or disaster is declared by the president of the United States or the governor of the state in which the injured worker is located .

(e) Medical necessity and appropriateness have been determined by the self-insuring employer.

(N) Self-insuring employers utilizing a PBM may apply the maximum allowable cost list of the pharmacy benefits manager.

(O) Injured workers who request a brand name drug or whose physician specifies a brand name drug designated by "dispense as written" on the prescription for a medication for which pharmaceutically and therapeutically equivalent medications exist, as defined in paragraph (J) of rule 4123-6-21 of the Administrative Code, shall be liable for the product cost difference between the AWP of the dispensed brand name drug minus fifteen per cent and the established maximum allowable cost price of the drug product. However, the self-insuring employer or its vendor may approve reimbursement of the dispensed brand name drug in accordance with paragraph (E) of this rule if the following circumstances are met:

(1) The injured worker has a documented, systemic allergic reaction as a result of taking the generic equivalent; or

(2) The injured worker has not achieved the intended therapeutic benefit after a reasonable trial or an unacceptable adverse event has occurred as a result of taking the generic equivalent.

(P) A self-insuring employer has sufficient grounds to refuse to pay for the dispensing of drugs and other medications when a pharmacy provider fails to observe any state or federal law relating to his or her professional licensure or to the dispensing of drugs and other medication.

Last updated February 17, 2026 at 8:00 AM

History

Effective: February 16, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-21.2 Pharmacy and therapeutics committee.

The bureau of workers' compensation pharmacy and therapeutics (P&T) committee was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medication therapy issues for injured workers. The bureau will develop and maintain a list of physician and pharmacist providers, each holding a professional license in good standing, who have expressed an interest in serving on the P&T committee and who would add credibility and diversity to the mission and goals of the committee . Providers may be nominated for inclusion on the list by provider associations and organizations including but not limited to: deans of Ohio's allopathic and osteopathic medical schools, deans of Ohio's colleges of pharmacy, presidents of Ohio's various allopathic and osteopathic medical associations, the Ohio pharmacists association, the Ohio state medical board, and the Ohio state board of pharmacy.

(A) The P&T committee consists of the bureau's pharmacy program director, chief medical officer, and not more than thirteen nor less than five voting members who are licensed physicians and licensed pharmacists representing the diverse group of providers that provide medical care to the injured workers of Ohio as administered through the bureau. Subject to approval by the administrator, the committee may create any subcommittees the committee determines are necessary to assist the committee in performing its duties. Subcommittees will submit their recommendations to the P & T committee.

(B) P&T committee members must:

(1) Be familiar with issues relating to the treatment of injured workers in the Ohio workers' compensation system.

(2) Be a doctor of medicine (MD) or doctor of osteopathic medicine (DO), if a physician.

(3) Possess significant clinical or administrative experience in health care delivery, including but not limited to pain management, pharmacy practice, medical quality assurance, disease management, and utilization review.

(4) Have experience with and an understanding of the concepts of evidence-based medicine as well as contemporary best practices in their respective areas of practice.

(5) Not be, or within the previous twenty-four months have been, an employee of any pharmaceutical manufacturer, pharmacy benefits manager, or any non-governmental firm or entity administering state purchased health care program benefits or pharmaceutical rebates.

(C) The appointing authority for members of the P&T committee is the administrator or the administrator's designee(s), who will appoint members of the committee from the list of qualified providers developed and maintained by the bureau. Terms of membership for individual members of the P&T committee are for one year. Individuals may be reappointed to subsequent terms as determined by the administrator. Members may resign or be removed by the administrator at any time. Vacated terms are filled in a like manner as for the full term appointments for the remaining term of the vacated member.

(D) The pharmacy program director of the bureau is the chairperson of the P&T committee and is responsible for providing notice of meetings to the members and for the meeting agenda. In addition, the pharmacy program director may be self-designated as an ad hoc member of any subcommittees of the P&T committee. However, the pharmacy program director is only a voting member of the P&T committee and any subcommittees in the case of tie votes. The bureau's chief medical officer and the industrial commission's medical advisor may participate in discussions; however, they are not voting members. The pharmacy program director may designate an alternate to serve in the director's absence.

(E) The P&T committee will develop and establish bylaws for the organization and operations of the committee and subcommittees, consistent with the provisions of this rule and approval by the administrator and the chief medical officer.

(F) The P&T committee may make such recommendations as it deems necessary to address any issue impacting the bureau related to pharmacy or medication therapeutics. The committee is responsible for responding to requests for recommendation on any such issue submitted by the bureau's administrator, chief of medical services, chief medical officer, or pharmacy program director, including:

(1) Development and review of a formulary of approved medications.

(2) Development of prior authorization criteria.

(3) Review of proposed medication treatment guidelines.

(4) Review of clinical criteria related to drug utilization review or specific medication issues.

(5) Review of the bureau's pharmacy providers' professional performance. Any peer review conducted by the P&T committee will be in accordance with generally accepted standards of pharmacy practice. The P&T committee may recommend sanctions as well as termination of any pharmacy provider determined to have consistently failed to meet such standards.

(6) Review of any of the bureau's medical providers' medication prescribing patterns and practices. Any peer review conducted by the P&T committee will be in accordance with generally accepted standards of medical practice applicable to medication prescribing. The P&T committee may recommend sanctions as well as decertification of any provider determined to have consistently failed to meet such standards. Any decertification or sanction of a provider by the bureau pursuant to recommendation of the P&T committee will be conducted in accordance with rule 4123-6-17 of the Administrative Code.

(7) Review of the bureau's pharmacy benefit manager's performance and conduct regarding its management of prescription benefit services for the bureau.

(G) The P&T committee will hold at least two meetings annually. The P&T committee and all subcommittees will keep written records of the agenda and minutes of each meeting, which will be maintained by the bureau.

(H) The P&T committee will submit an annual report of its activities and recommendations to the administrator.

(I) Each member of the P&T committee and its respective subcommittees may be paid such fees as approved by the administrator or the administrator's designee. The expenses incurred by the P&T committee and its subcommittees and the fees of their members are paid in the same manner as other administrative costs of the bureau.

Last updated June 30, 2026 at 1:17 PM

History

Effective: August 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-21.3 Outpatient medication formulary.

(A) The administrator hereby adopts the formulary indicated in the appendix to this rule, developed with the recommendation of the bureau's pharmacy and therapeutics committee.

(B) Except as otherwise provided in paragraph (F) of this rule, the formulary indicated in the appendix to this rule shall constitute the complete list of medications that are approved for reimbursement by the bureau for the treatment of a work related injury or disease in an allowed claim when dispensed to an injured worker by a registered pharmacist from an enrolled outpatient pharmacy provider.

(C) The formulary indicated in the appendix to this rule also contains specific reimbursement, prescribing or dispensing restrictions that have been placed on the use of listed drugs. The formulary will be reviewed and updated as necessary. The most current version will be electronically published by the bureau.

(D) The administrator will consider current medical literature and best practices and the recommendations of the bureau's pharmacy and therapeutics committee when making additions, deletions, or modifications of coverage of medications listed in the formulary.

(E) The bureau shall provide an expedited review process for clinically or therapeutically unique medications when necessary.

(F) Notwithstanding paragraph (B) of this rule, in cases of medical necessity supported by medical documentation and evidence of need the bureau may reimburse for:

(1) New drugs approved for use in the United States by the food and drug administration (FDA) on or after the effective date of the formulary, and for new indications approved by the FDA on or after the effective date of the formulary for existing drugs that are not on the formulary, with prior authorization, for a period not to exceed one hundred eighty days from the adjudication date of the first prescription for the requested drug.

(2) Antineoplastic drugs prescribed for treatment of an allowed cancer condition in a claim.

(3) Antiretroviral drugs prescribed for:

(a) Treatment of an allowed condition of human immunodeficiency virus in a claim; or

(b) Post exposure treatment in an allowed claim or pursuant to section 4123.026 of the Revised Code.

(G) Notwithstanding the appendix to this rule, in cases of medical necessity supported by medical documentation and evidence of need the bureau may reimburse for new dosage forms or strengths approved by the FDA on or after the effective date of the formulary for existing drugs that are on the formulary, with prior authorization, for a period not to exceed one hundred eighty days from the adjudication date of the first prescription for the requested drug.

View Appendix

Last updated August 3, 2026 at 8:18 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-21.4 Coordinated services program.

The bureau, or a self-insuring employer with a point-of-service adjudication system, may establish a coordinated services program (CSP) that requires an injured worker to obtain prescription medications reimbursed by the bureau or self-insuring employer from a single designated pharmacy and/or prescriber.

(A) Placement in a CSP.

(1) The bureau or self-insuring employer with a point-of-service adjudication system may review an injured worker for possible placement in a CSP if a review of the claim indicates the injured worker meets one or more of the following criteria:

(a) Use of three or more different prescribers to obtain prescriptions of the same or comparable medications per three month time frame;

(b) Receipt of prescription drugs from more than two different pharmacies per three month time frame;

(c) Monthly receipt of three or more prescriptions including refills for drugs identified by therapeutic drug class as a narcotic analgesic per three month time frame;

(d) Monthly receipt of more than two concurrent narcotic analgesics in the same therapeutic drug class per three month time frame;

(e) Monthly receipt of more than two narcotic analgesics in the same therapeutic drug class, more than one benzodiazepine, and more than one sedative-hypnotics per three month time frame.

(2) Upon identification of an injured worker meeting one or more of the criteria identified in paragraphs (A)(1)(a) to (A)(1)(e) of this rule, the bureau or self-insuring employer with a point-of-service adjudication system shall obtain a physician review of the injured worker's most recent twelve months history of prescription medications reimbursed by the bureau or self-insuring employer.

(3) If, based on this physician review, the bureau or self-insuring employer with a point-of-service adjudication system determines that the injured worker's utilization of prescription medications during this period was at a frequency or in an amount that was not medically necessary or appropriate under the criteria set forth in paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code, or was potentially unsafe, the bureau or self-insuring employer may place the injured worker in a CSP.

(4) Notwithstanding paragraphs (A)(1) to (A)(3) of this rule, if the bureau or self-insuring employer with a point-of-service adjudication system determines that an injured worker has been convicted of or pled guilty to an offense under Chapter 2925. of the Revised Code or any other criminal offense related to the misuse of drugs, the bureau or self-insuring employer may place the injured worker in a CSP.

(5) Placement in a CSP shall be for an initial period of eighteen months. The bureau or self-insuring employer with a point-of-service adjudication system may place the injured worker in the CSP for additional eighteen month periods in accordance with paragraph (A)(6) of this rule.

(6) The bureau or self-insuring employer with a point-of-service adjudication system may evaluate an injured worker's medication utilization at the conclusion of each eighteen month period in the CSP. If the bureau or self-insuring employer determines that the injured worker's medication utilization continues to meet the criteria set forth in paragraphs (A)(1) to (A)(4) of this rule, the bureau or self-insuring employer may place the injured worker in the CSP for an additional eighteen month period.

(7) If an injured worker placed in the CSP enters a nursing home, residential care/assisted living facility, or hospice program, the injured worker shall be released from the CSP. If the injured worker is subsequently discharged from the nursing home, residential care/assisted living facility, or hospice program during the CSP period, the bureau or self-insuring employer with a point-of-service adjudication system may place the injured worker back into the CSP.

(B) Selection of designated pharmacy and/or prescriber.

(1) An injured worker placed into a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule shall be given the opportunity to select a designated pharmacy from a list of participating pharmacies maintained by the bureau or self-insuring employer. If an injured worker fails to select a designated pharmacy, or selects a designated pharmacy that is unable or unwilling to accept the injured worker, the bureau or self-insuring employer may select a designated pharmacy for the injured worker.

(2) An injured worker placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule may only change from one designated pharmacy to another in the following circumstances:

(a) The designated pharmacy becomes inaccessible to the injured worker due to relocation or incapacity of the injured worker or closing of the designated pharmacy,

(b) The designated pharmacy chooses to no longer participate in the CSP or to provide services to the injured worker in accordance with paragraph (D)(4) of this rule.

(c) The injured worker requests to be assigned to another designated pharmacy due to personal preference. Not more than one change due to personal preference shall be approved in a rolling twelve-month period.

(3) An injured worker placed in the CSP pursuant to paragraph (A)(4) of this rule shall be given the opportunity to select a designated prescriber from among those bureau certified providers who meet the definition of physician under paragraph (P) of rule 4123-6-01 of the Administrative Code. If an injured worker fails to select a designated prescriber, or selects a designated prescriber that is unable or unwilling to accept the injured worker, the bureau or self-insuring employer may select a designated prescriber for the injured worker.

(4) An injured worker placed in a CSP pursuant to paragraph (A)(4) of this rule may only change from one designated prescriber to another in the following circumstances:

(a) The designated prescriber becomes inaccessible to the injured worker due to relocation or incapacity of the injured worker or closing of the designated prescriber's practice,

(b) The designated prescriber chooses to no longer provide services to the injured worker,

(c) The injured worker requests to be assigned to another designated prescriber due to personal preference. Not more than one change due to personal preference shall be approved in a rolling twelve-month period.

(5) All requests for change of designated pharmacy or designated prescriber must be submitted in writing to the bureau or self-insuring employer.

(1) An injured worker placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule must obtain covered prescription medications from the injured worker's designated pharmacy. During the period the injured worker is placed in the CSP, the bureau or self-insuring employer shall deny reimbursement for prescription medications obtained from a pharmacy other than the injured worker's designated pharmacy, except in cases of emergency as set forth in paragraph (C)(2) of this rule.

(2) Emergency prescription fills shall be allowed in the following situations:

(a) The injured worker is unable to get to their designated pharmacy,

(b) The injured worker's designated pharmacy does not have the prescribed medication in stock.

(3) Emergency prescription fills shall be limited to a four-day supply. Records of dispensing for emergency prescription fills are subject to review by the bureau.

(4) An injured worker placed in a CSP pursuant to paragraph (A)(4) of this rule must obtain all prescriptions for covered medications from the injured worker's designated prescriber. During the period the injured worker is placed in the CSP, the bureau or self-insuring employer shall deny reimbursement for prescriptions written by providers other than the injured worker's designated prescriber, except:

(a) In cases of emergency as defined in paragraph (F) of rule 4123-6-01 of the Administrative Code;

(b) With prior authorization, prescriptions written by a specialist in cases where the injured worker has been referred to a specialist for care.

(D) Pharmacies participating in the bureau's CSP.

(1) The bureau shall maintain a list of pharmacies participating in the bureau's CSP that are eligible for selection by an injured worker as a designated pharmacy. To participate in the bureau's CSP, a pharmacy must meet the following criteria:

(a) The pharmacy must be enrolled with the bureau and have a signed agreement with the bureau's pharmacy benefits manager.

(b) The pharmacy must enter into a CSP agreement with the bureau.

(2) Pharmacies participating in the bureau's CSP agree to perform the following monitoring activities:

(a) For each injured worker in the bureau's CSP for whom the pharmacy is the designated pharmacy, the pharmacy shall conduct a bimonthly review of the injured worker's OARRS report from the Ohio board of pharmacy (or a similar automated prescription monitoring report from the injured worker's state of residence).

(b) The pharmacy shall notify the injured worker's prescribing physician of any critical findings discovered in the report. Critical findings are indications of any prescription related activity that could cause harm to the patient, including but not limited to:

(i) Duplication of therapy,

(ii) Excessive doses of concurrent medications,

(iii) Potential drug interactions or potentiation of side effects.

(d) BWC may request quarterly documentation of the pharmacy's monitoring activities under paragraphs (D)(2)(a) to (D)(2)(d) of this rule.

(3) Pharmacies participating in the CSP may receive compensation from the bureau under the CSP agreement for services provided as part of the CSP.

(4) Pharmacies participating in the bureau's CSP may terminate their CSP agreement with the bureau and discontinue their participation in the bureau's CSP at any time upon not less than thirty days written notice to the bureau. Pharmacies participating in the bureau's CSP may discontinue providing services to an individual injured worker at any time upon not less than thirty days written notice to the bureau, the injured worker, and the injured worker's authorized representative.

(5) The bureau may terminate the CSP agreement of a pharmacy participating in the bureau's CSP in accordance with the terms of the CSP agreement.

(E) Pharmacies participating in a self-insuring employer's CSP.

(1) A self-insuring employer with a point-of-service adjudication system who establishes a CSP shall maintain a list of pharmacies participating in the self-insuring employer's CSP that are eligible for selection by an injured worker as a designated pharmacy. The list of participating pharmacies shall cover a geographic area sufficient to provide the self-insuring employer's injured workers with reasonable access to pharmacy providers.

(2) Pharmacies participating in a self-insuring employer's CSP shall provide not less than thirty days written notice to an injured worker and the injured worker's authorized representative prior to discontinuing services to the injured worker.

(F) Disputes.

(1) Decisions by the bureau regarding an injured worker's placement in the bureau's CSP, assignment of a designated pharmacy or designated prescriber, or denial of an injured worker's request for change of designated pharmacy or designated prescriber may be appealed to the industrial commission in accordance with section 4123.511 of the Revised Code.

(2) Decisions by a self-insuring employer regarding an injured worker's placement in the self-insuring employer's CSP, assignment of a designated pharmacy or designated prescriber, or denial of an injured worker's request for change of designated pharmacy or designated prescriber shall indicate that the injured worker has the right to request a hearing before the industrial commission.

Last updated June 30, 2026 at 1:17 PM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-21.5 Standard dose tapering schedules.

(A) The bureau hereby adopts the standard dose tapering (weaning) schedules for the prescription medications indicated in this rule, and the appendix to this rule.

(B) These weaning schedules apply to denials for payment of the indicated medications by the bureau, self-insuring employers, MCOs, QHPs, and the industrial commission when:

(1) The medication has been previously allowed for treatment of an allowed condition in the claim;

(2) The denial is based upon a finding that the medication is no longer medically necessary or appropriate for treatment of the allowed condition; and

(3) The prescriber has submitted a written treatment plan reflecting an intention to discontinue the medication and a request for reimbursement of the weaning period.

(C) The approved weaning duration will be the weaning period requested by the prescriber, or the weaning period outlined in this rule or the appendix to this rule, whichever is less.

(D) Weaning from opioids: Upon denial of reimbursement for an opioid, reimbursement for a weaning period will only be approved if the prescribed total daily morphine equivalent dose is sixty or greater.

(1) The approved duration of the opioid weaning period must allow for a ten percent reduction of the total daily morphine equivalent dose per week, or a larger reduction with a shorter duration as requested by the prescriber.

(2) Requests to approve additional time for weaning for rates slower than a ten per cent dose reduction per week will be denied.

(E) Weaning from benzodiazepines: The weaning period for benzodiazepines is set forth in the appendix to this rule.

View Appendix

Last updated June 30, 2026 at 1:17 PM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-21.6 First fill of outpatient medications.

(A) In accordance with division (B) of section 4123.66 of the Revised Code, the administrator has established a program to make immediate payment, under the circumstances set forth in this rule, for the first fill of prescription drugs for medical conditions identified in an application for compensation or benefits under section 4123.84 or 4123.85 of the Revised Code that occurs prior to the date the administrator issues an initial determination order under division (B) of section 4123.511 of the Revised Code.

(B) The appendix to this rule shall constitute the complete list of medications, and the maximum quantity of such medications, that are approved for reimbursement by the bureau for first fill prior to issuance of an initial determination order. Except as otherwise provided in paragraph (C) of this rule, drugs not listed in the appendix to this rule are not eligible for reimbursement by the bureau under the first fill program.

(C) Notwithstanding paragraph (B) of this rule, in cases of medical necessity supported by clinical documentation and evidence of need the bureau may, with prior authorization, reimburse for the first fill of medications that are eligible for reimbursement under rule 4123-6-21.3 of the Administrative Code but are not listed in the appendix to this rule.

(D) Reimbursement of outpatient medications by the bureau under the first fill program shall be subject to the following limitations:

(1) Approval for reimbursement of medications under the first fill program will be limited to the quantity limits listed in the appendix to this rule, and no refills will be approved;

(2) With the exception of antivirals, antiretrovirals, and antibiotics, approval for reimbursement of medications under the first fill program will be limited to one drug per therapeutic drug class listed in the appendix to the rule;

(3) Extemporaneous compounded prescriptions are not eligible for reimbursement by the bureau under the first fill program.

(E) Pharmacy providers shall be reimbursed for dispensing drugs under this rule in the manner described in rule 4123-6-21 of the Administrative Code provided that the prescriber, or their agent has indicated the prescription is for a work related injury and signed the prescription blank. A pharmacist or pharmacy intern who receives a telephone prescription may also write and sign that it is work related on the prescription.

(F) If a claim in which the first fill of outpatient medication was reimbursed by the bureau pursuant to this rule is ultimately disallowed in a final administrative or judicial order, and if the employer is a state fund employer who pays assessments into the surplus fund account created under section 4123.34 of the Revised Code, the payment for outpatient medication made pursuant to this rule shall be charged to and paid from the surplus fund account and not charged through the state insurance fund to the employer against whom the claim was filed.

View Appendix

Last updated August 3, 2026 at 8:18 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-21.8 Reimbursement for services to assist in the discontinuation of medications.

This rule governs the bureau's reimbursement for services to aid injured workers in discontinuing medications which may be necessary and appropriate in the treatment of work related injuries, but which may increase the risk of dependency, misuse, and substance use disorder in some injured workers if continued. Medically necessary and appropriate services to aid injured workers in discontinuing these medications may include services which provide functional restoration and pharmacologic and non-pharmacologic treatment alternatives.

The bureau will reimburse:

(A) Assessment services when the medical documentation reflects:

(1) The injured worker is currently receiving a medication prescribed for and reimbursed in the injured worker's claim;

(2) The injured worker has expressed a desire to discontinue the medication(s) and is willing to participate in a treatment program; and

(3) The physician of record determines, based on clinical observation and other factors, that a dependency assessment may be appropriate.

(B) Ongoing services, including outpatient, inpatient, or any combination of inpatient and outpatient treatment, when the results of the dependency assessment indicate treatment is medically necessary and appropriate to aid in the discontinuation of the medication and a treatment plan and monthly documentation of the injured worker's participation and progress in the treatment plan are submitted to the bureau.

(C) Medically necessary and appropriate medications prescribed for assisting the injured worker's discontinuance of the targeted medication.

Last updated June 30, 2026 at 1:17 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-22 Stakeholders' health care quality assurance advisory committee.

The bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) was created to advise the administrator, the chief of medical services, and the chief medical officer with regard to medical quality issues. A list of medical providers, each holding a professional license in good standing, who have expressed an interest in serving on the HCQAAC, and who would add credibility and diversity to the mission and goals of the HCQAAC shall be developed and maintained by the the bureau. Providers may be nominated for inclusion on the list by provider associations and organizations including but not limited to: deans of Ohio's allopathic and osteopathic medical schools, deans of Ohio's colleges of pharmacy, deans of Ohio's dental schools, the dean of the Ohio college of podiatric medicine, the Ohio state medical association, the Ohio state osteopathic association, the Ohio state chiropractic association, specialty board associations of Ohio, the Ohio podiatric medical association, the Ohio psychological association, the Ohio dental association, the Ohio pharmacists association, the Ohio hospital association, the Ohio state medical board, the Ohio state chiropractic board, the Ohio state psychology board, the Ohio state pharmacy board, and the Ohio state dental board.

(A) The HCQAAC shall consist of the bureau's chief medical officer, the chief of medical services and not more than thirteen nor less than five voting members representing the diverse group of providers that provide medical care to the injured workers of Ohio as administrated through the bureau. The committee may create any subcommittees that the committee determines are necessary to assist the committee in performing its duties. Any subcommittee recommendations shall be submitted to the HCQAAC committee.

(B) HCQAAC members must meet the following requirements:

(1) Providers must be familiar with issues relating to the treatment of injured workers in the Ohio workers' compensation system.

(2) Providers must possess significant clinical or administrative experience in health care delivery, including but not limited to, medical quality assurance, disease management, and utilization review.

(3) Providers must have experience with and an understanding of the concepts of evidence based medicine as well as contemporary best practices in their respective areas of practice.

(C) The appointing authority for members of the HCQAAC shall be the administrator or the administrator's designee(s), who shall appoint members of the HCQAAC from the list of qualified providers developed and maintained by the bureau. Terms of membership for individual members of the HCQAAC shall be for one year. Individuals may be reappointed to subsequent terms as determined by the administrator. Vacated terms shall be filled in a like manner as for the full term appointments and shall be for the remaining term of the vacated member.

(D) The chief medical officer of the bureau shall be the chairperson of the HCQAAC and shall provide notice of meeting to the members and be responsible for the meeting agenda. In addition, the chief medical officer and chief of medical services may be self-designated as an ad hoc member of any subcommittees of the HCQAAC. However, the chief of medical services is not a voting member of the HCQAAC or any subcommittee, and the chief medical officer is a voting member of the HCQAAC and any subcommittees only in the case of tie votes. The industrial commission's medical advisor, and one physician chosen by the MCOs may participate in discussions; however, they are not voting members.

(E) The HCQAAC shall develop and establish bylaws for the organization and operations of the committee and subcommittees, subject to the requirements of this rule and approval by the administrator and the chief medical officer.

(F) The HCQAAC shall be responsible to respond to requests for recommendation on any medical quality assurance issue submitted by the bureau's administrator, chief of medical services, or chief medical officer including :

(1) Review of medical treatment guidelines referred to the bureau;

(2) Review of any of the bureau's policies and procedures related to medical quality assurance issues;

(3) Review of any of the bureau's medical providers' professional performance and conduct, including bureau certification and malpractice issues. Any peer review conducted by the HCQAAC will be in accordance with generally accepted standards of medical practice. The HQAAC may recommend sanctions as well as decertification of any provider determined to have consistently failed to meet such standards . Any decertification or sanction of a provider by the bureau pursuant to recommendation of the HCQAAC will be conducted in accordance with rule 4123-6-17 of the Administrative Code;

(4) Review of any of the bureau's managed care organizations' professional performance and conduct regarding the management of medical services for the bureau. This may include interfacing with any quality assurance committee of any of the individual managed care organizations.

The HCQAAC may make such recommendations as it deems necessary to address any medical quality assurance issue impacting the bureau.

(G) The HCQAAC shall hold at least quarterly meetings. The HCQAAC and all subcommittees shall keep written records of the agenda and minutes of each meeting, which will be maintained by the bureau.

(H) The HCQAAC shall submit an annual report of its activities and recommendations to the administrator.

(I) Each member of the HCQAAC and its respective subcommittees may be paid such fees as approved by the administrator or administrator's designee. The expenses incurred by the HCQAAC and its subcommittees and the fees of their members shall be paid in the same manner as other administrative costs of the bureau.

Last updated February 1, 2022 at 9:34 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-25 Payment for medical supplies and services.

(A) Medical or other services to be approved for payment must be rendered as a result of an injury sustained or occupational disease contracted by an injured worker in the course of and arising out of employment. The claim must be allowed by an order of either the bureau of workers' compensation or the industrial commission, or have been recognized by a self-insuring employer.

Medical supplies and services will be considered for payment when they are reasonably related to the work related injury, the requested services are reasonably necessary for treatment of the work related injury, and the costs of the services are medically reasonable. Payment for services rendered to an injured worker shall be paid to a health care provider only when the provider has either delivered, rendered or supervised the examination, treatment, evaluation or any other medically necessary and related services. Provider supervision of services shall comply with the requirements of the provider's regulatory board and the centers for medicare and medicaid services (CMS), if applicable, for supervision of the service, as in effect on the billed date of service, unless otherwise specified in the bureau's provider billing and reimbursement manual in effect on the billed date of service. By submitting any fee bill to the bureau, in either hardcopy or electronic format, the health care provider affirms that medical supplies and services have been provided to the injured worker as required by this rule.

Providers billing for services rendered shall follow the procedures set forth in the bureau's provider billing and reimbursement manual in effect on the billed date of service.

(B) Services rendered by health care providers are subject to review for coding requirements outlined in paragraph (C) of this rule. Payments to health care providers may be adjusted based upon these guidelines.

(1) Billing codes.

(a) Practitioners are required to use the edition of the CMS healthcare common procedure coding system (HCPCS) in effect on the billed date of service to indicate the procedure or service rendered to injured workers.

(b) Inpatient and outpatient hospital services must be billed using the national uniform billing committee's revenue center codes in effect on the billed date of service (date of discharge for inpatient services).

(c) To insure accurate data collection, the bureau shall adopt a standardized coding structure which shall be adopted by any MCO, QHP, or self-insuring employer.

(2) Diagnosis codes.

Providers must use the appropriate "International Classification of Diseases, clinical modification" codes for the condition(s) treated to indicate diagnoses.

(D) Prior to services being delivered, the provider must make reasonable effort to notify the injured worker, bureau, MCO, QHP or self-insuring employer when the provider has knowledge that the services may not be related to the claimed or allowed condition(s) related to the work related injury or illness, or that a service is non-covered. The provider may not knowingly bill or seek payment from the bureau, MCO, QHP or self-insured employer for services that are not related to the claimed or allowed condition(s) related to the work related injury or illness. The provider may not knowingly mislead or direct providers of ancillary services to bill or seek payment for services that are not related to the claimed or allowed condition.

The provider may not bill or seek payment from the injured worker for services determined as medically unnecessary through the use of bona fide peer review based on accepted treatment guidelines.

Last updated February 1, 2022 at 9:34 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-26 Claimant reimbursement.

(A) When the claimant or any other person making payment on behalf of the claimant, including a volunteer, pays for medical services or supplies directly to a health care provider and the medical services or supplies meet the criteria in paragraph (B) of rule 4123-6-16.2 of the Administrative Code, the payor shall be reimbursed upon submission of evidence of the receipt and payment for that medical service or supply. Except as otherwise provided in paragraphs (A)(1) and (A)(2) of this rule, the payor will receive no more than the amount that would have been paid to the health care provider as provided by this chapter.

(1) In cases where the payor is the claimant's health insurer, if the claimant seeks reimbursement for an out-of-pocket copayment, the claimant may be reimbursed for the copayment and the claimant's health insurer may be reimbursed up to the amount that would have been paid to the health care provider as provided by this chapter.

(2) In cases where the claimant pays a pharmacy out of pocket for an outpatient medication because the medication is not payable under division (I) of section 4123.511 of the Revised Code on the date of service, if the medication later becomes payable, the claimant may be reimbursed the full amount of the claimant's out-of-pocket payment.

(B) When the bureau has already made payment to the health care provider, the payor shall be informed to seek reimbursement from the provider. The bureau shall inform a claimant or payor whether a health care provider participates in the HPP or QHP.

(C) Requests for reimbursement pursuant to this rule shall be subject to the timeframes set forth in division (B) of section 4123.52 of the Revised Code and in rule 4123-3-23 of the Administrative Code.

Last updated February 1, 2022 at 9:35 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-27 Treatment by more than one physician.

Medical fees shall not be approved for treatment by more than one physician for the same condition over the same period of time, except where a consultant, anesthetist, or assistant is required, or where the necessity for treatment by a specialist is clearly shown and approved in advance of treatment. This rule does not apply in cases of emergency, or where the physician of record's approved treatment plan indicates the necessity for multidisciplinary services.

Last updated September 9, 2025 at 11:40 AM

History

Effective: February 12, 1997
Promulgated Under: Ch 119.

Ohio Adm.Code 4123-6-29 Request for information by the treating provider.

A provider treating an injured worker may, at any time, make a request in writing, facsimile, or e-mail, in accordance with the bureau's confidentiality and sensitive data requirements, for relevant information concerning conditions, treatment or history for the claim. The request for information shall be accompanied by an appropriate patient release of medical information. A prompt response will be given to this request.

Last updated May 31, 2023 at 11:03 AM

History

Effective: February 1, 2010
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-30 Payment for physical medicine.

(A) "Physical medicine" is the evaluation and treatment of an injured worker by physical measures and the use of rehabilitative procedures, with or without assistive devices, for the purpose of preventing, correcting, or alleviating any work related disability. Physical medicine includes the establishment and modification of physical rehabilitation programs, treatment planning, instruction, and consultative services. "Physical measures" include massage, heat, cold, air, light, water, electricity, sound, manipulation, and the performance of tests of neuromuscular function as an aid to such treatment. Physical medicine does not include the diagnosis of a patient's disability, the use of roentgen rays or radium for diagnostic or therapeutic purposes, or the use of electricity for cauterization or other surgical purposes. Physical medicine includes, but not limited to, chiropractic treatments, physiotherapy, and physical therapy.

(B) Physical medicine must be prescribed by the physician of record or other approved treating provider licensed to practice medicine, osteopathy, chiropractic, mechanotherapy, dentistry, podiatry, or a certified registered nurse anesthetist, nursing clinical nurse specialist, certified nurse midwife, certified nurse practitioner, or physician assistant. Physical medicine may be provided in the physician's office or referred to another licensed provider.

(C) To be eligible for reimbursement, physical medicine services must be provided by a physician or chiropractic physician, or a physical therapist, occupational therapist, massage therapist, athletic trainer, or other qualified non-physician provider practicing within the scope of their license, certification, or registration.

(D) Fees for up to twelve physical medicine treatments within sixty days following the date of injury may be reimbursed without prior authorization, provided the treatments are for allowed soft tissue and musculoskeletal conditions in allowed claims and the criteria set forth in paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code are met. Otherwise, physical medicine treatment must be prior authorized.

Last updated February 1, 2022 at 9:35 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-31 Payment for miscellaneous medical services and supplies.

(A) Acupuncture.

Acupuncture is eligible for reimbursement when prior authorized and administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine, a doctor of chiropractic who holds a certificate to practice acupuncture from the Ohio state chiropractic board, or a non-physician acupuncturist licensed pursuant to and practicing in compliance with Chapter 4762. of the Revised Code.

(B) Orthotic devices.

(1) Payment is made only for those orthotic devices prescribed in writing by the physician of record or treating physician for treatment of an allowed injury or occupational disease.

(2) Orthotic devices are eligible for reimbursement only when custom fitted or custom fabricated and delivered to the satisfaction of the prescribing physician and the administrative agencies. Repairs, modifications, and adjustments to secure satisfactory application of the orthotic appliance will be made within sixty days of fitting and application without additional charge by the supplier of the orthotic device.

(3) Measurement, transportation, or other expenses incurred by the supplier-orthotist are not eligible for reimbursement, except when the supplier-orthotist needs to travel beyond the limits of the metropolitan community in which they maintain their place of business by reason of the physical incapacity of the claimant or by reason of direct prescription by the attending physician. The supplier-orthotist in those circumstances will be paid for traveling expenses on a round-trip basis when separately specified on the supplier-orthotist's billing, including the points of travel and the name of the physician prescribing the travel. Payment will be made for a maximum of three round-trip calls.

(1) Payment for dental care will be made in the following cases:

(a) Where the work related accident causing the injury also results in the damage or loss of the injured worker's artificial teeth or other denture. Once the artificial teeth or other denture(s) have been repaired, replaced, or adjusted, no further repair, replacement, or adjustment will be approved.

(b) Where a work related injury or occupational disease has caused damage or adversely affected the injured worker's natural teeth.

(2) Responsibility for the repair of both natural and artificial teeth is limited to the damage done at the time of the accident, or to the damage caused by an allowed injury or occupational disease.

(D) Eyeglasses and contact lenses.

(1) Payment for eyeglasses or contact lenses will be made in the following cases:

(a) Where the work related accident causing the injury also results in the damage or loss of the injured worker's eyeglasses or contact lenses. Once the eyeglasses or contact lenses have been repaired, replaced, or adjusted, no further repair, replacement, or adjustment will be approved.

(b) Where loss of vision is the result of an allowed injury or occupational disease.

(2) Refractions will be approved in situations described in paragraph (D)(1)(b) of this rule.

(3) When medical evidence indicates a need due to an allowed injury or occupational disease contact lenses may be approved instead of eyeglasses.

(4) Glasses or contact lenses will be approved for treatment purposes, when necessary, as a result of the allowed injury or occupational disease. Any subsequent adjustment or change in an injured worker's glasses or contact lenses, if medically necessary for treatment of the allowed injury or occupational disease, will also be approved.

(E) Hearing aids.

Payment for hearing aids will be made in the following cases:

(1) Where the work related accident causing the injury also results in the damage or loss of the claimant's hearing aid(s) Once the hearing aid(s) have been repaired, replaced, or adjusted, no further repair, replacement or adjustment will be approved.

(2) When a partial loss of hearing is the result of an allowed injury or occupational disease.

(F) Diagnostic testing, nerve injections, and imaging.

(1) Requests for diagnostic electromyography (EMG), nerve conduction study (NCS), epidural injections, nerve blocks, and medical imaging will be reimbursed when medical evidence shows that the diagnostic EMG, NCS, epidural injection, nerve block, or medical imaging is medically necessary either to develop a plan of treatment for, or to pursue more specific diagnoses reasonably related to, an allowed condition and the criteria of paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code are met.

(2) When the results of the diagnostic EMG, NCS, epidural injections, nerve block, or medical imaging indicate a non-allowed condition, therapeutic treatment for such non-allowed condition will not be reimbursed unless the condition is additionally allowed in the claim.

(3) Requests for duplicative diagnostic EMG, NCS, or medical imaging will not be reimbursed absent evidence of new or changed medical circumstances since the last diagnostic EMG, NCS, or medical imaging, or other medical evidence supporting the need for additional diagnostic testing or imaging that meets the criteria of paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code.

(4) With medical evidence supporting the necessity, reimbursement for diagnostic epidural injections or nerve blocks:

(a) May include up to three spinal levels, unilaterally or bilaterally, contiguous to the level of the allowed condition; and

(b) May include one repeat diagnostic injection to confirm a pain relief response prior to submission of requests for reimbursement of therapeutic treatment at the allowed level.

(5) Medical imaging includes magnetic resonance imaging (MRI), computed tomography scan (CT), discogram, positron emission tomography (PET), myelogram, X-ray, and ultrasound.

(G) Once payment for orthotic devices, artificial teeth or other dentures, eyeglasses, contact lenses, or hearing aids has been made, replacement requests may be denied in instances of malicious damage, neglect, culpable irresponsibility, or wrongful disposition.

Last updated June 3, 2024 at 8:32 AM

History

Effective: June 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-31.1 Supportive care.

This rule governs the identification and medical management of claims necessitating supportive care, including medical treatment reimbursement authorization. The objective is to ensure the timely and efficient provision of medically necessary and appropriate treatment reasonably related to the allowed conditions, in order to maintain or improve the injured worker's level of function, minimize or prevent regression or relapse, effectively manage symptoms, minimize disease or impairment progression, provide continuity of care, and minimize reliance on medication treatment.

(A) As used in this rule, "supportive care" means care that is medically necessary and that cannot be administered or performed by the injured worker independently and is needed to maintain therapeutic benefit, prevent or treat exacerbations, maintain function, or return to baseline function.

(B) A claim necessitating supportive care is a claim in which the injured worker has reached a plateau in recovery and which requires some level of ongoing care or medical treatment.

Such claims can be manifested by reduced function due to ongoing impairment, pain, or distress related to the allowed condition which diminishes quality of life, mobility, the ability to perform activities of daily living (ADLs), or work activity.

(C) The MCO shall evaluate the request for supportive care services through a review of the medical documentation in the file which must include the following applicable information:

(1) A comprehensive history and physical exam by the physician of record or treating physician that includes:

(a) The nature of the reported symptoms of the allowed conditions, their onset, duration, exacerbations, and any alleviating or aggravating circumstances;

(b) Objective findings of recent examinations;

(c) Report of current level of functioning using validated instruments and tools to assess life function and disruption of function due to the allowed conditions and the expected impact of the proposed plan of care on the current limitations caused by the allowed conditions;

(d) Prior treatment and response to treatment, including the results of any withdrawal of treatment; and

(e) Confounding factors, if any, affecting treatment plan decision-making.

(2) Clinical rationale for the treatment being requested;

(3) A treatment plan that includes:

(a) A description of the interventions requested, including proposed frequency and duration of treatment;

(b) Lifestyle modifications, if appropriate;

(d) Specific goals to be achieved by the treatment being requested.

(D) The MCO shall consider the following while reviewing the medical documentation and determining if the claim necessitates supportive care:

(1) The allowed conditions;

(2) Changes in the injured worker's medical condition, which have occurred over the course of care, if any, including medication utilization, and physical and/or psychological function;

(3) Improvement or regression in function compared to baseline;

(4) Any confounding factors which may have impeded or aggravated the injured worker's progress; and

(5) Prior treatment and response to treatment, including the results of any withdrawal of treatment.

(E) The MCO shall, when approving or denying a request for supportive care, consider and document:

(1) Prior industrial commission decisions relating to prior requests for the same treatments;

(2) Any new or updated circumstances or information which support a different decision than the prior decision(s) of the industrial commission;

(3) Consistency or lack thereof of the current treatment reimbursement request with previously authorized requests; and

(4) Denial of any request for supportive, non-surgical care when a request for the same treatment has previously been granted by the industrial commission must be supported by documentation as to how the injured worker's current circumstances, which could include any new or updated information, differ from those present or presented when the industrial commission issued its order.

(F) Frequency and duration of medical treatment reimbursement requests for supportive care meeting the criteria outlined in this rule shall be approved regardless of whether they exceed treatment guidelines adopted by the bureau pursuant to rule 4123-6-16.1 of the Administrative Code.

Last updated February 3, 2025 at 8:36 AM

History

Effective: February 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-32 Payment for lumbar fusion surgery.

Reimbursement for lumbar fusion surgery for treatment of allowed conditions in a claim resulting from an allowed industrial injury or occupational disease shall be limited to claims in which current best medical practices as implemented by this rule are followed.

This rule governs the bureau's reimbursement of lumbar fusion surgery to treat a work related injury or occupational disease. It is not meant to preclude, or substitute for, the surgeon's responsibility to exercise sound clinical judgment in light of current best medical practices when treating injured workers.

A provider's failure to comply with the requirements of this rule may constitute endangerment to the health and safety of injured workers, and claims involving lumbar fusion surgery not in compliance with this rule may be subject to peer review by the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the Administrative Code or other peer review committee established by the bureau.

Medical treatment reimbursement requests (on form C-9 or equivalent) for lumbar fusion surgery are not subject to dismissal by the MCO pursuant to paragraph (F)(7) of rule 4123-6-16.2 of the Administrative Code.

(A) Prerequisites to consideration of lumbar fusion surgery.

Except as otherwise provided in paragraph (A)(4) of this rule, authorization for lumbar fusion shall be considered only in cases in which the following criteria are met:

(1) Conservative care.

(a) The injured worker must have had at least sixty days of conservative care for low back pain, with an emphasis on:

(i) Physical reconditioning;

(ii) Avoidance of opioids, when possible; and

(iii) Avoidance of provider catastrophizing the explanation of lumbar MRI findings.

(b) The injured worker's comprehensive conservative care plan may include, but is not limited to, one or more of the following:

(i) Relative rest/ice/heat;

(ii) Anti-inflammatories;

(iii) Pain management / physical medicine rehabilitation program;

(iv) Chiropractic / osteopathic treatment;

(v) Physical medicine treatment as set forth in rule 4123-6-30 of the Administrative Code;

(vi) Interventional spine procedures / injections.

(2) The operating surgeon requesting authorization for lumbar fusion surgery must have personally evaluated the injured worker on at least two occasions prior to requesting authorization for lumbar fusion surgery.

(3) The injured worker must have undergone a comprehensive evaluation, coordinated by both the injured worker's physician of record or treating physician and the operating surgeon, in which all of the following have been documented:

(a) Utilization and correlation of all of the following tools:

(i) Visual analog scale (VAS);

(ii) Pain diagram;

(iii) Oswestry low back disability questionnaire.

(b) A comprehensive orthopedic / neurological examination, including documentation of all of the following categories:

(i) Gait;

(ii) Spine (deformities, range of motion, palpation);

(iii) Hips and sacroiliac joints;

(iv) Motor;

(v) Sensation;

(vi) Reflexes;

(vii) Upper motor neuron signs.

(i) Lumbar X-rays (including flexion and extension views) and a lumbar MRI or lumbar CT (with or without myelography) must be performed;

(ii) Electromyography (EMG) / nerve conduction study (NCS) may be performed if questions still remain during surgical planning.

(d) Discussion and consideration of opportunities for vocational rehabilitation.

(e) Review of current and previous medications taken.

(i) If opioid management is in process, review for best practices;

(ii) Consider impact of surgery on opioid load.

(f) Health behavioral assessment (pre-surgical).

Biopsychosocial factors that may affect treatment of the injured worker's allowed lumbar conditions are considered modifiable conditions that may change the need for surgery or improve surgical outcomes if appropriately addressed, and must be addressed if identified in the assessment. The health behavioral assessment and any identified interventions may be ordered by the injured worker's physician of record or treating physician, or the operating surgeon.

(g) Accounting and assessment of the following co-morbidities to stratify additional associated risks:

(i) Smoking;

(ii) Body mass index (BMI);

(iii) Diabetes;

(iv) Coronary artery disease;

(v) Peripheral vascular disease.

The co-morbidities indicated above are considered modifiable conditions that may improve surgical outcomes if appropriately addressed, and must be addressed if identified in the assessment.

(h) The injured worker and the physician of record, the treating physician, or the operating surgeon must have reviewed and signed the educational document, "What BWC Wants You to Know About Lumbar Fusion Surgery," attached as an appendix to this rule.

(4) The prerequisites to consideration of lumbar fusion surgery set forth in paragraphs (A)(1) to (A)(3) of this rule may be waived in cases of:

(a) Progressive functional neurological deficit;

(b) Spinal fracture;

(d) Infection;

(e) Trauma care;

(f) Emergency as defined in rule 4123-6-01 of the Administrative Code; and/or

(g) Other catastrophic spinal pathology causally related to the injured worker's allowed conditions.

(B) Authorization for lumbar fusion surgery where the injured worker has no prior history of lumbar surgery at the level for which the fusion is requested.

(1) Authorization for lumbar fusion shall be considered in cases where the injured worker has no prior history of lumbar surgery only when the injured worker remains highly functionally impaired despite a trial of at least sixty days of conservative care as provided in paragraph (A)(1)(a) of this rule (unless waived pursuant to paragraph (A)(4) of this rule) and one or more of the following are present:

(a) Mechanical low back pain with instability of the lumbar segment and no history of lumbar surgery.

(b) Spondylolisthesis of twenty-five per cent or more with one or more of the following:

(i) Objective signs/symptoms of neurogenic claudication;

(ii) Objective signs/symptoms of unilateral or bilateral radiculopathy, which are corroborated by neurologic examination and by MRI or CT (with or without myelography);

(iii) Instability of the lumbar segment.

(d) Lumbar stenosis necessitating decompression in which facetectomy of greater than or equal to fifty per cent or more is required.

(e) Primary neurogenic claudication and/or radiculopathy associated with lumbar spinal stenosis in conjunction with spondylolisthesis or lateral translation of three mm or greater or bilateral pars defect.

(f) Degenerative disc disease (DDD) associated with significant instability of the lumbar segment.

(g) Spinal stenosis, disc herniation, or other neural compressive lesion requiring extensive, radical decompression with removal of greater than fifty per cent of total facet volume at the associated level.

The surgeon must document why the surgical lesion would require radical decompression through the pars interarticularis (critical stenosis, recurrent stenosis with extensive scarring, far lateral lesion).

(2) For purposes of this paragraph, instability of the lumbar segment is defined as at least four mm of anterior/posterior translation at L3-4 and L4-5, or five mm of translation at L5-S1, or eleven degrees greater end plate angular change at a single level, compared to an adjacent level.

(C) Request for lumbar fusion surgery where the injured worker has a history of prior lumbar surgery at the level for which the fusion is requested.

(1) If a trial of at least sixty days of conservative care as provided in paragraph (A)(1)(a) of this rule has failed to relieve symptoms (or has been waived pursuant to paragraph (A)(4) of this rule) and the injured worker has had a prior laminectomy, discectomy, or other decompressive procedure at the same level, lumbar fusion should be considered for approval only if the injured worker has one or more of the following:

(a) Mechanical (non-radicular) low back pain with instability at the same or adjacent levels.

(b) Mechanical (non-radicular) low back pain with pseudospondylolisthesis, rotational deformity, or other condition leading to a progressive, measureable deformity.

(c) Objective signs/symptoms compatible with neurogenic claudication or lumbar radiculopathy that is supported by EMG/NCS, lumbar MRI, or CT and detailed by a clinical neurological examination in the presence of instability of three mm lateral translation with at least two prior decompression surgeries at the same level.

(d) Evidence from post laminectomy structural study of either:

(i) One hundred per cent loss of facet surface area unilaterally; or

(ii) Fifty per cent combined loss of facet surface area bilaterally.

(e) Documented pseudoarthrosis or nonunion, with or without failed hardware, in the absence of other neural compressive lesion.

(D) Lumber fusion surgical after care.

The physician of record or treating physician must follow the injured worker until the injured worker has reached maximum medical improvement (MMI) for the allowed lumbar conditions.

The operating surgeon must follow the injured worker until the injured worker has reached a plateau relative to the lumbar fusion and the surgeon has determined no further surgical related treatment is medically necessary.

(1) In the first six months post-operatively, the injured worker must be seen by both the physician of record or treating physician and the operating surgeon at least every two months to monitor the injured worker's progress, rehabilitation needs, behavioral patterns or changes, and return to work willingness and/or status.

During this period, the physician of record or treating physician and the operating surgeon shall determine the following:

(a) Fusion status;

(b) Pain and functional status;

(d) Residual level of functional capacity;

(e) Appropriateness for vocational rehabilitation.

(2) From six months to one year post-operatively, if the injured worker continues to experience significant functional impairment despite the lumbar fusion, the following actions are recommended:

(a) Pain and functional status (repeat VAS / pain diagram / Oswestry)

(b) Repeat baseline orthopedic / neurological examination;

(d) Revisit appropriate diagnostic imaging.

(e) Coordinate with MCO to develop a plan of care / return to functional status.

View Appendix

Last updated February 1, 2022 at 9:36 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-33 Payment for health behavior assessment and intervention services.

This rule governs the bureau's reimbursement for health behavior assessment and intervention (HBAI) services offered to injured workers who may benefit from an assessment that focuses on identifying behavioral barriers impeding the injured worker's recovery which may be addressed through intervention services.

(A) An injured worker shall be eligible for consideration of HBAI services if the injured worker has the capacity to understand and respond meaningfully during the health behavior assessment process and:

(1) The injured worker's physician of record, treating physician, or operating surgeon determines:

(a) The injured worker is not progressing with their injury after the initial course of treatment; and

(b) The injured worker's healing appears to be delayed due to behavioral barriers; or

(2) The injured worker is being evaluated by the physician of record, treating physician or operating surgeon for lumbar fusion surgery pursuant to rule 4123-6-32 of the Administrative Code;

(3) The injured worker is being evaluated by the physician of record, treating physician, or operatng surgeon for implantation of a spinal cord stimulator pursuant to rule 4123-6-35 of the Administrative Code.

(B) Providers must indicate the appropriate "International Classification of Diseases, clinical modification" codes for the injured worker's allowed physical condition(s) being treated, and must utilize the applicable codes, from the edition of the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) in effect on the date of the request, for the services being requested:

(1) Provider types who are eligible to bill evaluation and management codes must utilize evaluation and management codes when billing for HBAI services;

(2) Provider types who are not eligible to bill evaluation and management codes must utilize the applicable HBAI service codes when billing for HBAI services;

(3) HBAI services must be directed toward, and billed with, the injured worker's allowed physical condition(s);

(4) The bureau of workers' compensation shall not reimburse any HBAI services rendered to diagnose or treat psychological conditions, as the focus of these services is not on mental health but on factors impacting the prevention, treatment, or management of physical health problems and treatments.

(1) The physician of record, treating physican, or operating surgeon requesting a health behavior assessment must submit a medical treatment reimbursement request for the assessment (on form C-9 or equivalent) to the injured worker's MCO.

(2) The physician of record, treating physican, or operating surgeon must document the following to support the request for the assessment:

(a) History of the industrial injury or occupational disease resulting in the allowed conditions in the claim;

(b) Recognized behavioral barriers impeding the injured worker's recovery from the allowed conditions in the claim;

(c) Documentation of the initial course of treatment, including all treatment and diagnostic studies as of the date of the request, including all results;

(d) The assessment is not duplicative of other provider assessments.

(3) The health behavior assessment may be performed by any provider whose professional scope of practice as defined under state law includes health behavior assessment services.

(4) The provider conducting the health behavior assessment must provide a written summary report to the physician of record, treating physican, or operating surgeon indicating the findings of the assessment and appropriate recommendations for intervention services, if any. The report shall include at a minimum the following:

(a) History of the industrial injury or occupational disease resulting in the allowed conditions in the claim;

(b) Overview of treatment and diagnostic studies to date and results;

(d) Assessment conclusions/findings including, at a minimum:

(i) Identification and/or validation of existence of behavioral barriers;

(ii) A statement as to whether the injured worker's healing or recovery progress from the allowed conditions is impeded by the identified behavioral barriers;

(iii) Recommendation of possible intervention services and goals to address the identified behavioral barriers; and

(iv) The expected duration of the recommended intervention services;

(5) Except as otherwise provided in rule 4123-6-32 of the Administrative Code, only one health behavior assessment per year may be approved for an injured worker.

(6) Health behavior re-assessment services.

(a) One re-assessment per year may be approved for an injured worker who has undergone health behavior intervention services.

(b) A physician of record, treating physican, or operating surgeon requesting a re-assessment must:

(i) Submit a medical treatment reimbursement request for the reassessment (on form C-9 or equivalent) to the injured worker's MCO; and

(ii) Provide clear rationale for why a re-assessment is required, including new and changed circumstances in the injured worker's physical status.

(D) Health behavior intervention services.

(1) After review of the assessment, the physician of record, treating physican, or operating surgeon shall:

(a) Determine the medically necessary and appropriate health behavior intervention services to be provided; and

(b) Submit a medical treatment reimbursement request for the services (on form C-9 or equivalent) to the injured worker's MCO.

(2) The health behavior intervention services may be performed by any provider whose professional scope of practice as defined under state law includes health behavior intervention services.

(3) Health behavior intervention services are limited to coaching and counseling services that address the behavioral barriers identified or validated in the assessment.

(4) Documentation for each intervention encounter must include the following:

(a) Goals;

(b) Progress, or lack thereof, toward goals and objectives;

(d) Time in and time out and duration of services.

(5) Health behavior intervention services shall be limited to up to six hours in a twelve month period. Additional intervention services may be approved during the twelve month period, if the physician of record, treating physican, or operating surgeon provides documentation the additional services are medically necessary.

Last updated November 3, 2025 at 7:38 AM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-34 Payment for treatment of concussion injuries.

This rule governs the bureau's reimbursement for services in an allowed claim related to concussion. It is not meant to preclude, or substitute for, the health care provider's responsibility to exercise sound clinical judgment in light of current best medical practices when treating injured workers.

(A) As used in this rule, "concussion" means a type of traumatic brain injury induced by external force, which might include a bump or blow to the head, or a jolt or hit to the body, which causes the brain to bounce around or twist in the skull, causing chemical changes in the brain and sometimes stretching and damaging brain cells.

(1) Concussion is manifest by at least one of the following:

(a) Any alteration in mental state at the time of the accident (feeling dazed, disoriented, or confused);

(b) Any period of loss of consciousness;

(d) Focal neurological deficit that may or may not be transient, but where the severity of the injury does not exceed the following:

(i) A loss of consciousness for approximately thirty minutes or less;

(ii) After thirty minutes, an initial "Glasgow Coma Score" of 13-15; or

(iii) Post-traumatic amnesia not greater than twenty-four hours.

(2) A concussion may involve different symptoms, clinical profiles and subtypes, and different recovery trajectories, which may be influenced by a variety of risk factors. Kontos, Anthony P. and Michael W. Collins. Concussion: a clinical profile approach to assessment and treatment. Washington, DC: American psychological association (2018), p.5. Adapted with permission.

(3) In concussion, even though by definition brain injury has occurred, standard imaging studies such as CT scan and MRI will commonly be normal.

(B) As used in this rule, "clinical domains" related to concussion means the following group of signs or symptoms related to a specific body part or system:

(1) Anxiety and mood: including ruminating thoughts, difficulty concentrating, hypervigilance, or fastidiousness.

(2) Vestibular: including impaired balance and equilibrium, dizziness, nausea, or environmental sensitivity,

(3) Ocular: including impaired vision and visual tracking, impaired comprehension, trouble focusing, or distractibility.

(4) Sleep: including trouble falling asleep or sleeping more or less than usual.

(5) Cervical: including neck pain, stiffness, or reduced range of motion.

(6) Cognitive fatigue: including impaired thinking abilities, feeling slow or "one step behind", physical and mental fatigue, general headache, or sleep disturbance.

(7) Headache (migraine, cervicogenic, and tension headache): including variable and intermittent severe headache, nausea, photosensitivity, or vestibular migraine.

(8) Cognitive impairment: including impairment in attention, memory, executive function, language processing, or visual perception and processing.

(C) Notwithstanding any provision to the contrary in any other rule of the bureau, medical treatment reimbursement requests relating to the clinical domains set forth in paragraph (B) of this rule, submitted within six months from the date of injury, for treatment not to exceed six months from the date of injury, may be authorized in an allowed claim, without disclaimer, when:

(1) The documented mechanism of injury in the claim included a bump or blow to the head, or a jolt or hit to the body: and

(2) Signs or symptoms related to the clinical domains have manifested within six weeks of the date of injury; and

(3) The requested medical treatment is determined to be medically necessary and appropriate, and reasonably related to treatment of concussion, based on the medical evidence.

(D) When concussion or other conditions relating to the clinical domains set forth in paragraph (B) of this rule and treated pursuant to paragraph (C) of this rule are determined to require ongoing treatment beyond six months, the physician of record or treating provider may request these conditions be additionally allowed in the claim.

Last updated September 9, 2025 at 11:41 AM

History

Effective: January 1, 2020
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-35 Payment for spinal cord stimulator.

Reimbursement for a spinal cord stimulator for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease is limited to claims in which current best medical practices as implemented by this rule are followed.

This rule governs the bureau's reimbursement of a spinal cord stimulator to treat a work related injury or occupational disease. It is not meant to preclude, or substitute for, the treating physician's responsibility to exercise sound clinical judgment in light of current best medical practices when treating injured workers.

A provider's failure to comply with this rule may constitute endangerment to the health and safety of injured workers, and claims involving a spinal cord stimulator not in compliance with this rule may be subject to peer review by the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the Administrative Code or other peer review committee established by the bureau.

Medical treatment reimbursement requests (on form C-9 or equivalent) for a spinal cord stimulator are not subject to dismissal by the MCO pursuant to paragraph (F)(7) of rule 4123-6-16.2 of the Administrative Code.

(A) Authorization for a spinal cord stimulator will be considered only in cases in which the following criteria are met:

(1) Allowed conditions. The injured worker has one or more of the following conditions allowed in their claim:

(a) Failed thoracic or lumbar spinal surgery.

(b) Complex regional pain syndrome.

(d) Neuropathic pain post-thoracic or post-lumbar surgery.

(e) Chronic thoracic or lumbar radiculopathy.

(f) Spinal cord injury dysesthesias.

(2) Conservative care. The injured worker has undergone at least sixty days of conservative care, which may include but is not limited to:

(a) Anti-inflammatory medication(s) treatment;

(b) Chiropractic or osteopathic treatment;

(d) Pain management program participation;

(e) Physical medicine rehabilitation program participation; or

(f) Physical therapy.

(3) Surgeon evaluation. The injured worker has been personally evaluated by the operating surgeon and undergone a comprehensive evaluation, in which all of the following have been documented:

(a) Date of injury;

(b) Mechanism of injury;

(i) Prior surgeries;

(ii) List of current medical and psychological conditions;

(iii) List of current medications;

(iv) List of drug allergies.

(d) Physical examination;

(e) Pertinent neurological and vascular testing;

(f) Completion of a health behavioral assessment and, when appropriate, identified intervention services;

(g) Consideration of vocational rehabilitation services.

(4) Education. The injured worker and physician of record, treating physician, or operating surgeon have reviewed and signed the educational document, "What BWC Wants You to Know About Spinal Cord Stimulators," attached as an appendix to this rule.

(5) Spinal cord stimulator trial. Having met the criteria outlined in paragraphs (A)(1) to (A)(4) of this rule, and prior to implantation of a spinal cord stimulator, the injured worker has completed an approved seven-day spinal cord stimulator trial, with documented improvement in a majority of the following areas:

(a) Activities of daily living, documented through use of an evidence-based tool (e.g., "OSWESTRY Disability Index Questionnaire or Roland Morris Disability Questionnaire");

(b) Gait;

(d) Pain level, documented through use of an evidence-based pain scale (e.g., visual analog scale) and a decrease of use of the morphine equivalent dosage of any pre-procedure opioid analgesic; and

(e) Sleep.

(B) BWC will not reimburse for a spinal cord stimulator:

(1) For the treatment of failed cervical spine surgery, neuropathic pain post-cervical surgery, or cervical radiculopathy;

(2) When the injured worker has an implanted pacemaker or defibrillator, metabolic or alcoholic neuropathy, or somatization disorder; or

(3) When any of the following documented conditions are uncontrolled or untreated:

(a) Substance use disorder;

(b) Psychosis; or

View Appendix

Last updated September 1, 2022 at 8:29 AM

History

Effective: September 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-36 Enhanced care program.

This rule governs the bureau's enhanced care program for injured workers who have sustained a compensable knee injury. The program is designed to simplify the claims management process and encourage higher quality, better coordinated care for eligible claims that results in improved outcomes.

(A) Notwithstanding any provision to the contrary in any other rule of the bureau, the administrator may, for purposes of the enhanced care program, allow one or more managed care organizations to authorize medical treatment reimbursement requests for the first sixty days from the initial allowance of an eligible claim for any conditions within the same knee as the conditions initially allowed in the claim, and presumed to be causally related to the same industrial injury or occupational disease, without disclaimer, during such time as the conditions for which treatment reimbursement is authorized but which are not yet allowed are being considered for allowance or being adjudicated.

(B) Claims meeting the following criteria are eligible for inclusion in the enhanced care program:

(1) The injured worker's claim is a work-related knee only injury as documented by the medical evidence in the claim, and is allowed for knee conditions only;

(2) The injured worker's physician of record is certified to participate in the HPP, and has signed and agrees to comply with the "Enhanced Care Program Provider Addendum" to the provider certification application and agreement or recertification application and agreement, in accordance with rule 4123-6-02.3 of the Administrative Code; and

(3) The injured worker's employer of record is not:

(a) A state agency; or

(b) A self-insuring employer providing compensation and benefits pursuant to section 4123.35 of the Revised Code.

(C) The operation of the enhanced care program does not impair in any manner the right of an employer, injured worker, or their representatives to appeal a claim, additional allowance, or medical treatment reimbursement determination under section 4123.511 of the Revised Code or rule 4123-6-16 of the Administrative Code. However, if the employer, injured worker, or their representatives exercises its right to appeal a claim, additional allowance, or medical treatment reimbursement determination, the claim will be removed from the enhanced care program.

Last updated January 3, 2023 at 9:45 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-37 Payment of hospital bills.

(A) Direct reimbursement will not be made to members of a hospital resident staff.

(B) Payment for personal comfort items, which include, but are not limited to, telephones, television, and private rooms provided at the patient's request, are not compensable.

(1) Bureau fees for hospital inpatient services will be based on usual and customary methods of payment, such as prospective payment systems, including diagnosis related groups (DRG), per diem rates, rates based on hospital cost to charge ratios or percent of allowed charges.

(2) Except in cases of emergency, prior authorization must be obtained in advance of all hospitalizations. The hospital must notify the bureau, the injured worker's MCO, QHP, or self-insuring employer of emergency inpatient admissions within one business day of the admission. Failure to comply with this rule shall be sufficient ground for denial of room and board charges by the bureau, MCO, QHP, or self-insuring employer from the date of admission up to the actual date of notification. Room and board charges denied pursuant to this rule may not be billed to the injured worker.

(D) Bureau fees for hospital outpatient services.

(1) Bureau fees for hospital outpatient services, including emergency services, will be reimbursed in accordance with usual and customary methods of payment which may include prospectively determined rates, allowable fee maximums, ambulatory payment categories (APC), hospital cost to charge ratios, or a percent of allowed charges, as determined by the bureau.

(2) Treatment in the emergency room of a hospital must be of an immediate nature to constitute an emergency as defined in this chapter. Prior authorization of such treatment is not required. However, in situations where the emergency room is being utilized to deliver non-emergency care, notification will be provided to the injured worker, the hospital, and the provider of record that continued use of the emergency room for non-emergent services will not be reimbursed.

(E) The bureau may establish the same or different fees for in-state and out-of-state hospitals based on the above reimbursement methodologies.

Last updated February 1, 2022 at 9:37 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-37.1 Payment of hospital inpatient services.

(A) HPP.

Except as provided in paragraphs (A)(7) and (A)(8) of this rule, reimbursement for hospital inpatient services with a discharge date of February 1, 2026 or after will be calculated as follows:

(1)

(a) Reimbursement for hospital inpatient services, other than outliers as defined in paragraph (A)(3) of this rule, services provided by hospitals subject to reimbursement under paragraph (A)(4) of this rule, or acute or subacute inpatient detoxification services subject to reimbursement on a per diem basis under paragraph (A)(7) of this rule, will be calculated using the applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system multiplied by a payment adjustment factor of 1.130 plus a new technology add-on payment (if applicable), according to the following formula:

MS-DRG reimbursement rate x 1.130 + new technology add-on payment (if applicable) = bureau reimbursement for hospital inpatient service.

(b) In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare inpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907d as amended as of the effective date of this rule, the "applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.

(2) In addition to the payment specified by paragraph (A)(1) of this rule, hospitals operating approved graduate medical education programs and receiving additional reimbursement from medicare for costs associated with these programs will receive an additional per diem amount for direct graduate medical education costs associated with hospital inpatient services reimbursed by the bureau. Hospital specific per diem rates for direct graduate medical education will be calculated annually by the bureau effective February first of each year, using the most current cost report data available from the centers for medicare and medicaid services, according to the following formula:

1.130 x [(total approved amount for resident cost + total approved amount for allied health cost)/ total inpatient days] = direct graduate medical education per diem.

Direct graduate medical education per diems will not be applied to outliers as defined in paragraph (A)(3) of this rule, services provided by hospitals subject to reimbursement under paragraph (A)(4) of this rule, or acute or subacute inpatient detoxification services subject to reimbursement on a per diem basis under paragraph (A)(7) of this rule.

(3)

(a) Reimbursement for outliers as determined by medicare's inpatient prospective payment system outlier methodology will be calculated using the applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system multiplied by a payment adjustment factor of 1.130 plus the applicable medicare operating outlier amount and medicare capital outlier amount plus a new technology add-on payment (if applicable), according to the following formula:

(MS-DRG reimbursement rate x 1.130) + medicare operating outlier amount + medicare capital outlier amount + new technology add-on payment (if applicable) = bureau reimbursement for hospital inpatient service outlier.

(4) Reimbursement for inpatient services provided by hospitals and distinct-part units of hospitals designated by the medicare program as exempt from the medicare inpatient prospective payment system will be determined as follows:

(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintains hospital-specific cost-to-charge ratio information on, reimbursement will be equal to the hospital's allowable billed charges multiplied by the hospital's reported operating cost-to-charge ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital's allowed billed charges.

(b) For hospitals the department of health and human services, centers for medicare and medicaid services does not maintain hospital-specific cost-to-charge ratio information on, reimbursement will be equal to the hospital's allowable billed charges multiplied by the applicable fiscal year 2026 urban or rural statewide average operating cost-to-charge ratio set forth in table 8A of the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average operating cost-to-charge ratio will be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital's allowed billed charges.

(5) Reimbursement for inpatient services provided by hospitals and distinct-part units of hospitals that do not participate in the medicare program will be calculated in accordance with the applicable provisions of paragraphs (A)(1) and (A)(3) of this rule using the national standardized amount for fiscal year 2026, full update, as found at 90 Fed. Reg. 37250 (2025).

(6) Reimbursement for inpatient services provided by "new hospitals" as defined in 42 C.F.R. 412.300(b) as published in the October 1, 2025 Code of Federal Regulations will be calculated in the same manner as provided under paragraph (A)(4)(b) of this rule.

(7) Reimbursement for acute or subacute inpatient detoxification services will be calculated in accordance with the applicable provisions of paragraph (A) of this rule, unless the hospital elects to be reimbursed for these services on a per diem basis, in which case the hospital will be reimbursed the lesser of the charges billed by the hospital for the allowed services rendered, the all-inclusive per diem rates set forth in Table 1 of the appendix to this rule, or the rate the MCO contracted or negotiated with the hospital.

(8) Except for services subject to reimbursement on a per diem basis under paragraph (A)(7) of this rule, if the MCO has contracted or negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement will be at the contracted or negotiated rate.

(9) For purposes of this rule, hospitals must report the applicable inpatient revenue codes for accommodation and ancillary services set forth in Table 2 of the appendix to this rule.

(10) For purposes of this rule, the "medicare severity diagnosis related group (MS-DRG) reimbursement rate," "medicare operating outlier amount," "medicare capital outlier amount," and "new technology add-on payment" will be determined in accordance with the medicare program established under Title XVIII of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1395 to 1395lll as amended as of the effective date of this rule, excluding 42 U.S.C. 1395ww(m), as implemented by the following materials, which are incorporated by reference:

(a) 42 C.F.R. Part 412 as published in the October 1, 2025 Code of Federal Regulations, excluding 42 C.F.R. 412.113(f), 42 C.F.R. 412.113(g), and 42 C.F.R. Part 412 Subpart O;

(b) Department of health and human services, centers for medicare and medicaid services' 42 CFR Parts 412, 495, and 512, office of the secretary 45 CFR Part 170 " medicare program; hospital inpatient prospective payment systems for acute care hospitals (IPPS) and the long-term care hospital prospective payment system and policy changes and fiscal year (FY) 2026 rates; changes to the FY 2025 IPPS rates due to court decision; requirements for quality programs; and other policy changes; health data, technology, and interoperability: electronic prescribing, real-time prescription benefit and electronic prior authorization," final rule, 90 Fed. Reg. 36536 - 37308 (2025).

(c) The department of health and human services, centers for medicare and medicaid services' hospital-specific cost-to-charge ratio information as of the July 2025 update to the department of health and human services, centers for medicare and medicaid services' inpatient provider specific file (IPSF).

(B) QHP or self insuring employer (non-QHP):

A QHP or self-insuring employer may reimburse hospital inpatient services at:

(1) The applicable rate under the methodology set forth in paragraph (A) of this rule; or

(2)

(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintains hospital-specific cost-to-charge ratio information on, the hospital's allowable billed charges multiplied by the hospital's reported operating cost-to-charge ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital's allowed billed charges;

(b) For hospitals the department of health and human services, centers for medicare and medicaid services does not maintain hospital-specific cost-to-charge ratio information on, the hospital's allowable billed charges multiplied by the applicable fiscal year 2026 urban or rural statewide average operating cost-to-charge ratio set forth in table 8A of the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average operating cost-to-charge ratio will be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital's allowed billed charges; or

(3) The rate negotiated between the hospital and the QHP or self-insuring employer in accordance with rule 4123-6-46 of the Administrative Code.

View Appendix

Last updated February 2, 2026 at 8:01 AM

History

Effective: February 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-37.2 Payment of hospital outpatient services.

(A) HPP:

Unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for hospital outpatient services with a date of service of May 1, 2026 or after will be the applicable rate set forth in this rule as follows:

(1) Except as otherwise provided in this rule, reimbursement for hospital outpatient services will be equal to the applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule, multiplied by a bureau-specific payment adjustment factor, which will be 3.414 for children's hospitals and 1.449 for all hospitals other than children's hospitals, plus the add-on payments set forth in paragraph (A)(4) of this rule, if applicable.

BWC will use the medicare integrated outpatient code editor and medicare medically unlikely edits in effect as implemented by the materials specified in paragraph (A)(9) of this rule and table 8 of the appendix to this rule to process bills for hospital outpatient services under this rule; however, BWC will not apply the outpatient code edits identified in table 1 of the appendix to this rule.

BWC will not apply the annual medicare outpatient prospective payment system outlier, hold harmless, and exempt cancer hospital reconciliation processes to payments for hospital outpatient services under this rule.

For purposes of this rule, hospitals are identified as critical access hospitals, rural sole community hospitals, essential access community hospitals and exempt cancer hospitals based on the hospitals' designation in the medicare outpatient provider specific file in effect implemented by the materials specified in paragraph (A)(10) of this rule.

For purposes of this rule, the following hospitals are recognized as "children's hospitals": nationwide children's hospital (Columbus), Cincinnati children's hospital medical center, shriners hospital for children (Cincinnati), university hospitals rainbow babies and children's hospital (Cleveland), Toledo children's hospital, children's hospital medical center of Akron, and children's medical center of Dayton.

Reimbursement for any hospital outpatient services identified in table 6 of the appendix to this rule will be determined using the medicare outpatient prospective payment system methodology as set forth in this paragraph, applying the status indicator and ambulatory payment classification specified for the service in table 6 of the appendix to this rule.

In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare outpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule, other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907(d) as amended as of the effective date of this rule, the "applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.

(2) Services reimbursed via fee schedule. These services will not be wage index adjusted.

(a) Services reimbursed via fee schedule to which the bureau-specific payment adjustment factor will be applied.

Except as otherwise provided in paragraphs (A)(2)(b)(ii) and (A)(2)(b)(iii) of this rule, hospital outpatient services reimbursed via fee schedule under the medicare outpatient prospective payment system will be reimbursed under the applicable medicare fee schedule in effect as implemented by the materials specified in paragraph (A)(10) of this rule, plus the add-on payments set forth in paragraph (A)(4) of this rule, if applicable.

(b) Services reimbursed via fee schedule to which the bureau-specific payment adjustment factor will not be applied.

The following services will be reimbursed the lesser of the charges billed by the hospital for the allowed services rendered, the applicable fee schedule rates set forth in tables 2, 3, 4 and 5 of the appendix to this rule, or the rate the MCO contracted or negotiated with the hospital:

(i) Hospital outpatient vocational rehabilitation services for which the bureau has established a fee as set forth in table 2 of the appendix to this rule.

(ii) Hospital outpatient services reimbursed via fee schedule under the medicare outpatient prospective payment system that the bureau has determined will be reimbursed at a rate other than the applicable medicare fee schedule in effect as implemented by the materials specified in paragraph (A)(10) of this rule, for which the bureau has established a fee as set forth in table 3 of the appendix to this rule.

(iii) Hospital outpatient services not reimbursed under the medicare outpatient prospective payment system that the bureau has determined are necessary for treatment of injured workers, for which the bureau has established a fee as set forth in tables 4 and 5 of the appendix to this rule.

(3) Services reimbursed at reasonable cost. To calculate reasonable cost, the line item charge will be multiplied by the hospital's outpatient cost to charge ratio from the medicare outpatient provider specific file in effect as implemented by the materials specified in paragraph (A)(10) of this rule. These services will not be wage index adjusted.

(a) Services reimbursed at reasonable cost to which the bureau-specific payment adjustment factor will be applied.

Notwithstanding any other reimbursement methodology set forth in this rule, critical access hospitals will be reimbursed at one hundred one per cent of reasonable cost for all payable line items.

(b) Services reimbursed at reasonable cost to which the bureau-specific payment adjustment factor will not be applied.

(i) Services designated as inpatient only under the medicare outpatient prospective payment system.

(ii) Hospital outpatient services reimbursed at reasonable cost as identified in tables 3 and 4 of the appendix to this rule.

(4) Add-on payments calculated using the applicable medicare outpatient prospective payment system methodology and formula in effect as implemented by the materials specified in paragraph (A)(10) of this rule. These add-on payments will be applied after the application of the bureau-specific payment adjustment factor.

(a) Outlier add-on payment. An outlier add-on payment will be provided on a line item basis for partial hospitalization services and for ambulatory payment classification reimbursed services for all hospitals other than critical access hospitals.

(b) Rural hospital add-on payment. A rural hospital add-on payment will be provided on a line item basis for rural sole community hospitals, including essential access community hospitals; however, drugs, biological, devices reimbursed via pass-through and reasonable cost items will be excluded. The rural add-on payment will be calculated prior to the outlier add-on payment calculation.

(c) Hold harmless add-on payment. A hold harmless add-on payment will be provided on a line item basis to exempt cancer centers and children's hospitals. The hold harmless add-on payment will be calculated after the outlier add-on payment calculation.

(5) Providers not participating in the medicare program.

Reimbursement for outpatient services provided by hospitals and distinct-part units of hospitals that do not participate in the medicare program will be calculated in accordance with the methodologies set forth in this rule, using the applicable FY26 urban or rural statewide average outpatient cost-to-charge ratio adopted by the medicare program pursuant to the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average cost-to-charge ratio will be used for hospitals outside the United States).

(6) Reimbursement for outpatient services provided by "new hospitals" as defined in 42 C.F.R. 412.300(b) as published in the October 1, 2025 Code of Federal Regulations shall be calculated in the same manner as provided under paragraph (A)(5) of this rule.

(7) For purposes of this rule, hospitals are to report the applicable outpatient revenue codes for accommodation and ancillary services set forth in table 7 of the appendix to this rule.

(8) For purposes of this rule, coverage status for designated hospital outpatient services is set forth in table 9 of the appendix to this rule.

(9) For purposes of this rule, services subject to always and sometimes therapy editing are set forth in table 10 of the appendix to this rule.

(10) For purposes of this rule, the "applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system" and the "medicare outpatient prospective payment system" will be determined in accordance with the medicare program established under Title XVIII of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1395 to 1395lll as amended, as of the effective date of this rule, as implemented by the following materials, which are incorporated by reference:

(a) 42 C.F.R. Part 419 as published in the October 1, 2025 Code of Federal Regulations;

(b) Department of health and human services, centers for medicare and medicaid services' "42 CFR Parts 410, 412, 413, 415, 416, and 419, and 45 CFR Part 180, Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Ratings; and Hospital Price Transparency," final rule 90 Fed. Reg. 53448 - 54088 (2025).

(c) The department of health and human services, centers for medicare and medicaid services' hospital-specific cost-to-charge ratio information as of the October 2025 update to the department of health and human services, centers for medicare and medicaid services' outpatient-provider specific file (OPSF).

(B) QHP or self-insuring employer (non-QHP):

A QHP or self-insuring employer may reimburse hospital outpatient services at:

(1) The applicable rate under the methodology set forth in paragraph (A) of this rule; or

(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintains hospital-specific cost-to-charge ratio information on, the hospital's allowable billed charges multiplied by the hospital's cost-to-charge ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.16, not to exceed sixty per cent of the hospital's allowed billed charges.

(b) For hospitals the department of health and human services, centers for medicare and medicaid services does not maintain hospital-specific cost-to-charge ratio information on the hospital's allowable billed charges multiplied by the applicable FY26 urban or rural statewide average outpatient cost-to-charge ratio adopted by the medicare program pursuant to the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average cost-to-charge ratio will be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.16, not to exceed sixty per cent of the hospital's allowed billed charges; or

(2) The rate negotiated between the hospital and the QHP or self-insuring employer in accordance with rule 4123-6-46 of the Administrative Code.

The bureau may request information from any facility billing the bureau for services as a provider-based facility as may be necessary to establish whether the facility meets the criteria for provider-based status under 42 C.F.R. 413.65 as published in the October 1, 2025 Code of Federal Regulations. The information requested may include an attestation by the facility.

View Appendix

Last updated May 1, 2026 at 8:10 AM

History

Effective: May 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-37.3 Payment of ambulatory surgical center services.

Unless an MCO has negotiated a different payment rate with an ambulatory surgical center pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for ambulatory surgical center services with a date of service of May 1, 2026 or after will be equal to the lesser of the ambulatory surgical center's allowable billed charges or the fee schedule amount indicated in the appendix to this rule, developed with provider and employer input and effective May 1, 2026.

Ambulatory surgical centers determined as of the effective date of this rule by the centers for medicare and medicaid services (CMS) to not meet quality measures for the calendar year 2026 full payment update under the CMS ambulatory surgical center quality reporting (ASCQR) program, established by 42 U.S.C. 1395l as in effect as of the effective date of this rule and 42 C.F.R. Part 416, Subpart H as published in the October 1, 2025 Code of Federal Regulations, will be subject to a two per cent reduction to the BWC 2026 ambulatory surgical center fee schedule amounts indicated in the appendix to this rule.

However, if such an ambulatory surgical center, upon reconsideration, is subsequently determined by CMS to meet quality measures for the calendar year 2026 full payment update under the CMS ASCQR program, upon the ambulatory surgical center's request the ambulatory surgical center will no longer be subject to the two per cent reduction, and the bureau will adjust any bills for dates of service on or after the effective date of this rule that were previously reduced pursuant to this rule.

View Appendix

Last updated May 1, 2026 at 8:10 AM

History

Effective: May 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-38 Payment for home health nursing services and home health aide services.

(A) Except as provided in rule 4123-6-38.1 of the Administrative Code, home health nursing services and home health aide services shall be provided by registered nurses or licensed practical nurses and home health aides employed by a home health agency meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(B) Authorization for home health nursing services and home health aide services.

(1) Authorization for home health nursing services will be considered only in cases where, as the result of an allowed injury or occupational disease:

(a) The injured worker is mentally or physically incapable of independently performing activities of daily living; or

(b) Home health nursing services or home health aide services are ordered for discharge follow-up or by a treating physician as part of a written treatment plan.

(2) The request for authorization from the physician of record or treating physician must include a written treatment plan that identifies the reason for home health nursing services or home health aide services, the period of time the services will be needed, the specific services needed, and the number of hours per day that are needed.

(3) Authorization must be obtained prior to rendering home health nursing services or home health aide services, except in cases of emergency or where the injured worker's allowed conditions could be endangered by the delay of services.

(C) Except as otherwise provided in paragraph (D) of this rule, only part-time or intermittent home health nursing services or home health aide services will be authorized, in accordance with the written treatment plan. Part-time or intermittent care means that total home health nursing services and home health aide services do not exceed eight hours per day.

(D) When more than eight hours of total home health nursing services or home health aide services are medically necessary, the bureau will consider more appropriate alternative settings. In exceptional cases, the bureau may authorize more than eight hours of total home health nursing services or home health aide services when medically necessary and appropriate.

(E) Authorized home health aide services may include:

(1) Bathing, dressing, grooming, hygiene, including shaving, skin care, foot care, ear care, hair, nail, and oral care needed to facilitate care or prevent deterioration of the injured worker's health.

(2) Feeding, assistance with elimination including administering enemas (unless the skills of a home health nurse are necessary), routine catheter care, routine colostomy care, assistance with ambulation, changing position in bed, and assistance with transfers.

(3) Performing a selected nursing activity or task delegated in accordance with Chapter 4723-13 of the Administrative Code and performed as specified in the written treatment plan.

(4) Assisting with activities such as routine maintenance exercises and passive range of motion as specified in the written treatment plan developed by either a licensed therapist or a licensed registered nurse within their scope of practice. These activities are directly supportive of skilled therapy services but do not necessitate the skills of a therapist to be safely and effectively performed.

(5) Performing routine care of prosthetic and orthotic devices.

(F) Incidental services performed by a home health aide for the injured worker, such as laundry, minor meal preparation, or light housekeeping, are not direct health care services and will not be reimbursed, except to the extent they are ancillary to providing direct health care services. Incidental services may not extend the service hours provided, and may only be performed for the injured worker, not other members of the household.

(G) The services of an adult day care facility meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code may be utilized in lieu of home health nursing services or home health aide services. The hours of such adult day care facility services will be included in the calculation of service hours referenced in paragraph (C) of this rule.

(H) A physical examination of the injured worker must be conducted by the physician of record or treating physician no less than annually to ensure that home health nursing services or home health aide services, and the number of service hours requested, are medically necessary and appropriate as a result of the allowed injury or occupational disease. In extraordinary circumstances when an in-person physical examination is not reasonably possible, BWC may accept a telemedicine visit with the physician of record or treating physician.

(I) Home health agency providers must maintain records which fully document the extent of services provided to each injured worker, in compliance with rule 4123-6-45.1 of the Administrative Code. The bureau may request detailed hourly descriptions of care delivered to an injured worker to review care needs, medical necessity and appropriateness, and billing accuracy.

Last updated February 1, 2022 at 9:38 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-38.1 Payment for nursing and caregiver services provided by persons other than home health agency employees.

(A) Nursing services provided prior to December 14, 1992.

(1) Registered nurses and licensed practical nurses who are not employed by a home health agency a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code may continue to provide authorized services to an injured worker if the services began prior to December 14, 1992.

(2) The need for nursing services must be the result of an allowed injury or occupational disease.

(3) In the event the registered nurse or licensed practical nurse is no longer able to provide approved services or if services are stopped and later restarted, nursing services shall be provided only by an employee of a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code.

(B) Non-licensed caregiver services.

(1) Requests for extension of non-licensed caregiver services initially provided prior to December 14, 1992.

(a) Prior to December 14, 1992, caregiver services provided by a non-licensed person including injured worker's spouse, friend or family member were considered for reimbursement in cases where the injured worker, as a result of an allowed injury or occupational disease, was bedfast, confined to a wheelchair, had a disability of two or more extremities which prevented the injured worker from caring for their own body needs or was otherwise unable to take care of their own bodily functions. Services include, but are not limited to, feeding, bathing, dressing, providing personal hygiene, and transferring from bed to chair. Household, personal or other duties related to maintaining a household, including but not limited to care or upkeep to the inside or outside of the residence, washing clothes, preparing meals, or running errands, are not considered nursing services, and will not be reimbursed, except to the extent such services are incidental to care of the injured worker.

(b) Requests for an extension of caregiver services initially approved prior to December 14, 1992, delivered by a non-licensed person, other than an attendant, aide, or injured worker's spouse, but including other family members or friends, will be approved only if:

(i) The injured worker does not have a spouse because the injured worker is not married, or the injured worker's spouse is deceased, or the claimant's spouse is physically or mentally incapable of caring for the injured worker; and,

(ii) The approved home health agency is greater than thirty-five miles from the injured worker's location and the home health agency refuses to provide services to the injured worker.

(c) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code.

(2) Requests for extension of caregiver services initially provided on or after December 14, 1992 and prior to January 9, 1995.

(a) Requests for approval of caregiver services delivered by a non-licensed person, other than an attendant, aide, or injured worker's spouse were considered for reimbursement only if the injured worker did not have a spouse or the spouse was physically or mentally incapable of caring for the injured worker, or an approved home health agency was greater than thirty-five miles from the injured worker's location and the home health agency refused to provide services to the claimant.

(b) Criteria for approval of caregiver services were as indicated in paragraph (B)(1)(a) of this rule.

(c) After January 9, 1995, persons who are not home health agency home health aides or attendants, but who are currently approved to provide caregiver services to an injured worker, may continue to do so until services are no longer medically necessary or unless services are not authorized. After January 9, 1995, approval of caregiver services shall only be considered when services are rendered by a home health agency home health aide or attendant.

(d) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code.

(C) All covered home health services must comply with rule 4123-6-38 of the Administrative Code, except as otherwise provided in this rule.

(D) A review of the claim or assessment of the injured worker will be conducted at least annually to ensure that nursing or caregiver services are necessary as a result of the allowed injury or occupational disease.

Last updated February 1, 2022 at 9:38 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-38.2 Payment of nursing home and residential care/assisted living services.

(A) Payment to a nursing home or residential care/assisted living facility for the care of an injured worker who sustained an injury or contracted an occupational disease in the course of and arising out of employment shall be made only when the need for such care is the direct result of the allowed conditions in the claim.

(B) Payment will be made only for care provided in nursing homes and residential care/assisted living facilities meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(C) Nursing home or residential care/assisted living facility care must be pre-authorized, except when a nursing home or residential care/assisted living facility is used immediately following an approved or emergency hospitalization.

(1) The allowed per diem rate for an injured worker shall be no greater than the bureau's fee schedule or the rate negotiated between the nursing home or residential care/assisted living facility and the bureau, MCO, QHP, or self-insuring employer.

(2) Nursing home care shall be provided on a semiprivate bed basis, unless a situation exists when the use of a private room is medically necessary due to the allowed condition. In these cases, the use of such a private room must be pre-authorized, except in cases of emergency, as defined in rule 4123-6-01 of the Administrative Code, or where the injured worker's condition would be endangered by delay.

(3) Prescription medication provided to an injured worker in a nursing home for the treatment of an allowed injury or occupational disease is included in the nursing home's per diem rate, and is not separately payable.

Last updated February 1, 2022 at 9:38 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-39 Payment for prosthetic device or other artificial appliances.

(A) For purposes of this rule:

(1) "Amputee clinic" means an interdisciplinary group of professional providers led by a physician with a specialty in physical medicine and rehabilitation, orthopedic surgery, vascular surgery, or other applicable speciality knowledgeable in the field of prosthetics and physical disabilities, comprised of members that may include a podiatrist, physical therapist, occupational therapist, prosthetist, and other medical specialists that serves individuals requiring prosthetic devices.

(2) "Artificial appliance" means any item that replaces a body part or function of a body part of an injured worker who has received a scheduled loss or facial disfigurement award for that body part under division (B) of section 4123.57 of the Revised Code, and that the amputee clinic at the Ohio state university medical center, the opportunities for Ohioans with disabilities agency, or a multidisciplinary amputee clinic or prescribing physician approved by the administrator or the administrator's designee determines is needed by the injured worker. Examples of artificial appliances include, but are not limited to, prosthetic devices, wheelchairs, canes, crutches, walkers, braces, etc.

(3) "Prosthetic device" means a custom fabricated or fitted medical device that is a type of artificial appliance used to replace a missing appendage or other external body part. It includes an artificial limb, hand, foot, eye, or intraocular lens. "Prosthetic device" does not include devices implanted into the body by a physician, dental appliances, eyeglasses, hearing aids, ostomy products, cosmetic devices such as breast prostheses, eyelashes, wigs, or any other devices that do not have a significant impact on the musculoskeletal functions of the body.

(B) In all cases arising under division (B) of section 4123.57 of the Revised Code, the bureau will pay the cost of purchasing or repairing an artificial appliance out of the surplus fund, regardless of whether the artificial appliance is part of the injured worker's vocational rehabilitation, or if the injured worker has, or will ever be able, to return to work, if an injured worker requires the purchase or repair of an artificial appliance as determined by any one of the following:

(1) The amputee clinic at the Ohio state university medical center;

(2) The opportunities for Ohioans with disabilities agency;

(3) A multidisciplinary amputee clinic or prescribing physician approved by the administrator or the administrator's designer.

(C) When a claimant has sustained an amputation or a loss enumerated in division (B) of section 4123.57 of the Revised Code as a result of an injury or occupational disease, the administrator will pay the cost to purchase, repair, or replace a prosthetic device out of the surplus fund, even if no award has been made under division (B) of section 4123.57 of the Revised Code.

(D) The bureau is responsible for processing requests for artificial appliance and travel expenses associated with the artificial appliance in all self-insured claims. When an artificial appliance is needed in a self-insured claim, the provider will send a request for the artificial appliance and/or request for repair, as well as the subsequent bills, to the bureau.

(E) It is the prosthetist's responsibility to ensure that any prosthetic device fits properly for three months from the date of dispensing. Any modifications, adjustments, or replacements within three months from the date of dispensing are the responsibility of the prosthetist who supplied the item and the bureau will not reimburse for those services. The provision of these services by another provider will not be separately reimbursed.

(F) Once payment for the artificial appliance has been made, replacement requests may be denied in instances of malicious damage, neglect, culpable irresponsibility, or wrongful disposition.

(G) The bureau will not pay the cost of purchasing or repairing a prosthetic device that is designed solely to enable the injured worker to engage in sports, hobbies, or other recreational activities.

Last updated May 1, 2026 at 8:10 AM

History

Effective: May 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-40 Payment of claimant travel expenses.

(A) An injured worker's reasonable and necessary travel expenses shall be paid, upon the filing of a proper request, under the following circumstances:

(1) When the injured worker has been ordered or authorized to undergo a medical examination outside of the city or community limits where he resides. The injured worker shall be reimbursed for travel only if the travel distance exceeds forty-five miles round trip.

(2) When treatment necessary for the allowed work related condition cannot be obtained within the city or community where the injured worker resides, and the treatment has been pre-authorized and approved. The injured worker shall be reimbursed for travel only if the travel distance exceeds forty-five miles round trip.

(3) When the injured worker's allowed conditions require taxicab or other special transportation for treatment or examination on account of an allowed injury or occupational disease. Taxicab or other special transportation must be pre-authorized.

(4) When travel expenses are authorized as part of an approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan pursuant to rule 4123-18-08 of the Administrative Code.

(B) In situations described in paragraphs (A)(1), (A)(2), and (A)(4) of this rule, the injured worker will be reimbursed for the following:

(1) If the injured worker is traveling by automobile, mileage on a per mile basis if the mileage exceeds the distance established as provided under paragraph (A) of this rule, portal to portal, using the most direct and practical route;

(2) If the claimant is traveling by airplane, railroad or bus, the actual and necessary airplane, railroad or bus fare;

(3) The reasonable cost of necessary meals, based on distance traveled;

(4) Necessary lodging bills at reasonable actual cost. Lodging must be pre-authorized; and

(5) The actual and necessary cost of tolls and parking.

(C) When the injured worker has been requested to undergo a medical examination by a physician of the employer's choice, travel expenses incurred as a result of the examination are to be paid by the employer immediately upon the receipt of the bill. Payment of the bill shall not require an order of the bureau or commission, unless there is a dispute. The employer shall provide the injured worker with a proper form to be completed by the injured worker for reimbursement of traveling expenses. The minimum mileage provision of paragraphs (A)(1) and (A)(2) of this rule shall not apply for reimbursement of examinations under this paragraph (C) of this rule.

(D) The payment rates for meals, lodging, and travel are available at https://www.bwc.ohio.gov/downloads/blankpdf/C-60-A.pdf.

(E) This rule applies to all claims for work related injuries or occupational diseases, regardless of whether the employer is part of the state fund, is self-insuring, is non-complying, etc.

Last updated February 1, 2022 at 9:39 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-41 No legal relationship between the industrial commission or bureau and a health care provider.

(A) Direct payment to a health care provider or other person by the industrial commission, self-insuring employer, bureau of workers' compensation, or their agent, for medical care rendered to an injured worker does not imply or create a legal relationship between the provider or person and the commission, self-insuring employer, bureau, or their agent.

(B) The services rendered to the injured worker are the legal obligation of the injured worker. The direct payment to the health care provider is a discretionary method by which the award made to the injured worker for medical expenses may be discharged.

(C) Except as prohibited by division (O) of section 4121.44 of the Revised Code, when payment is made to the injured worker, the sole legal recourse of the health care provider is against the injured worker.

Last updated February 1, 2022 at 9:40 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-42 Interest on late payments for equipment, materials, goods, supplies or services in state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, and marine industry fund claims.

(A) Payment is made for equipment, materials, goods, supplies, or services incurred by the claimant in connection with claims against the state insurance fund, public work relief employees' compensation fund, coal workers pneumoconiosis fund, or marine industry fund in accordance with section 126.30 of the Revised Code. For the purpose of this rule, the required payment date is the date on which payment is due under the terms of a written agreement between the bureau, or its agent, and the provider. Payment will be made either thirty days after the bureau, or its agent, receives a proper invoice for the amount of the payment due, or thirty days after the final adjudication allowing payment of an award to the claimant, whichever is later.

(1) A "proper invoice" includes but is not limited to the claimant's name, claim number, date of injury or occupational disease, employer's name, provider's name and address and assigned payee number, a description of the service provided, the procedure code for the service provided, the date provided, and the amount of the charge. If more than one item has been included in the invoice, each item is to be considered separately to determine if it is a proper invoice.

(2) If the bureau or its agent determines that an invoice is improper, the bureau or its agent shall send notification to the provider through the MCO at least fifteen days prior to what would be the required payment date if the invoice did not contain an error. The notice shall describe the error and the additional information needed to correct the error. The required payment date shall be redetermined upon receipt of a proper invoice.

(3) If an invoice is for payment of either a condition not allowed in a claim, or for a claim that is not allowed, the payment date is thirty days after final adjudication of allowance of the condition or claim. As defined in section 126.30 of the Revised Code, "final adjudication" is the date that the decision of the bureau, industrial commission, or court becomes final, with no further right of appeal. If any section of the Revised Code contains a faster timetable for payments, however, such provisions shall not be superseded by this rule.

(B) Interest shall be paid based on division (E) of section 126.30 of the Revised Code. Any interest charges payable under section 126.30 of the Revised Code are to be paid by the bureau of workers' compensation.

Last updated May 31, 2023 at 11:04 AM

History

Effective: February 1, 2010
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-43 Payment for transcutaneous electrical nerve stimulators and neuromuscular electrical stimulators.

(A) Payment will be approved for a transcutaneous electric nerve stimulator (TENS) unit for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease, as provided in this rule.

(1) Prior authorization is required for TENS units and supplies. An injured worker shall be provided only one TENS unit at a time. For each TENS unit request approved, the unit shall be rented for a thirty day trial period before purchase of the TENS unit. This trial period is to evaluate the medical necessity and effectiveness of the TENS treatment. TENS treatment will be discontinued at the end of the thirty day trial period where the treatment has not proven to be medically necessary or effective. Reimbursement of rental costs will be considered only for that portion of the trial period that the TENS unit was actually used if treatment was discontinued early. For each TENS unit provided, payment shall be limited to necessary disposable or rechargeable batteries, but not both.

(2) The bureau shall apply all rental payments previously made to the purchase price of the TENS unit. A TENS unit purchased and furnished to the injured worker is not the personal property of the injured worker, but remains the property of the bureau or self-insuring employer. The bureau or self-insuring employer reserves the right to reclaim and recover the TENS unit from the injured worker at the completion of the course of TENS treatment. Once a TENS unit is purchased, the bureau or self-insuring employer will reimburse for repair or replacement of the unit upon submission of a request from the physician of record or treating provider that includes medical documentation substantiating the continued medical necessity and effectiveness of the unit.

(3) To be eligible for reimbursement under this rule, the TENS unit must be prescribed by a physician and furnished by a provider holding a current, valid, license or certificate of registration from the state of Ohio board of pharmacy to sell or rent home medical equipment.

(B) The injured worker's MCO shall regularly determine the specific TENS supplies needed by the injured worker throughout the period of time authorized for TENS use. The TENS provider must receive authorization from the injured worker's MCO prior to the delivery of supplies and/or equipment. The TENS provider shall then deliver the supplies and bill the injured worker's MCO after authorization is received. A self-insuring employer may, but is not required to, follow the same procedure as an MCO under this rule; provided, however, that in no event shall a self-insuring employer require a injured worker to submit a written request for TENS supplies and/or equipment. The injured worker's MCO shall retain documentation of the contact with the injured worker substantiating the injured worker's need for supplies in accordance with the time frames set forth in rule 4123-6-14.1 of the Administrative Code. The TENS provider's bill must indicate the actual date of service, reflecting the date that services or supplies were provided. The bureau, MCO, QHP, or self-insuring employer may adjust bills upon audit if the audit discloses the provider's failure to comply with this rule.

(1) Authorizations of TENS supplies or equipment received from the injured worker's MCO, and all other documentation relating to the injured worker's need for TENS supplies or equipment received by the provider prior to the delivery of the supplies or equipment, including any requests received from the injured worker, if applicable;

(2) Records of the provider's wholesale purchase of TENS supplies or equipment;

(3) Records of delivery of supplies to injured workers and of the delivery or return of TENS units; and

(4) The TENS provider's current, valid, license or certificate of registration from the state of Ohio board of pharmacy to sell or rent home medical equipment.

Upon request, the provider shall supply copies of the record information to the requester at no cost. Failure to provide the requested records may result in denial or adjustment of bills related to these records.

(D) The bureau shall not pay for the rental or sale of devices that are labeled by the food and drug administration (FDA) for over-the-counter use and are identified with the FDA product code "NUH.OTC.TENS."

(E) Payment will be approved for a neuromuscular electrical stimulator (NMES) unit for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease, as provided in the bureau's provider billing and reimbursement manual in effect on the billed date of service.

Last updated February 1, 2022 at 9:40 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-44 Bureau fees for provider services rendered by in-state and out-of-state providers.

Bureau fees for in-state or out-of-state providers will be established by the bureau. The bureau may establish different fees for in-state and out-of-state providers. The methods of payment may include rates based on resource based relative value scale (RBRVS), per cent of allowed charges, or usual, customary and reasonable fee maximas, as determined by the bureau. Rates will be reviewed at least annually by the bureau to determine the need for appropriate adjustment.

Payment for provider services will be made in accordance with rule 4123-6-10 of the Administrative Code.

Last updated February 1, 2022 at 9:40 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-45 Audit of providers' patient and billing related records.

(A) Providers' patient and billing related records, including but not limited to those records described in rule 4123-6-45.1 of the Administrative Code, may be reviewed by the bureau or the MCO to ensure workers are receiving proper and necessary medical care, and to ensure compliance with the bureau's statutes, rules, policies, and procedures.

(1) Based on division (B)(15)(c) of section 4121.121 of the Revised Code, provider records may be reviewed before, during, or after the delivery of services. Reviews may be random, with no unreasonable infringement of provider rights, or may be for cause. Reviews may include the utilization of statistical sampling methodologies and projections based upon sample findings. Records reviews may be conducted at or away from the provider's place of business.

(2) Based on division (B)(15)(c) of section 4121.121 of the Revised Code, legible copies of providers' records may be requested. Providers shall furnish copies of the requested records within thirty calendar days of receipt of the request. The bureau shall establish a schedule for payment of reasonable costs for copying records, which shall be published in the health care provider billing and reimbursement manual.

(3) Original records shall not be removed from the provider's premises, except upon court order or subpoena issued by the bureau pursuant to section 4121.15 or 4123.08 of the Revised Code.

(B) Upon any finding of improper or unnecessary medical care, the administrator shall, if requested by the provider, appoint a subcommittee of the stakeholders' health care quality assurance advisory committee to review and advise the administrator as provided in paragraph (F) of rule 4123-6-22 of the Administrative Code. The administrator may sanction, suspend, or exclude a health care provider from participation in the workers' compensation system based on rule 4123-6-17 of the Administrative Code.

(C) The bureau or the MCO may deny payment for services or declare as overpaid previous payments to providers who fail to provide records or access to records to either the bureau or the MCO. The bureau may decertify a health care provider that fails to provide records requested pursuant to Chapters 2913., 4121., and 4123. of the Revised Code.

Last updated February 1, 2022 at 9:41 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-45.1 Records to be retained by provider.

(A) A health care provider shall create, maintain, and retain sufficient records, papers, books, and documents in such form to fully substantiate the delivery, value, necessity, and appropriateness of goods and services provided to injured workers under the HPP or of significant business transactions. The provider shall retain such records for a minimum period of five years from the date of payment for said goods or services, or five years from the date of referral to a certified or non-certified provider, or until any initiated audit or investigation is completed, whichever is longer. The provider shall create and maintain the records at the time the goods or services are delivered or within seven days from the date the service was rendered.

(B) The provider shall retain records documenting the following minimum information concerning the goods or services provided to injured workers:

(1) Date the service was provided;

(2) Description of service, treatment or product provided;

(3) Record of patient appointments, if appropriate;

(4) Dates where injured worker canceled or failed to appear for a scheduled examination, treatment, or procedure;

(5) Treatment plans;

(6) Subjective and objective complaints, if the provider is the practitioner or physician of record;

(7) Injured worker's progress, if the provider is the practitioner or physician of record;

(8) Wholesale purchase records, if goods, products, or prescriptions are delivered;

(9) Delivery records, if goods, products, or prescriptions are delivered by way of a third party;

(10) The identity and qualifications of any individual involved in the delivery of health care or billing for services to injured workers on behalf of the provider billing for the services.

(C) A provider's failure to create, maintain, and retain such records shall be sufficient cause for the bureau to deny payment for goods or services, to declare overpaid previous payments made to the provider, or to decertify the provider.

Last updated February 1, 2022 at 9:41 AM

History

Effective: February 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-46 Standardized or negotiated payment rates for services or supplies.

(A) The bureau or self-insuring employer may negotiate payment rates with health care providers for services and supplies provided in the treatment of workers' compensation claims.

(B) The bureau or self-insuring employer may enter into volume-based or optional-use contracts with medical providers for services including, but not limited to, the purchase or rental of durable medical equipment and supplies and catastrophic claim services.

(C) The bureau or self-insuring employer may inform injured workers of the availability of services, supplies, or equipment from particular health care providers with whom a contract for services or supplies, a negotiated payment rate for services or supplies, or a contract for cost-effective payment levels or rates has been entered into, so long as access to quality and convenient medical services or supplies for injured workers is maintained.

Last updated May 31, 2023 at 11:04 AM

History

Effective: November 13, 2015
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-51 Employer participation in the QHP system - bureau certification of QHPs.

(A) A health plan that satisfies the QHP certification requirements of this chapter shall be certified by the bureau as a QHP to manage medical treatment, direct care or provide services or supplies to or on behalf of an employee for an injury or occupational disease that is compensable under Chapter 4121., 4123., or 4131. of the Revised Code.

(B) An employer may establish a bureau certified QHP, that shall comply with the thirteen standards set forth in divisions (A)(1) to (A)(13) of section 4121.442 of the Revised Code, division (P) of section 4121.44 of the Revised Code, and rules 4123-6-53 and 4123-6-54 of the Administrative Code.

(D) The bureau shall periodically develop and make available information that describes employer and employee rights under the QHP.

(E) The bureau shall continue to certify health plans and shall periodically update its list of certified QHPs.

Last updated November 4, 2025 at 2:12 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-52 Employer participation in the QHP system - bureau recertification of QHPs.

(A) The bureau shall initiate the recertification process by sending certified QHPs a recertification application, which must be completed, signed, and submitted to the bureau if the QHP wishes to be considered for recertification.

(B) Except as otherwise provided in paragraph (E) of this rule, if the bureau receives a completed and signed recertification application from a QHP, the QHP's certification shall remain in effect until the bureau issues a final order approving or denying the QHP's application for recertification.

(C) If the bureau does not receive a completed and signed recertification application from the QHP within sixty days from the date of the notice sent in accordance with paragraph (A) of this rule, the bureau shall send a second notice to the QHP stating that the QHP has thirty days from the date of the second notice to complete, sign, and submit the recertification application to the bureau if the QHP wishes to be considered for recertification.

(D) If the bureau does not receive a completed and signed recertification application from the QHP within thirty days from the date of the notice sent in accordance with paragraph (C) of this rule, the QHP's certification shall lapse. Such lapse of certification is not an adjudication order and is not subject to appeal pursuant to rule 4123-6-17 of the Administrative Code.

(E) If the bureau receives a completed and signed recertification application from a QHP after the QHP's certification has lapsed pursuant to paragraph (D) of this rule, the QHP's certification shall remain lapsed until the bureau issues a final order approving or denying the QHP's application for recertification.

Last updated November 4, 2025 at 2:12 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-53 Employer participation in the QHP system - QHP quality assurance program required.

(A) Each QHP shall have a quality assurance program that monitors the operation and measures the effectiveness of peer review, utilization review, and dispute resolution within the QHP. Data collected from the quality assurance program shall be used to assist an employer in determining the quality, efficiency, and effectiveness of the employer's QHP and the QHP system in accordance with division (A) of section 4121.442 of the Revised Code.

(B) Each quality assurance program shall include a mechanism for monitoring and the methodology for measuring and improving the QHP's compliance with each of the following eleven elements:

(1) Peer review and evaluation of clinical performance;

(2) Credentialing and recredentialing and use of provider profiling;

(3) Utilization management to determine the appropriateness of care;

(4) Evaluation of employee and provider dispute resolution procedures and outcomes;

(5) Evaluation of outcomes of care based on clinical data;

(6) Procedures for remedial action for inappropriate or substandard services;

(7) Evaluation of employee satisfaction with the plan;

(8) Evaluation of provider satisfaction with the plan;

(9) Evaluation of employer satisfaction with the plan;

(10) Periodic evaluation of medical records and office procedures; and

(11) Practice patterns compared to accepted medical criteria.

(C) The quality assurance program shall include a quality assurance committee or other mechanism adequate to evaluate the outcomes of each of the eleven elements listed in paragraph (B) of this rule.

Last updated November 4, 2025 at 2:12 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-54 Employer participation in the QHP system - QHP certification application.

(A) Upon request by an employer or health plan seeking certification, the bureau shall mail the employer or health plan seeking certification a QHP application for certification.

(B) The QHP application for certification shall include a list of bureau certified providers in the QHP's provider network.

(C) The QHP application for certification shall include, at a minimum, the following provisions, as more fully detailed within the QHP certification application 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;

(2) Proof that a self-insured employer has been granted status as a self-insuring employer in accordance with section 4123.35 of the Revised Code;

(3) A description of the geographic or regional area of the state of Ohio to be serviced by the QHP, taking into account the unique circumstances of the individual employer, such as multiple locations or the need for a statewide network;

(4) A description of the role of each vendor that will be a component of the QHP including, but not limited to, the following: if an employer uses or anticipates using company-based providers, a description of the role of company-based providers as distinguished from QHP network providers; if an employer uses or anticipates using a third party administrator, a description of the role of the third party administrator;

(5) If an employer contemplates contracting with a vendor that has been certified by the bureau under Chapter 4123-6 of the Administrative Code to provide services under the employer's QHP, proof that certification has been granted by the bureau and that such certification is current;

(6) A description of the structure of the medical management component and the health care provider network to be offered by the QHP;

(7) A description of the QHP's plan and methodology for providing, at least annually, QHP network provider information, by provider type, and updated QHP network provider directories to employees;

(8) A description of the QHP's quality assurance program, including but not limited to a description of the proposed structure and operation and a description of the mechanism for monitoring and the methodology for measuring and improving the QHP's compliance with the elements listed in paragraph (B) of rule 4123-6-53 of the Administrative Code;

(9) A description of the QHP's employee education program. The description shall include but shall not be limited to a description of the process to be used to educate employees regarding their rights and responsibilities in the QHP system; a description of the process to be used to explain the time, place, and manner of services to be delivered under the QHP; and a description of the process to be used to explain options available to injured workers, including the process for changing providers within the QHP and referral and transfer to the HPP; and

(10) A description of the plan satisfactory to the bureau to be implemented by the QHP in the event a final order to revoke certification, or to refuse to recertify the QHP is issued by the administrator pursuant to rule 4123-6-55 of the Administrative Code that includes, but is not limited to a plan that describes continuation and continuity of care of injured workers and a plan that describes payment of providers for medical services rendered prior to the bureau's revocation of certification or refusal to certify. The injured worker may continue receiving medical services from the same provider or may choose a provider in a new approved plan for delivery of medical services, both of whom shall accept medical management of the medical services through the employer's new approved plan.

(D) The bureau shall review the application for certification submitted by the health plan seeking certification. The bureau reserves the right to cross-check data with other governmental agencies or licensing or accrediting bodies.

(E) The bureau shall hold as confidential and proprietary the vendor's descriptions of process, methodology, policies, procedures, and systems as required for the application for certification to the extent such qualify as a "trade secret" under division (D) of section 1333.61 of the Revised Code.

Last updated November 4, 2025 at 2:12 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-55 Employer participation in the QHP system - bureau's authority to decertify, to refuse to certify or recertify a QHP.

(A) The bureau may refuse to certify or recertify or may decertify a QHP from participation in the QHP system.

(B) Should the bureau determine that sufficient evidence exists that an employer or QHP has failed to comply with applicable workers' compensation statutes or rules governing QHPs, the bureau will take one of two courses of action:

(1) The bureau will serve written notice to the employer, employee representative, and QHP of the facts and issues relating to the bureau's determination that the employer or QHP has failed to comply with applicable workers' compensation statutes or rules governing QHPs. Such notice will set forth a period of time for the employer or QHP to resolve or correct the problem. Failure of the employer or QHP to resolve or correct the problem within the time period will result in the bureau serving notice to the employer and QHP in writing of administrative action that might result in a bureau determination to revoke certification or refuse to certify or recertify, and the employer's and QHP's right to a hearing within thirty days of the notice, if requested by the employer or QHP, pursuant to rule 4123-6-17 of the Administrative Code.

(2) Serve written notice to the employer, employee representative, and QHP of administrative action that might result in a bureau determination to revoke certification or refuse to certify or recertify, and the employer's and QHP's right to a hearing within thirty days of the notice, if requested by the employer or QHP, pursuant to rule 4123-6-17 of the Administrative Code.

(3) For the purpose of this rule, "employee representative" does not include the employee's attorney.

(4) The bureau will serve all notices pursuant to this rule in accordance with section 119.05 of the Revised Code.

(C) Upon a final order of the administrator to decertify, refuse to recertify, or revoke or suspend the certification of a QHP, employees and employers cannot receive services from such QHP pursuant to the QHP system.

Last updated November 4, 2025 at 2:13 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-58 Provider access to the QHP system - provider participation in QHP system and other related health care program not linked.

A QHP or vendor that provides medical management and cost containment services shall not require a provider to participate in a workers' compensation network of providers in order to maintain membership in a related health care program. If the QHP utilizes a leased provider network, the QHP shall not apply the discounted payment rates of the leased network to services rendered by the provider in the QHP unless the signed, written consent of the provider has been obtained.

Last updated August 14, 2025 at 10:10 AM

History

Effective: February 1, 2010
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-59 Provider access to the QHP system - QHP provider selection.

(A) An employer that develops a QHP, a vendor within the QHP system, or a QHP shall develop and implement standards of credentialing of providers in the QHP network that meet but may exceed the bureau credentialing requirements in the HPP.

(B) An employer that develops a QHP may selectively contract with providers or contract with a vendor that selectively contracts with providers.

(C) Only a bureau certified provider is eligible for selection by an employer that develops a QHP, by a QHP as a QHP panel provider, or by a vendor as a panel provider to participate in the QHP system. A provider identified by a QHP for inclusion in its panel of providers that is not a bureau certified provider may be assisted by the QHP in applying for bureau provider credentialing and certification.

(D) The bureau, an employer, a QHP, or a vendor shall not discriminate against any category of health care provider when establishing categories of providers for participation in the QHP system. However, an employer, a QHP, or a vendor is not required to accept or retain any individual provider in the QHP system.

(E) The bureau, an employer, a QHP, and a vendor shall comply with state and federal laws prohibiting discrimination based on race, color, religion, sex, age, disability, military status as defined in section 4112.01 of the Revised Code, national origin, ancestry, or sexual orientation.

(F) A QHP shall include in its panel a substantial number of the medical, professional, and pharmacy providers currently being utilized by employees. A QHP may limit the number of providers on its provider panel but shall do so based upon objective data that demonstrates that the fundamental needs of the employer and employees are met based on reasonable standards, such as historical claims data or other geographic information approved by the bureau. In addition, a QHP shall include in its application for QHP certification information including reasonable patient access, the potential number of employees the QHP is applying to service, and other performance criteria, without discrimination by provider type. A QHP seeking QHP certification may select out-of-state providers as members of the QHP panel.

Last updated November 4, 2025 at 2:13 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-65 Payment in the QHP system - employer payment to vendor that provides medical management and cost containment services and/or QHPs.

The bureau shall not interfere with nor impose restrictions upon an arrangement for payment negotiated between an employer and a vendor that provides medical management and cost containment services and/or a QHP under the QHP system, except that no financial arrangement between an employer and a vendor that provides medical management and cost containment services and/or a QHP shall incentivize a reduction in the quality of medical care received by an injured worker.

Last updated August 14, 2025 at 10:10 AM

History

Effective: September 5, 1996
Promulgated Under: Ch 119.

Ohio Adm.Code 4123-6-69 QHP dispute resolution process.

(A) This rule shall provide time frames and procedures for review of requests for the delivery of medical services and for the resolution of disputes that may arise between an employee and an employer, an employee and a provider, or an employer and a provider. This rule applies to, but is not limited to, reviews of records; disputes involving individual health care providers; and medical disputes arising over issues such as quality assurance, utilization review, a determination that a service provided to an employee is not covered, is covered or is medically unnecessary.

(B) Initial review and decision upon requests for the delivery of medical services that include, but are not limited to, medical treatment, major diagnostic testing, hospitalization, surgery, and physical therapy, shall be completed by the QHP. The employee, employer, and provider shall be notified verbally of the outcome of the initial review within forty-eight hours of the request. Within seven working days of the verbal notification, the verbal notification shall be committed to writing and mailed to the employee, employer, and provider.

(C) A QHP shall have a dispute resolution process beyond initial review that includes one independent level of professional review ("peer review").

(D) A QHP dispute resolution process shall be completed and the QHP shall notify the parties to the dispute and their representatives in writing within twenty-one days of the initial written notice of a dispute, unless an extension of time is otherwise agreed to by the parties. If the QHP schedules the injured worker for an independent medical examination for the peer review, the twenty-one day time frame shall be tolled, and in such cases the QHP shall complete the dispute resolution process within seven days after receipt of the independent medical examination report.

(E) The dispute resolution process shall begin upon written notice of the dispute by the party maintaining the dispute to the parties of the dispute.

(1) If an individual health care provider eligible to be physician of record would be providing the services requested in the dispute, the peer review shall consist of a peer review conducted by an individual or individuals licensed pursuant to the same section of the Ohio Revised Code as the health care provider who would be providing the services requested.

(2) Notwithstanding paragraph (E)(1) of this rule, if the QHP has already obtained one or more peer reviews during previous disputes involving the same treatment, the QHP may obtain a different perspective review from a licensed physician who falls outside the peer review criteria set forth in this paragraph.

(3) ) If an individual health care provider not eligible to be physician of record would be providing the services requested in the dispute, the peer review shall consist of a provider review conducted by an individual or individuals eligible to be physician of record whose scope of practice includes the services requested.

(4) If the QHP receives a dispute where the requested treatment appears to be the same as a previous treatment request for which the QHP conducted a peer review, and the previous treatment request was ultimately denied based on the peer review, the QHP may use the previous peer review to satisfy the independent level of professional review requirement of this paragraph, provided the peer review was conducted within six months of the current request and there are no new or changed circumstances in the injured worker's condition documented in the claim file.

(F) A dispute unresolved by a QHP dispute resolution process may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.

(G) Notwithstanding the requirements set forth in paragraph (F) of this rule, a dispute unresolved by a QHP providing medical management and cost containment services for a state fund employer shall be referred by the QHP to the bureau within seven working days of the final decision rendered within the QHP dispute resolution process. Within fourteen days of receipt of an unresolved medical dispute, the bureau shall conduct an independent review of the unresolved medical dispute received from the QHP and enter a final bureau order pursuant to section 4123.511 of the Revised Code. This order shall be mailed to all parties and may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code. Parties to a dispute shall exhaust the dispute resolution procedures of this rule prior to filing an appeal under section 4123.511 of the Revised Code.

Last updated November 4, 2025 at 2:13 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-70 Evaluation of the QHP system by the bureau; reporting requirements by employers and QHPs.

(A) To enhance the quality of the QHP system and pursuant to division (L)(1) of section 4121.44 of the Revised Code, the administrator shall require employers and QHPs that participate in the workers' compensation QHP system to report data to be used by the administrator to measure and perform comparison analyses of costs, quality, appropriateness of medical care, and effectiveness of medical care delivered by all components of the workers compensation system.

(B) The bureau shall evaluate the effectiveness of the QHP system based on standardized data and reporting requirements developed by the bureau.

(C) The bureau may receive, define, and publish data elements and data collection techniques that meet the thirteen standards set forth in divisions (A)(1) to (A)(13) of section 4121.442 of the Revised Code and are necessary to evaluate the effectiveness of the QHP system. Performance indicators used by the bureau to evaluate the effectiveness of the QHP system may include, but shall not be limited to, the following: customer satisfaction; system cost drivers; improvements in quality; and cost reductions.

Last updated November 4, 2025 at 2:13 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-6-72 Confidentiality.

Subject to the requirements and protections contained in Ohio law pertaining to release of confidential or privileged information in the course of medical management in the QHP system, confidential information may be exchanged among the bureau, the QHPs, an employer and its representative, an employee and his or her representative, and the provider. All parties providing or requiring such confidential information for use in the QHP system shall not provide or use such confidential information for any purpose other than to perform duties required under the QHP system and shall prevent such information from further disclosure or use by unauthorized persons.

Last updated November 4, 2025 at 2:13 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Chapter 4123-10 Accessing Confidential Personal Information

Ohio Adm.Code 4123-10-01 Definitions.

For the purposes of administrative rules promulgated in accordance with section 1347.15 of the Revised Code, the following definitions apply:

(A) "Access" as a noun means an opportunity to copy, view, or otherwise perceive whereas "access" as a verb means to copy, view, or otherwise perceive.

(B) "Acquisition of a new computer system" means the purchase of a "computer system," as defined in this rule, that is not a computer system currently in place nor one for which the acquisition process has been initiated as of the effective date of the bureau rule addressing requirements in section 1347.15 of the Revised Code.

(C) "Computer system" means a "system," as defined by section 1347.01 of the Revised Code, that stores, maintains, or retrieves personal information using electronic data processing equipment.

(D) "Confidential personal information" (CPI) has the meaning as defined by division (A)(1) of section 1347.15 of the Revised Code and identified by rules promulgated by the bureau in accordance with division (B)(3) of section 1347.15 of the Revised Code that reference the federal or state statutes or administrative rules that make personal information maintained by the bureau confidential.

(E) "Employee of the bureau" means each employee of the bureau regardless of whether he/she holds an elected or appointed office or position within the bureau. "Employee of the bureau" is limited to the bureau.

(F) "Incidental contact" means contact with the information that is secondary or tangential to the primary purpose of the activity that resulted in the contact.

(G) "Individual" means natural person or the natural person's authorized representative, legal counsel, legal custodian, or legal guardian.

(H) "Information owner" means the individual appointed in accordance with division (A) of section 1347.05 of the Revised Code to be directly responsible for a system.

(I) "Person" means natural person.

(J) "Personal information" has the same meaning as defined in division (E) of section 1347.01 of the Revised Code.

(K) "Personal information system" means a "system" that "maintains" "personal information" as those terms are defined in section 1347.01 of the Revised Code. "System" includes manual and computer systems.

(L) "Research" means a methodical investigation into a subject.

(M) "Routine" means commonplace, regular, habitual, or ordinary.

(N) "Routine information that is maintained for the purpose of internal office administration, the use of which would not adversely affect a person" as that phrase is used in division (F) of section 1347.01 of the Revised Code means personal information relating to the bureau's employees that is maintained by the bureau for administrative and human resource purposes.

(O) "System" has the same meaning as defined by division (F) of section 1347.01 of the Revised Code.

(P) "Upgrade" means a substantial redesign of an existing system for the purpose of providing a substantial amount of new application functionality, or application modifications that would involve substantial administrative or fiscal resources to implement, but would not include maintenance, minor updates and patches, or modifications that entail a limited addition of functionality due to changes in business or legal requirements.

Last updated August 4, 2026 at 10:30 AM

History

Effective: October 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 4123-10-02 Procedures for accessing confidential personal information.

For personal information systems, whether manual or computer systems, that contain confidential personal information, the bureau shall do the following:

(A) Criteria for accessing confidential personal information. Personal information systems of the bureau are managed on a "need-to-know" basis whereby the information owner determines the level of access required for an employee of the bureau to fulfill his/her job duties. The determination of access to confidential personal information shall be approved by the employee's supervisor and the information owner prior to providing the employee with access to confidential personal information within a personal information system. The bureau shall establish procedures for determining a revision to an employee's access to confidential personal information upon a change to that employee's job duties including, but not limited to, transfer or termination. Whenever an employee's job duties no longer require access to confidential personal information in a personal information system, the employee's access to confidential personal information shall be removed.

(B) Individual's request for a list of confidential personal information. Upon the signed written request of any individual for a list of confidential personal information about the individual maintained by the bureau, the bureau shall do all of the following:

(1) Verify the identity of the individual by a method that provides safeguards commensurate with the risk associated with the confidential personal information;

(2) Provide to the individual the list of confidential personal information that does not relate to an investigation about the individual or is otherwise not excluded from the scope of Chapter 1347. of the Revised Code; and

(3) If all information relates to an investigation about that individual, inform the individual that the bureau has no confidential personal information about the individual that is responsive to the individual's request.

(1) Upon discovery or notification that confidential personal information of a person has been accessed by an employee for an invalid reason, the bureau shall notify the person whose information was invalidly accessed as soon as practical and to the extent known at the time. However, the bureau shall delay notification for a period of time necessary to ensure that the notification would not delay or impede an investigation or jeopardize homeland or national security. Additionally, the bureau may delay the notification consistent with any measures necessary to determine the scope of the invalid access, including which individuals' confidential personal information invalidly was accessed, and to restore the reasonable integrity of the system.

"Investigation" as used in this paragraph means the investigation of the circumstances and involvement of an employee surrounding the invalid access of the confidential personal information. Once the bureau determines that notification would not delay or impede an investigation, the bureau shall disclose the access to confidential personal information made for an invalid reason to the person.

(2) Notification provided by the bureau shall inform the person of the type of confidential personal information accessed and the date(s) of the invalid access.

(3) Notification may be made by any method reasonably designed to accurately inform the person of the invalid access, including written, electronic, or telephone notice.

(D) Appointment of a data privacy point of contact. The administrator of the bureau shall designate an employee of the bureau to serve as the data privacy point of contact. The data privacy point of contact shall work with the chief privacy officer within the office of information technology to assist the bureau with both the implementation of privacy protections for the confidential personal information that the bureau maintains and compliance with section 1347.15 of the Revised Code and the rules adopted pursuant to the authority provided by that chapter.

(E) Completion of a privacy impact assessment. The agency director shall designate an employee of the bureau to serve as the data privacy point of contact who shall timely complete the privacy impact assessment form developed by the office of information technology.

Last updated August 4, 2026 at 10:31 AM

History

Effective: June 30, 2011
Promulgated Under: 119.03

Ohio Adm.Code 4123-10-03 Valid reasons for accessing confidential personal information.

Pursuant to the requirements of division (B)(2) of section 1347.15 of the Revised Code, this rule contains a list of valid reasons, directly related to the bureau's exercise of its powers or duties, for which only employees of the bureau may access confidential personal information (CPI) regardless of whether the personal information system is a manual system or computer system:

(A) Performing the following functions constitute valid reasons for authorized employees of the bureau to access confidential personal information:

(1) Responding to a public records request;

(2) Responding to a request from an individual for the list of CPI the bureau maintains on that individual;

(3) Administering a constitutional provision or duty;

(4) Administering a statutory provision or duty;

(5) Administering an administrative rule provision or duty;

(6) Complying with any state or federal program requirements;

(7) Processing or payment of claims or otherwise administering a program with individual participants or beneficiaries;

(8) Auditing purposes;

(9) Licensure [or permit, eligibility, filing, etc.] processes;

(10) Investigation or law enforcement purposes;

(11) Administrative hearings;

(12) Litigation, complying with an order of the court, or subpoena;

(13) Human resource matters (e.g., hiring, promotion, demotion, discharge, salary/compensation issues, leave requests/issues, timekeeping approvals/issues);

(14) Complying with an executive order or policy;

(15) Complying with a bureau policy or a state administrative policy issued by the department of administrative services, the office of budget and management or other similar state agency; or

(16) Complying with a collective bargaining agreement provision.

(B) To the extent that the general processes described in paragraph (A) of this rule do not cover the following circumstances, for the purpose of carrying out specific duties of the bureau, authorized employees would also have valid reasons for accessing CPI in these following circumstances:

(1) Authorized bureau employees may review CPI of individuals who have applied for workers' compensation benefits as well as CPI regarding amenable employers.

(2) Authorized bureau employees may review CPI of bureau employees and contractors in furtherance of auditing, investigational and legal matters.

(3) Authorized bureau employees may review CPI regarding bureau employee information, investment data and other financial information.

(4) Authorized bureau employees in the IT division may review CPI in furtherance of their official IT duties as defined by their job description.

(5) Authorized bureau employees may review CPI of employers, including professional employer organizations, group sponsors, and third party administrators, to investigate the impacts of workers' compensation strategies, policies, and recommendations.

(6) Authorized bureau employees may review CPI of providers as part of the bureau certification process.

(7) Authorized bureau employees may review CPI of financial and other relevant information concerning MCOs as part of the bureau certification process

Last updated August 4, 2026 at 10:31 AM

History

Effective: January 1, 2022
Promulgated Under: 119.03

Ohio Adm.Code 4123-10-04 Confidentiality statutes.

The following federal statutes or regulations or state statutes and administrative rules make personal information maintained by the bureau confidential and identify the confidential personal information within the scope of rules promulgated by the bureau in accordance with section 1347.15 of the Revised Code:

(A) Social security numbers, unless the individual was told that the number would be disclosed. See 5 U.S.C. 552a.

(B) Bureau of criminal investigation and information criminal records check results. See section 4776.04 of the Revised Code.

(C) Any information in respect of any claim. Division (A) of section 4123.88 of the Revised Code provides that no employee of the bureau "shall divulge any information in respect of any claim or appeal which is or may be filed with a district or staff hearing officer, the bureau, or commission to any person other than members of the commission or to the superior of the employee except upon authorization of the administrator of workers' compensation or a member of the commission or upon authorization of the claimant or employer."

(D) Addresses and telephone numbers cannot be divulged without authorization. See division (B) of section 4123.88 of the Revised Code.

(E) Employer and third party information, payroll report, and child support / public assistance information. See section 4123.27 of the Revised Code.

(1) Information submitted by the employer in the payroll report (payroll, premium and number of employees) and any other additional required information shall not be open to the public.

(2) No person in the employ of the bureau, except those who are authorized by the administrator of workers' compensation, shall divulge any information secured by the person while in the employ of the bureau in respect to the transactions, property, claim files, records, or papers of the bureau or in respect to the business or mechanical, chemical, or other industrial process of any company, firm, corporation, person, association, partnership, or public utility to any person other than the administrator or to the superior of such employee of the bureau.

(3) The bureau can share information with the Ohio department of job and family services or with the auditor of state but will otherwise protect confidentiality of child support or public assistance recipients.

(F) Peer review committee proceedings and records for the bureau's disability evaluators' panel and provider certification. All "proceedings and records within the scope of a peer review committee of a health care entity." See division (E)(2)(j) of section 2305.25 of the Revised Code and section 2305.252 of the Revised Code.

(G) Governmental records that are exempt from disclosure under the public records act. See section 149.43 of the Revised Code.

(H) Investment information provided by a bureau approved investment manager. See division (B)(2) of section 4123.444 of the Revised Code.

Last updated August 4, 2026 at 10:31 AM

History

Effective: October 13, 2016
Promulgated Under: 119.03

Ohio Adm.Code 4123-10-05 Restricting and logging access to confidential personal information in computerized personal information systems.

For personal information systems that are computer systems and contain confidential personal information, the bureau shall do the following:

(A) Access restrictions. Access to confidential personal information that is kept electronically shall require a password or other authentication measure.

(B) Acquisition of a new computer system. When the bureau acquires a new computer system that stores, manages or contains confidential personal information, the bureau shall include a mechanism for recording specific access by employees of the bureau to confidential personal information in the system.

(C) Upgrading existing computer systems. When the bureau modifies an existing computer system that stores, manages or contains confidential personal information, the bureau shall make a determination whether the modification constitutes an upgrade. Any upgrades to a computer system shall include a mechanism for recording specific access by employees of the bureau to confidential personal information in the system.

(D) Logging requirements regarding confidential personal information in existing computer systems.

(1) Each employee of the bureau who accesses confidential personal information within computer systems shall maintain a log that records that access.

(2) Access to confidential information is not required to be entered into the log under the following circumstances:

(a) The employee of the bureau is accessing confidential personal information for official bureau purposes, including research, and the access is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(b) The employee of the bureau is accessing confidential personal information for routine office procedures and the access is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(c) The employee of the bureau comes into incidental contact with confidential personal information and the access of the information is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(d) The employee of the bureau accesses confidential personal information about an individual based upon a request made under either of the following circumstances:

(i) The individual requests confidential personal information about himself/herself.

(ii) The individual makes a request that the bureau takes some action on that individual's behalf and accessing the confidential personal information is required in order to consider or process that request.

(3) For purposes of this paragraph, the bureau may choose the form or forms of logging, whether in electronic or paper formats.

(E) Log management. The agency shall issue a policy that specifies the following:

(1) Who shall maintain the log;

(2) What information shall be captured in the log;

(3) How the log is to be stored; and

(4) How long information kept in the log is to be retained.

Nothing in this rule limits the bureau from requiring logging in any circumstance that it deems necessary.

Last updated August 4, 2026 at 10:31 AM

History

Effective: June 30, 2011
Promulgated Under: 119.03

Chapter 4123-14 Noncomplying Employer

Ohio Adm.Code 4123-14-01 Non-complying employers within the meaning of the law.

(A) An employer, as defined in division (B) of section 4123.01 of the Revised Code, that either fails to establish or maintain industrial coverage, or fails to make payments of premiums to the state insurance fund, as set forth by Chapter 4123. of the Revised Code and the rules of the industrial commission and the bureau of workers' compensation, or fails to comply with the requirements for self-insurance under section 4123.35 of the Revised Code and the rules of the industrial commission or bureau of workers' compensation, is a non-complying employer.

(B) An employer, as defined in division (B) of section 4123.01 of the Revised Code that, after a final adjudication, has failed to pay an obligation, billing, account or assessment that is greater than one thousand dollars on or before its due date, is a non-complying employer.

(1) For purposes of this rule, due date is defined as sixty days after the invoice date of an obligation, billing, account or assessment that is greater than one thousand dollars if no administrative appeal as permitted by law is filed or sixty days following an administrative or court order that has become final.

(2) Coverage will lapse if an obligation, billing, account or assessment that is greater than one thousand dollars remains unpaid as of the due date as defined in paragraph (B)(1) of this rule.

(C) An employer found to be a non-complying employer under paragraph (B) of this rule will have coverage reinstated as of the date of payment of an obligation, billing, account or assessment that is greater than one thousand dollars from which no appeal or protest is filed.

(D) An employer found to be a non-complying employer under paragraph (B) of this rule and that has filed a timely protest or appeal, will have coverage reinstated and noncompliance period vacated, pending final administrative adjudication of that protest or appeal.

Last updated October 1, 2024 at 9:13 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-14-02 Procedures for the collection of premiums from non-complying employers.

(A) Whenever the bureau of workers' compensation finds that an employer that was subject to division (B)(2) of section 4123.01 of the Revised Code failed to comply with the law in matters of workers' compensation coverage, the bureau shall notify the employer in writing of such a finding. The notice will outline the period of time during which the employer was an amenable employer, and specify that the employer has twenty days from the service of the notice to pay the applicable premium or penalty as set forth by law.

(B) If the employer does not pay the applicable premium or penalty within the twenty day period referred to in paragraph (A) of this rule, the bureau or its authorized agent shall immediately make an assessment of the amount due from the employer, based on such information as may be in the possession of the bureau, in accordance with sections 4123.32 and 4123.37 of the Revised Code.

(C) The bureau or its authorized agent shall give the employer written notice of any action taken. The notice shall be mailed to the employer at its residence or usual place of business by certified mail with return receipt requested. The notice will inform the employer that unless it files with the bureau within twenty days after receipt of the notice, a petition for reassessment in writing, verified under oath by the employer, or its authorized agent having knowledge of the facts, setting forth in detail the items of the assessment objected to and the reason for the objection, the assessment shall become final and the amount thereof shall be due and payable from the employer so assessed to the state insurance fund.

(D) The bureau or its authorized agent, under the authority of section 4123.78 of the Revised Code, shall file with the county recorder of any counties in which such employer's property may be located a certificate of the amount of premium and penalty due from such employer and the amount due shall be a lien from the date of filing against the real and personal property of the employer within each county in which such certificate is filed.

(E) In the event a petition objecting to the assessment is duly filed by the employer, the bureau shall reexamine the assessment that is the subject of the petition and refer the matter to the secretary of the adjudicating committee, who will schedule the matter for a hearing before the bureau of workers' compensation adjudicating committee. The notice of hearing shall be mailed to the petitioner by certified mail and to its representative, setting forth the date, time and place of the hearing. It will be mailed to the parties, as indicated above, not less than fourteen days before the date of such a hearing. In justifiable cases an emergency hearing may be arranged.

(F) A copy of the administrator's finding and order shall be mailed by certified mail to the party assessed and by regular mail to the representative of such a party.

(G) If the administrator orders the employer to pay the assessment, payment is due ten days after the notice of the finding and order of the administrator was mailed to such employer.

(H) The employer has the right to appeal the administrator's decision to the court of common pleas of Franklin county upon the execution of a bond to the state in double the amount due and ordered paid by the bureau, upon the condition that the employer will pay any judgment and costs rendered against it for the premium, as provided in section 4123.37 of the Revised Code.

(I) When no petition objecting to the assessment is filed or when a finding is made affirming or modifying such an assessment after hearing, a certified copy of the assessment, as affirmed or modified, shall be filed by the bureau not later than twenty days from the date the order has become final, with the clerk of the common pleas court in any county in which the employer has property or in which the employer has a place of business, for the purpose of obtaining a judgment for the state against the employer in the amount shown on the assessment. As soon as the judgment is rendered, proper action shall be taken to levy execution on said judgment.

(J) However, an assessment or judgment, as outlined in the preceding paragraphs of this rule, shall not be a bar to the adjustment of the employer's account upon the employer furnishing his payroll records to the bureau.

(K) In addition to the procedures outlined in paragraphs (A) to (I) of this rule, the administrator of the bureau will, in justifiable cases, certify the matter to the attorney general's office with a request that the employer be enjoined from further operation in accordance with section 4123.79 of the Revised Code and/or that criminal proceedings be instituted against the employer for penalties under division (C) of section 4123.99 of the Revised Code. Furthermore, in cases where the employer failed to furnish to the bureau the annual payroll report and other related information as set forth by section 4123.26 of the Revised Code, a civil action will be brought against such employer in the name of the state to collect the penalty, as provided in that section.

(L) For counties and public employer taxing districts, the bureau shall keep an individual account showing the amount of money paid into the public insurance fund and the amount of losses incurred against the fund. When any such employer defaults in the payment of sums required to be contributed to such fund or any official fails to perform any act required to be performed in reference to the making of payments, the bureau shall institute the proper proceedings in the court to compel such payment.

Last updated October 1, 2024 at 9:13 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-14-03 Requests for waiver of a default in the payment of premium, for approval of the original workers' compensation coverage retroactively, and for abatement of penalties.

(A) The administrator of the bureau of workers' compensation, for good cause shown, may do any of the following:

(1) Waive a default in the payment of premium by an employer where workers' compensation coverage has lapsed, if such a default is of less than sixty days duration. If such a waiver is granted, workers' compensation coverage will be reinstated retroactively;

(2) Approve the original workers' compensation coverage to take effect retroactively;

(3) Abate penalties imposed on employers for failure to comply with the state of Ohio's workers' compensation statutes.

(4) Waive penalties for failure to file or pay amounts due under the annual payroll report.

(B) The term "good cause," as used in paragraph (A) of this rule, means a substantial reason, one that affords a legal justification or a legal excuse. If the employer is unable to establish "good cause" under this definition, the employer may also show "good cause" if the default is a one-time violation of the payment of premium or the filing of the annual payroll report.

(C) Such requests shall be submitted to the bureau by the employer concerned or by its duly authorized representative. The reason for the relief sought shall be fully explained. The bureau may hold a request in abeyance until the request is properly completed, and will notify the applicant of its response accordingly.

(D) The administrator may refer such requests to the bureau of workers' compensation adjudicating committee for further consideration and for the determination of the issue raised.

Last updated October 1, 2024 at 9:13 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-14-04 Procedures to recover from a non-complying employer the amount of money paid out of the state insurance fund for an industrial injury, occupational disease and/or death.

(A) Upon the filing of a workers' compensation claim, naming a non-complying employer as the employer, the attorney general's office will prepare and the bureau will file for record in the office of the county recorder in any counties where the employer's property is located, if known, or in any counties where the employer's business is located, an affidavit showing the date on which the application for compensation or benefits was filed, the name and address of the employer against whom it was filed, and the fact that said employer has not complied with section 4123.35 of the Revised Code. A copy of the application for compensation or benefits shall be filed with the affidavit. The affidavit constitutes a lien on employer's real property and tangible personal property within each county where it was filed.

(B) The bureau shall notify the employer, by mail and within the shortest time possible, of the filing of the application. Such notice shall be accompanied by a copy of the application and a copy of the affidavit, as described in paragraph (A) of this rule, and shall advise the employer that unless it files a timely answer to the application, the claim will be adjudicated upon the filed application.

(C) The employer, or its agent or attorney, shall verify its answer. Upon filing of such answer, the bureau shall immediately mail a copy of the answer to the employee. If the employee is represented, the bureau shall mail a copy to the representative.

(D) The lien on employer's property, as described in paragraph (A) of this rule, shall be cancelled under the following circumstances:

(1) The employer has paid the amount of all awards made by the commission and/or the bureau;

(2) There was a final order of disallowance of a claim;

(3) The employer has filed a bond or other security in such an amount and with such a surety as the bureau approves, conditioned on the employer's payment of all awards made by the commission and/or the bureau. The bureau may, in its discretion, grant a partial release of the lien, should this be necessary to facilitate the conduct of the employer's business, provided a sufficient security remains to pay any award that may be made in the claim;

(4) Settlement of employer's liability as provided in rule 4123-14-05 of the Administrative Code;

(5) The bureau, industrial commission, or court has determined that the employer subject to the lien is not the employer of record in the claim.

(E) In all cases of an employer's failure to pay the award of compensation or benefits, as approved by the industrial commission or the bureau, or to furnish a satisfactory bond within ten days after notification of such award, payment of the award from the surplus fund and the recovery of the monies so paid by the bureau will be in accordance with section 4123.75 of the Revised Code.

(F) The award of compensation or benefits, referred to in paragraph (D) of this rule, constitutes a liquidated claim for damages against the non-complying employer. The bureau shall certify the record to the attorney general to institute a civil action against the employer for collection of the award. Such action may be joined with the action to recover premium due from such employer.

Last updated October 1, 2024 at 9:14 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-14-05 Settlement of liability of a non-complying employer.

(A) A non-complying employer may apply to the administrator of the bureau of workers' compensation for settlement of its liability to the state insurance fund. The request shall:

(1) Be submitted to the bureau by the employer concerned or by its duly authorized representative. The bureau may hold a request in abeyance until it is properly completed, and will notify the applicant of its response accordingly;

(2) Clearly set forth the circumstances by reason of which the proposed settlement is deemed desirable;

(3) Include, but not be limited to, the following information:

(a) The size of employer's business, including the number of employees;

(b) The location of the business, including each state in which the business is located;

(d) The nature and type of the employer's business for the past five years;

(e) A copy of the employer's federal and state income tax return for the past three years;

(f) A notarized financial statement of current assets and liabilities;

(g) A sworn statement to explain the reason for noncompliance with the "Ohio Workers' Compensation Act";

(h) The amount of the requested settlement; and

(i) Whether the employer is in business at the present time and complying with the "Ohio Workers' Compensation Act."

(B) The administrator may refer the request to the legal division of the bureau of workers' compensation for review, preparation of memorandum, and presentation to the adjudicating committee for approval or disapproval of the offer of settlement. The employer's past history with the bureau, if any, as reflected by the records of the bureau or industrial commission, may be verified. If additional information is needed for proper disposition of the case, the matter may be referred for investigation. In justifiable situations, an independent financial statement and the employer's credit rating may be obtained.

(C) The adjudicating committee may accept the offer of settlement if it finds by a preponderance of the evidence that such a settlement:

(1) Is in the best interest of the state insurance fund;

(2) Is in the best interest of the employees of the employer concerned;

(3) Will be beneficial to the general welfare of the community; or

(4) Will best serve any other public purpose.

The decision of the adjudicating committee shall be reduced to writing and shall be mailed to all interested parties. An alternative delivery method may be used if agreed upon by the parties. The bureau may structure the payment of settlement with the employer for a period not exceeding twenty four months. Interest charges for the structured settlement shall be determined in accordance with section 131.02 of the Revised Code.

(D) The administrator will process an application to settle a liability for violation of a specific safety requirement in the same manner as set forth in this rule.

Last updated October 1, 2024 at 9:14 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-14-06 Bureau of workers' compensation adjudicating committee.

(A) The administrator of the bureau of workers' compensation may delegate the authority granted to the administrator under Chapters 4121., 4123., and 4131. of the Revised Code and the rules adopted by the bureau of workers' compensation for determining employer premium, assessment, or penalty obligations or liabilities, eligibility for alternative premium plans or discount programs, or other employer-related disputes or issues as may be authorized under the workers' compensation statutes and rules. For this purpose, the administrator may appoint an adjudicating committee to provide employers with hearings on such matters referred by the administrator.

(1) An employer may file with the bureau a request for a hearing with the adjudicating committee only after the employer's request, protest, petition, or application has been reviewed by the appropriate bureau business unit and only after that business unit has notified the employer of the bureau's initial decision regarding the employer's request, protest, petition, or application.

(2) Unless a different time is provided by the Revised Code or the Administrative Code for such matter, an employer shall file a protest or appeal of the bureau's decision on the request, protest, petition, or application within two years of receipt of the bureau's determination.

(3) The employer shall state the specific grounds or reasons for the protest or appeal of the bureau's determination, and include supporting documentation. The bureau may refuse to grant a hearing to the employer where the employer has failed to state the specific grounds or reasons for the protest or appeal or has failed to provide supporting documentation as set forth by this rule.

(B) The adjudicating committee consists of three members appointed by the administrator who have expertise or experience in matters relating to employers.

(C) The adjudicating committee shall hold meetings and hearings to determine matters referred to it by the administrator. With the approval of the administrator, the adjudicating committee members may delegate alternate bureau employees to act on their behalf. The adjudicating committee may issue decisions without formal hearing, but shall afford an employer the opportunity for a formal hearing upon request. A prompt, efficient, and expeditious determination of matters will be ensured to protect the interests of employers and the state insurance fund.

(D) If an employer requests a hearing before the adjudicating committee, and has complied with paragraph (A)(1) of this rule, or the adjudicating committee determines that a hearing is in the best interests of the employer or the state insurance fund, the adjudicating committee shall notify the employer and its representatives not less than fourteen days before the date of such hearing, setting forth the date, time and place of the hearing. In justifiable cases, an emergency hearing may be arranged with the adjudicating committee and the fourteen day time period for notice may be waived.

(E) The adjudicating committee shall keep a record of its dockets and proceedings. The adjudicating committee's decisions shall be reduced to writing and mailed to all interested parties and state the reason for the adjudicating committee's decision, including the evidence upon which the decision was based. The decision of the adjudicating committee is the decision of the administrator. If the employer files a written appeal within thirty days of the employer's receipt of the decision, the administrator or the administrator's designee shall hear the appeal of the decision and conduct a hearing for such purpose. Mail service may be waived by any party where e-mail or alternative means of delivery is agreed upon.

(F) The administrator may authorize the adjudicating committee to consider the following matters:

(1) Requests for waiver of a default in the payment of a premium under section 4123.37 of the Revised Code;

(2) Requests for settlement of liability of a non-complying employer under section 4123.75 of the Revised Code;

(3) Petitions objecting to assessment of premium under rule 4123-14-02 of the Administrative Code and section 4123.37 of the Revised Code;

(4) Employer's request for abatement of penalties under rule 4123-14-03 of the Administrative Code and section 4123.32 of the Revised Code;

(5) Protests of audit findings, manual classifications, experience ratings, retrospective ratings, or transfers or combinations of risk experience;

(6) Any other risk or premium matter under Chapters 4121., 4123., and 4131. of the Revised Code; and

(7) Petitions objecting to the amount of security required under division (D) of section 4125.05 of the Revised Code and the rules adopted pursuant to that section or under division (D) of section 4133.07 of the Revised Code and the rules adopted pursuant to that section.

Last updated October 1, 2024 at 9:14 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Chapter 4123-15 Code of Ethics

Ohio Adm.Code 4123-15-01 Code of ethics, title and rules covering.

This rule and rules 4123-15-02 to 4123-15-04 and 4121-15-01 to 4121-15-04 of the Administrative Code shall be titled, "Code of Ethics for the Bureau of Workers' Compensation and the Industrial Commission of Ohio" and shall contain the code of ethics for employees of these agencies, including the members of the bureau of workers' compensation board of directors.

In addition to any civil or criminal penalties that may be provided by statute or rule, an employee who violates any of the provisions in the code of ethics shall be subject to discipline as provided in the employee handbook of the employee's agency.

Last updated August 14, 2025 at 10:10 AM

History

Effective: January 1, 2014
Promulgated Under: 119.03

Ohio Adm.Code 4123-15-02 Policy.

(A) It is essential that the public has confidence in the administration of the industrial commission and the bureau of workers' compensation. This public confidence depends in a large degree on whether the public trusts that employees of these agencies are impartial, fair, and act only in the interest of the people, uninfluenced by any consideration of self-interest, except those inherent in the proper performance of their duties. Each employee, of whatever position, should, therefore, maintain the highest standards of personal integrity, since the public often judges the actions of an employee as reflecting the standards of the employing agency.

(B) The industrial commission and the bureau of workers' compensation are entrusted with the collection and distribution of a large fund. Their employees must respect this trust and should welcome public scrutiny of the way in which they perform their duties in connection with the administration of this fund. They should be willing to accept restrictions on their conduct that may not be necessary of public employees in other agencies, who are not in similar positions of trust. They must avoid not only impropriety, but the appearance of impropriety.

Last updated August 14, 2025 at 10:10 AM

History

Effective: January 1, 1978
Promulgated Under: Ch 119.

Ohio Adm.Code 4123-15-03 Standards of conduct.

(A) Purpose.

It is the policy of the industrial commission and the bureau of workers' compensation to carry out its mission in accordance with the strictest ethical guidelines and to ensure that commission and bureau employees conduct themselves in a manner that fosters public confidence in the integrity of the commission and the bureau, its processes, and its accomplishments.

The commission and the bureau hereby adopt the provisions of the Ohio ethics law, including but not limited to the provisions of Chapters 102. and 2921. of the Revised Code, and as interpreted by the Ohio ethics commission and Ohio courts.

(B) Prohibited conduct.

(1) No industrial commission member, the administrator of workers' compensation, bureau of workers' compensation board of directors member, commission employee, bureau employee, ombudsperson, or employee of the office of ombudsperson shall do any of the following acts:

(a) Solicit or accept anything of value from anyone doing business with the commission or the bureau;

(b) Solicit or accept employment from anyone doing business with the commission or the bureau, unless the member or employee completely withdraws from any commission or bureau discretionary or decision-making activity regarding the party offering employment, and the commission or the bureau approves the withdrawal;

(c) Use his or her public position to obtain benefits for the member or employee, a family member, or anyone with whom the member or employee has a business or employment relationship;

(d) Be paid or accept any form of compensation for personal services rendered on a matter before, or sell goods or services to the commission or the bureau;

(e) Be paid or accept any form of compensation for personal services rendered on a matter before, or sell (except by competitive bid) goods or services to, any state agency other than the commission or the bureau, as applicable, unless the member or employee first discloses the services or sales and withdraws from matters before the commission or the bureau that directly affect officials and employees of the other state agency, as directed in section 102.04 of the Revised Code;

(f) Hold or benefit from a contract with, authorized by, or approved by the commission or the bureau, (the ethics law does accept some limited stockholdings, and some contracts objectively shown as the lowest cost services, where all criteria under section 2921.42 of the Revised Code are met);

(g) Vote, authorize, recommend, or in any other way use his or her position to secure approval of a commission or bureau contract (including employment or personal services) in which the member or employee, a family member, or anyone with whom the member or employee has a business or employment relationship, has an interest;

(h) Solicit or accept honoraria (see division (H) of section 102.01 and division (H) of section 102.03 of the Revised Code) except that employees who are not financial disclosure filers may receive an honorarium only if the honorarium is paid in recognition of a demonstrable business, profession, or esthetic interest of the employee that exists apart from public office or employment, and is not paid by any person or other entity, or by a representative or association of those persons or entities, doing business with the commission or the bureau, as applicable;

(i) During public service, represent any person, in any fashion, before any public agency, with respect to a matter in which the member or employee personally participated while serving with the commission or the bureau, as applicable; and for one year after leaving public service shall not represent any person, in any fashion, before any public agency, with respect to a matter in which the member or employee personally exercised discretionary authority while serving with the commission or the bureau; after separation from state employment, this policy does not apply to ministerial acts on behalf of a client or customer;

(j) Use or disclose confidential information protected by law, unless appropriately authorized;

(k) Use, or authorize the use of, his or her title, the name of the commission or the bureau, or the agencies logos in a manner that suggests impropriety, favoritism, or bias by the commission or the bureau, or by a member or employee;

(l) Solicit or accept any compensation, except as allowed by law, to perform his or her official duties or any act or service in his or her official capacity; and

(m) Sponsor parties or other entertainment for the personnel of their agencies, the costs of which are covered in whole or in part by donations or receipts from the sale of tickets to individuals or entities, who are doing or seeking to do business with the commission or bureau.

(2) For purposes of this rule, these phrases have the following meanings:

(a) "Anything of value" includes anything of monetary value, including, but not limited to, money, loans, gifts, food or beverages, social event tickets and expenses, travel expenses, golf outings, consulting fees, compensation, or employment. "Value" means worth greater than de minimis or nominal.

(b) "Anyone doing business with the commission or the bureau" includes, but is not limited to, any person, corporation, or other party that is doing or seeking to do business with, regulated by, or has interests before the commission or the bureau, including anyone who is known or should be known to be an agent or acting on behalf of such party, including any person or entity marketing or otherwise attempting to secure business with the commission or the bureau. Having a policy of insurance with the bureau for workers' compensation coverage, without more, is not "doing business with the commission or the bureau" for purposes of this rule.

(c) "Compensation" means money, thing of value, or financial benefit. "Compensation" does not include reimbursement for actual and necessary expenses incurred in the performance of official duties.

No employee of these agencies shall engage in outside employment that results in a conflict or apparent conflict with the employee's official duties and responsibilities.

(1) Outside employment or activity in which an employee with or without pay represents a claimant or employer in any matter before the industrial commission, or the bureau of workers' compensation is prohibited.

(2) Outside employment with an attorney, representative or entity that involves work concerning industrial claims, whether filed or to be filed, or which is in any way related to workers' compensation matters is prohibited.

(D) Professional code of ethics.

In the event there is any conflict between a professional code of ethics governing any employee of these agencies and this code of ethics for employees, the professional code of ethics shall take precedence over the code of ethics for employees but the conflict shall be promptly reported to the employing agency. In such case the agency shall promptly determine the degree of conflict and take such further action as may be indicated.

(E) An employee shall not use state property of any kind for other than approved activities. The employee shall not misuse or deface state property. The taking of state property for the private purposes of an employee is prohibited. The use of state property for the private purposes of an employee is prohibited, except for nominal, minimal, occasional, or emergency use. The employee shall protect and conserve all state property, including equipment and supplies entrusted to or issued to the employee.

(F) Diligence and impartiality in work.

Employees are encouraged to avoid absenteeism and tardiness, to not use sick leave unless necessary and to abide by rules of the Ohio civil service. Recognizing that the industrial commission and bureau of workers' compensation serve many people whose interests are divergent, employees should work in a speedy and efficient manner, strive to be courteous, fair and impartial to the people they serve, and responsive to the problems that come before them. All segments of the public are to be treated equally, without regard to age, race, sex, religion, country of origin, or disability.

(G) It is understood that standards of ethical conduct may involve a myriad of situations. The good conscience of individual employees shall remain the best guarantee of the moral quality of their activities. The overall intent of this code of ethics is that employees avoid any action, whether or not prohibited by the preceding provisions, which result in, or create the appearance of:

(1) Using public office for private gain, or

(2) Giving preferential treatment to any person, entity, or group.

(H) Confidential information.

The confidentiality of all information which comes into possession of commission and bureau employees shall be respected. In order to properly discharge this duty, all employees must acquaint themselves with those areas of information that are designated as confidential by statutes, rules, and policy of the bureau, by the courts and by the attorney general. Furthermore, they must become familiar with the circumstances under which and the persons to whom such information can be released.

(I) Every member or employee required to file a financial disclosure statement must file a complete and accurate statement with the Ohio ethics commission by May fifteenth of each year. Any member or employee appointed, or employed in a filing position after February fifteenth of each year, and required to file a financial disclosure statement must file a statement within ninety days of appointment or employment.

(J) Every member or employee subject to the bureau personal investment policy is required to file a personal trading policy annual affirmation with the bureau by May fifteenth of each year.

(K) Nothing in this rule shall prohibit any member of the bureau of workers' compensation board of directors from receiving compensation or other things of value from the member's outside employer, provided that the member completely withdraws from any discretionary or decision-making activity matters that definitely and directly affect his or her outside employer.

Last updated November 4, 2025 at 2:14 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-15-04 Posting, distribution and employee acknowledgement and receipt.

(A) The code of ethics for employees of the bureau of workers' compensation and industrial commission shall be posted in a conspicuous place in every office of the bureau and commission, and will be posted electronically on the bureau's website.

(B) A copy of this code of ethics shall be distributed to each employee. After two weeks from such receipt each employee will certify that the employee has received and read this code. The certification shall be placed in the employee's personnel file.

Last updated November 4, 2025 at 2:14 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-15-05 Purpose: eliminating outside influence; producing impartiality in handling of claims and employer risk accounts and avoiding favoritism.

In accordance with division (C) of section 4121.122 of the Revised Code and division (B)(12) of section 4121.121 of the Revised Code, the rules numbered 4123-15-05 to 4123-15-09 and 4121-15-05 to 4121-15-09 of the Administrative Code are for the purpose of eliminating improper outside influence on employees of the bureau of workers' compensation and the industrial commission, producing an impartial workers' compensation claims and employer risk account handling process and avoiding favoritism in that process.

Last updated August 14, 2025 at 10:10 AM

History

Effective: June 10, 2017
Promulgated Under: 119.03

Ohio Adm.Code 4123-15-06 Furnishing employees' code of ethics and rules on improper influence to representatives.

To the extent possible, all those who represent claimants or employers shall be furnished without charge with a copy of the "Code of Ethics of the Bureau of Workers' Compensation and the Industrial Commission of Ohio" and with a copy of the rules concerning the elimination of outside influence, producing impartial claims and risk account handling, and avoiding favoritism in this process. The rules of this chapter shall also, to the extent possible, be furnished to employees or agents of those who represent claimants or employers and who may be permitted to inspect claims and employer risk files, or whose work requires personal contact with employees of the bureau or commission. The bureau will also post the rules electronically on the bureau's website.

Last updated November 4, 2025 at 2:14 PM

History

Effective: November 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-15-07 Representatives' responsibility relative to employees' code of ethics.

Representatives of claimants and employers as well as their employees and agents shall conduct their business with the employees of the bureau of workers' compensation, and the industrial commission in accordance with the highest moral principles and are expected to support the "Code of Ethics of the Bureau of Workers' Compensation and the Industrial Commission of Ohio" by conduct that will not tempt employees of the bureau and commission to violate that code but will encourage them to fully observe it. Employees of the bureau and commission shall report to their immediate superior any activity which is, or appears to be, in violation of this rule, for further action by the administrator or by the industrial commission, as the case may be.

Last updated August 14, 2025 at 10:10 AM

History

Effective: January 1, 2014
Promulgated Under: 119.03

Ohio Adm.Code 4123-15-08 Remedial action against persons exercising improper influence and engaging in favoritism.

Upon receipt of information indicating a violation of rule 4123-15-07 of the Administrative Code, to ensure appropriate corrective action, the industrial commission or the administrator, as the case may be, shall take every action to ensure the matter is investigated, and, provided the circumstances warrant it, shall notify the office of deputy inspector general for the bureau of workers' compensation and industrial commission, and any other appropriate agency or official.

Last updated August 14, 2025 at 10:11 AM

History

Effective: February 15, 2008
Promulgated Under: 119.03

Ohio Adm.Code 4123-15-09 Prohibition against unnecessary claim file possession.

No employee shall access a workers' compensation claim file unless the file is necessary to the performance of the employee's duties. Any violation of this rule shall be referred to the chief legal counsel for the bureau of workers' compensation, the administrator or the industrial commission for action consistent with division (A) of section 4121.122 of the Revised Code. A copy of this rule shall be distributed to each employee for certification that he has received and read this rule. This certification shall be placed in the employee's personnel file.

Last updated August 14, 2025 at 10:11 AM

History

Effective: June 10, 2017
Promulgated Under: 119.03

Chapter 4123-16 Personal Information Systems

Ohio Adm.Code 4123-16-01 Definitions.

(A) "Combination of systems" means a unification of systems that belong to more than one agency, or to an agency and another organization, into a single system in which the records that belong to each agency or organization may or may not be obtainable by the others.

(B) "Computer readable" means in a form capable of being sensed by optical, electronic, or some other mechanical means which is used in connection with electronic data processing equipment. Computer readable includes storage in magnetic cord memories, punched cards, paper tape, magnetic media, and specifically marked forms capable of being decoded by optical scanners or other similar devices.

(D) "Administrator" means the administrator of the bureau of workers' compensation.

(E) "Bureau" means the bureau of workers' compensation.

(F) "Disclosure of personal information" is any action which reveals personal information in a personal information system to any individual or organization other than employees of the state agency who must use the personal information in the performance of their assigned duties.

(G) "Electronic data processing equipment" means a machine or group of interconnected machines, consisting of input, storage, computing, control and output devices where electronic circuitry is used to perform arithmetic and logical operations, using internally stored or externally controlled programmed instructions. Electronic data processing equipment does not include accounting and bookkeeping machines, office calculators, magnetic card typewriters, and other similar devices. Electronic data processing equipment includes terminals which are linked to computers.

(H) "Interconnection of systems" means a linking of systems that belong to more than one agency or to an agency and other organizations, which linking of systems results in a system that permits each agency or organization involved in the linking to have unrestricted access to the systems of the other agencies and organizations.

(I) "Maintains" means state agency ownership of, control over, responsibility for, or accountability for systems and includes, but is not limited to, state agency depositing of information with a data processing center for storage, processing, or dissemination. An agency maintains all systems of records which are required by law to be kept by the agency.

(J) "Person" includes any individual, corporation, business trust, estate, trust, partnership, or association.

(K) "Personal information" means any information that describes anything about a person, or indicates actions done by or to a person, or indicates that a person possesses certain personal characteristics, and that contains, and can be retrieved from a system by a name, identifying number, symbol, or other identifier assigned to a person.

(L) "System" means any collection or group of related records that are kept in an organized manner and that are maintained by a state agency, and from which personal information is retrieved by the name of the person or by some identifying number, symbol, or other identifier assigned to the person. System includes both records that are manually stored and records that are stored using electronic data processing equipment. System does not include collected archival records in the custody of or administered under the authority of the Ohio history connection, published directories, reference materials or newsletters, or routine information that is maintained for the purpose of internal office administration, the use of which would not adversely affect a person.

(M) "Use of personal information" is any action which causes personal information in a personal information system to be referenced, processed, or disseminated. The disclosure of personal information is a use of personal information.

Last updated May 31, 2023 at 11:55 AM

History

Effective: May 20, 2018
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-02 Personal information systems.

(A) Chapter 4123-16 of the Administrative Code shall apply to all personal information systems maintained by the bureau unless exempted in paragraph (C) or (D) of this rule.

(B) The bureau maintains a personal information system which it deposits or stores in a record center or stores in or has processed by a data center. The bureau does not maintain a personal information system belonging to another state agency, which is stored in or processed by the state data center.

(C) The following types of personal information systems are exempted from the provisions of Chapter 1347. of the Revised Code, and Chapter 4123-16 of the Administrative Code.

(1) Collected archival records in the custody of or administered under the authority of the Ohio history connection:

(2) Published directories:

(3) Reference materials;

(4) Newsletters; or

(5) Routine information that is maintained for the purpose of internal office administration, the use of which would not adversely affect a person.

(D) Personal information systems that are comprised of investigatory material compiled for law enforcement purposes are exempt from the provisions of Chapter 1347. of the Revised Code, and Chapters 123:3-1 and 4123-16 of the Administrative Code.

Last updated May 31, 2023 at 11:55 AM

History

Effective: May 20, 2018
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-03 Privacy officer.

(A) The administrator shall appoint a privacy officer to be responsible for agency compliance with Chapter 1347. of the Revised Code and Chapter 4123-16 of the Administrative Code.

(B) The privacy officer, or the privacy officer's designee, shall oversee the staff instruction required by rule 4123-16-12 of the Administrative Code. The privacy officer shall also provide interpretation and guidance relative to specific compliance questions.

(C) The privacy officer shall be designated to receive all correspondence or inquiries relative to privacy matters unless otherwise indicated in Chapter 4123-16 of the Administrative Code.

(D) The privacy officer shall be responsible for monitoring policies and procedures established under Chapter 4123-16 of the Administrative Code and modifying such policies and procedures when appropriate.

Last updated May 31, 2023 at 11:56 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-05 Collection, maintenance and use of only personal information which is necessary and relevant.

The bureau shall collect, maintain and use only personal information which is necessary and relevant to the functions it is required or authorized to perform by statute, ordinance, code or rule and eliminate such information when it is no longer necessary to those functions.

(A) Within three months after any change in the purpose of the personal information system, the privacy officer shall review a random sampling of records to determine if personal information in the system is necessary for and relevant to the performance of lawful functions. Personal information which does not meet these requirements shall no longer be collected.

(B) When an existing personal information system is substantially enlarged or a new personal information system is established, the privacy officer shall examine:

(1) The function for which the personal information system is being enlarged or created to ensure that it is required or authorized by statute, ordinance, code or rule; and

(2) The personal information to be collected and maintained to ensure that it is necessary and relevant to the function to be performed.

(C) Retention periods shall be established to ensure the deletion of personal information which is no longer necessary for or relevant to the performance of lawful functions. The establishment of retention periods shall conform to sections 121.211 and 149.34 of the Revised Code.

Last updated May 31, 2023 at 11:56 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-06 Maintenance of personal information which is accurate, relevant, timely and complete.

(A) Employees who use a personal information system shall monitor the contents of the records and report to the privacy officer the existence of personal information which appears inaccurate, irrelevant, untimely or incomplete.

(B) The privacy officer shall keep a record of the reported incidence of error in each personal information system. If it appears the reported errors are characteristic of the system as a whole, the privacy officer shall establish procedures to correct existing records and record-keeping methods.

(C) In order to maintain personal information which is accurate, relevant, timely and complete, employees of the bureau shall:

(1) Verify the accuracy of personal information which does not appear reasonable or is doubtful, vague, or inconsistent.

(2) Correct inaccurate personal information.

(3) Limit the collection and maintenance of subjective personal information to only that information which is required to accomplish the purpose of the system and, when feasible, verify such information.

(4) When feasible, collect personal information from the data subject rather than a third-party source or verify with the data subject information provided by a third party.

(5) Not include in, or allow to remain in, a personal information system personal information known to be inaccurate, untimely, unnecessary, or irrelevant.

(6) Update personal information systems which provide an historical account or for which an outcome is anticipated.

(7) Make no determination based on personal information in a personal information system if the data is known or suspected to be incomplete.

Last updated May 31, 2023 at 11:56 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-07 Notice to persons asked to supply personal information.

(A) Any person asked to supply personal information for a personal information system shall be advised whether he or she is legally required, or may refuse, to supply the information. A statement to this effect shall be provided with any written or verbal request for information and included on all forms.

(B) Any person asked to supply personal information that will be placed in an interconnected or combined system shall be provided with information relevant to the system, including the identity of the other agencies or organizations that have access to the personal information in the system.

(C) If personal information is requested from the same source on a continuous basis, the person may be advised, as required under paragraph (A) or (B) of this rule, one time, in writing, rather than prior to each request.

Last updated May 31, 2023 at 11:56 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-08 Data subject's right to inspect personal information.

(A) Upon the request and proper identification of any person who is the subject of personal information in a personal information system, the bureau shall:

(1) Inform the person of any personal information in the system of which the person is the subject;

(2) Except as provided in paragraph (C) or (D) of this rule, permit the person, his or her legal guardian, or an attorney with a signed written authorization made by the person, or his or her guardian, to inspect all personal information in the system of which the person is the subject; and

(3) Inform the person about the types of uses made of the personal information, including the identity of any users usually granted access to the system.

(B) Any person who wishes to exercise a right provided by this rule may be accompanied by another individual of the person's choice.

(C) Upon request, medical, psychiatric or psychological information shall be disclosed to the person who is the subject of the information or to the person's legal guardian, unless a physician, psychiatrist, or psychologist determines for the agency that the disclosure of the information is likely to have an adverse effect on the person, in which case the information shall be released to a physician, psychiatrist, or psychologist who is designated by the person or by his or her legal guardian.

(D) Upon the request of an individual who is authorized to inspect personal information, the bureau shall provide, at cost, copies of personal information the data subject is authorized to inspect that is maintained in a personal information system by the bureau.

(E) The bureau of workers' compensation or officer or employee thereof shall not deny to any person or his or her legal guardian the person's rights to inspect and correct personal information pursuant to sections 1347.08 and 1347.09 of the Revised Code.

Last updated May 31, 2023 at 11:56 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-09 Investigation of data subject's dispute of the accuracy, relevance, timeliness or completeness of personal information.

(A) If a person who is the subject of personal information in a personal information system maintained by the bureau disputes the accuracy, relevance, timeliness or completeness of the personal information, the person may request the bureau to investigate the current status of the information.

(B) Requests to investigate personal information shall be made to the privacy officer or the director who is responsible for the system.

(C) Within ninety days after receiving the request from the disputant, the bureau shall make a reasonable investigation to determine whether the disputed information is accurate, relevant, timely and complete and shall notify the disputant of the results of the investigation and of the action that the bureau plans to take with respect to the disputed information. The bureau shall delete any information that it cannot verify or that it finds to be inaccurate.

(D) If after the bureau's determination, the disputant is not satisfied, the bureau shall do either of the following:

(1) Permit the disputant to include within the system a brief statement of his or her position on the disputed information, or

(2) Permit the disputant to include within the system a notation that the disputant protests that the information is inaccurate, irrelevant, outdated, or incomplete. The agency shall maintain a copy of the disputant's statement of the dispute.

The department may limit the statement to not more than one hundred words if the bureau assists the disputant to write a clear summary of the dispute.

(E) The bureau shall include the statement or notation in any subsequent transfer, report or dissemination of the disputed information and may include with the statement or notation of the disputant a statement by the bureau that it has reasonable grounds to believe that the dispute is frivolous or irrelevant and of the reasons for its belief.

(F) The presence of contradictory information in the person's file does not alone constitute reasonable grounds to believe that the dispute is frivolous or irrelevant.

(G) Following any deletion of information that is found to be inaccurate or the accuracy of which can no longer be verified, or if a statement of dispute was filed by the disputant, the bureau shall, at the written request of the disputant, furnish notification that the information has been deleted, or furnish a copy of the disputant's statement of the dispute, to any person specifically designated by the disputant. The bureau shall specifically disclose to the disputant that he or she has the right to make such a request.

Last updated May 31, 2023 at 11:56 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-10 Participation in interconnected or combined systems.

(A) The bureau shall not place personal information in an interconnected or combined system, or use personal information that is placed in an interconnected or combined system by another state or local agency or another organization, unless the interconnected or combined system will contribute to the efficiency of the involved agencies in implementing programs that are authorized by law.

(B) The bureau shall not use personal information placed in an interconnected or combined system by another state or local agency or another organization unless the personal information is necessary and relevant to the performance of a lawful function of the bureau.

(C) The participation in an interconnected or combined system or the use of personal information in an interconnected or combined system shall be approved by the privacy officer.

Last updated May 31, 2023 at 11:57 AM

History

Effective: March 15, 1982
Promulgated Under: Ch 119.

Ohio Adm.Code 4123-16-11 Security precautions.

(A) The bureau shall take reasonable precautions to protect personal information in the system from unauthorized modification, destruction, or disclosure of personal information. In determining what is reasonable, consideration shall be given to the following:

(1) The nature and vulnerability of the personal information.

(2) The physical facilities where the personal information is maintained or used.

(3) The need for the feasibility of keeping personal information in a secure place, considering paragraphs (A)(1) and (A)(2) of this rule, the cost of providing a secure place and the need for access to the place where information is kept by personnel of the agency and the general public.

(B) The bureau shall adopt, implement and enforce a security plan for the protection of personal information. This plan shall include the following:

(1) A statement of the security precautions for each personal information system determined appropriate from the analysis conducted in accordance with paragraph (A) of this rule. When electronic data processing equipment is used, the requirements of rule 123:3-1-01 of the Administrative Code shall be included in the statement of security precautions.

(2) A method of informing agency employees concerning appropriate and inappropriate uses, disclosure and access to the personal information as well as penalties and sanctions, civil or criminal, for the unlawful use or disclosure of personal information and the failure to take reasonable precautions to protect the security of personal information.

(3) A method for reporting violations of the security plan to responsible officials or employees of the agency.

(4) A method for monitoring the effectiveness of the security plan.

A copy of the security plan shall be kept in the office of the privacy officer.

(C) The bureau may require a background investigation of any individual who has access to confidential personal information or to computer equipment used to process such information.

(D) The requirements of Chapter 1347. of the Revised Code and of Chapter 4123-16 of the Administrative Code shall apply to personal information stored, processed, or disseminated under contract with the bureau by any contractor. Any such contract shall contain covenants that the contract will:

(1) Use the information only as specified in the contract;

(2) Not disclose information except with the express permission of the bureau; and

(3) Protect the security of the information.

This paragraph shall apply only to contracts entered into after the effective date of Chapter 4123-16 of the Administrative Code.

Last updated May 31, 2023 at 11:57 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-12 Privacy instruction for department employees.

(A) The bureau shall adopt written policies and procedures which inform employees of the applicable provisions of Chapter 1347. of the Revised Code and of all rules adopted in accordance with the chapter.

(B) The privacy officer shall inform each employee of the bureau who has responsibility for the operation or maintenance of the personal information system of the policies and procedures adopted under Chapter 4123-16 and of the specific application of these policies and procedures to the personal information system.

Last updated May 31, 2023 at 11:57 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Ohio Adm.Code 4123-16-13 Disciplinary measures.

(A) Any employee who intentionally violates any provision of Chapter 1347. of the Revised Code or any rule adopted in accordance with this chapter shall be subject to disciplinary action.

(B) Any employee who initiates or otherwise contributes to any disciplinary or other punitive action against any individual who brings to the attention of appropriate authorities, the press, or any member of the public evidence of unauthorized use of personal information shall be subject to suspension or possible removal.

Last updated May 31, 2023 at 11:57 AM

History

Effective: October 14, 2002
Promulgated Under: 119.03

Chapter 4123-17 General Rating for the State Insurance Fund

Ohio Adm.Code 4123-17-01 Annual rate revision, method of adoption, effective date, publication.

(A) Private employers.

(1) The annual revision of premium rates as provided in division (B) of section 4123.34 of the Revised Code applies to all renewals, reinstatements, and new coverage effective on or after July first of each year, unless otherwise specifically provided. The bureau of workers' compensation may adopt such changes in classification of occupations or industries with respect to their degree of hazard as will best serve to determine the risks of the different classes of occupations and will enable the establishing of appropriate premium rates measured by the hazard involved.

(2) The revised premium rates and changes in classification of occupations or industries with respect to their degree of hazard, as provided in paragraph (A)(1) of this rule, will be adopted by rules recommended by the administrator of workers' compensation and with the advice and consent of the bureau of workers' compensation board of directors as provided under division (F) of section 4121.12 of the Revised Code.

(3) The rule, with any revised premium rates and changes in classification of occupations or industries attached thereto, will be filed in accordance with section 111.15 of the Revised Code. Any revised premium rates and changes in classification of occupations or industries become effective on the date indicated on the filed rule.

(B) Public employers, taxing districts.

(1) The annual revision of premium rates for the taxing districts, as provided in section 4123.39 of the Revised Code, applies to all renewals, reinstatements, and new coverage effective on or after January first of each year, unless otherwise specifically provided. The bureau may adopt such changes in classification of occupations or industries with respect to their degree of hazard, as will best serve to determine the risks of the different classes of occupations and will enable the establishing of appropriate premium rates measured by the hazard involved.

(2) The revised premium rates and changes in classification of occupations or industries with respect to their degree of hazard as provided in paragraph (B)(1) of this rule, will be adopted by rules recommended by the administrator and with the advice and consent of the bureau's board of directors as provided under division (F) of section 4121.12 of the Revised Code.

(3) The rule with any revised premium rates and changes in classification of occupations or industries attached thereto, will be filed in accordance with section 111.15 of the Revised Code. Any revised premium rates and changes in classification of occupations or industries become effective on the date indicated on the filed rule.

(1) The annual revision of contribution rates for the state of Ohio, its agencies and instrumentalities, as provided in section 4123.40 of the Revised Code, for all state agencies is effective July first of each year.

(2) The revised contribution rates as provided in paragraph (C)(1) of this rule will be adopted by rules recommended by the administrator and with the advice and consent of the bureau's board of directors as provided under division (F) of section 4121.12 of the Revised Code.

(3) The rule with the revised contribution rates will be filed in accordance with section 111.15 of the Revised Code. The revised rates become effective on the date indicated on the filed rule.

Last updated July 27, 2023 at 9:07 AM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-02 Successorship.

(A) Responsibilities.

(1) Whenever one employer succeeds another employer in the operation of a business in whole or in part, the successor shall notify the bureau of workers' compensation of the succession.

(2) Pursuant to this rule, the bureau will provide to the parties to the transfer of experience the necessary forms and instructions to complete the transfer of the appropriate payrolls and claims. The bureau will review the transfer and if any questions arise, the bureau may conduct a premium audit on each party's account.

(3) The successor must preserve the predecessor's payroll records for the five years preceding the date of succession.

(B) Experience.

(1) Where one legal entity, not having coverage in the most recent experience period, wholly succeeds another legal entity in the operation of a business, the successor's rate will be based on the predecessor's experience within the most recent experience period.

(2) Where a legal entity having an established coverage or having had experience in the most recent experience period wholly succeeds one or more legal entities having established coverage or having had experience in the most recent experience period, the experience of all the involved entities will be combined to establish the rate of the successor.

(3) Where a legal entity succeeds in the operation of a portion of a business of one or more legal entities having an established coverage or having had experience in the most recent experience period, the successor's rate will be based on the predecessor's experience within the most recent experience period, pertaining to the portion of the business acquired by the successor.

(4) When any combination or transfer of experience is indicated under any of the provisions of this rule, the effective date of such combination or transfer to the beginning date of the following policy year. In cases where an entity institutes workers' compensation coverage on the same date it wholly succeeds another entity or in cases where the date of succession is determined to be the first date of the policy year, the experience of the predecessor will be transferred to the successor effective as of the actual date of succession.

(5) For an out of state employer purchasing an existing Ohio operation, the bureau may use the out of state experience of the employer as a factor in determining the employer's experience.

(6) In addition to paragraphs (B)(1) to (B)(5) of this rule, and regardless of whether the predecessor's transfer to the successor was voluntary or through an intermediary bank or receivership, the bureau will transfer the predecessor's experience under the workers' compensation law to the successor if any of the following criteria are met:

(a) The successor expressly or impliedly agrees to assume such obligations;

(b) The succession transaction amounts to a de facto consolidation or merger;

(d) The succession transaction is entered into for the purpose of escaping obligations under the workers' compensation law.

(7) If all of the following conditions are met, the bureau will not transfer the experience from the predecessor to the successor:

(a) There is a material change in ownership;

(b) There is a change in governing classification; and

(8) In addition to paragraph (B)(7) of this rule, the bureau will not transfer the experience from the predecessor to the successor if both of the following are met:

(a) The time between the predecessor ceasing all operations and the effective date of purchase is greater than six months; and

(b) There is no family relationship or other connection between the predecessor and the successor.

(9) The bureau will consider, but is not bound by, language in a purchase agreement between parties regarding non-assumed liabilities when determining experience transfers.

(1) Where one employer wholly succeeds another in the operation of a business, the bureau will transfer the predecessor's rights and obligations under the workers' compensation law to the successor.

(2) In addition to paragraph (C)(1) of this rule and regardless of whether the predecessor's transfer to the successor was voluntary or through an intermediary bank or receivership, the bureau will transfer the predecessor's rights and obligations under the workers' compensation law to the successor if any of the following criteria are met:

(a) The successor expressly or impliedly agrees to assume such obligations;

(b) The succession transaction amounts to a de facto consolidation or merger;

(d) The succession transaction is entered into for the purpose of escaping obligations under the workers' compensation law.

(3) If all the following conditions are met, the bureau will not transfer the predecessor's rights and obligations to the successor:

(a) There is a material change in ownership;

(b) There is a change in governing classification; and

(4) In addition to paragraph (C)(3) of this rule, the bureau will not transfer the predecessor's rights and obligations to the successor if both of the following are met:

(a) The time between the predecessor ceasing all operations and the effective date of purchase is greater than six months; and

(b) There is no family relationship or other connection between the predecessor and the successor.

(5) The bureau will consider, but is not bound by, language in a purchase agreement between parties regarding non-assumed liabilities when determining rights and obligations transfers.

(6) The successor will be credited with any credits of the predecessor available at the time the bureau completes the transfer. This paragraph applies where an employer wholly succeeds another employer in the operation of a business on or after September 1, 2006.

(D) No retroactive coverage may be granted except as provided in rule 4123-14-03 of the Administrative Code.

Last updated July 27, 2023 at 9:07 AM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-03 Employer's experience rating plan.

(A) Definitions.

As used in this rule:

(1) "Experience period" means:

(a) For private employer policy years commencing on or after July 1, 2016, the oldest four of the latest five completed policy years immediately preceding the beginning of the policy year to which a rate is applicable.

(b) For public employer taxing districts policy years commencing on or after January 1, 2016, the oldest four of the last five completed calendar years immediately preceding the beginning of the policy year to which the rate is applicable.

(2) "Inactive employer" means an employer that satisfies all the following criteria:

(a) The employer is assigned a "cancelled" policy status or a "no coverage" policy, and

(b) As of the last day of September for private employers, or the last day of March for public employers, the employer is not paying premiums or assessments to the Ohio state insurance fund under either its own identity, the identity of any successor entity, or as a self-insured entity.

(3) "Significant negative impact" occurs when:

(a) An inactive employer reported ten per cent or more of the payroll in a manual classification during the experience period, and

(b) The base rate for the manual classification is higher by including the payroll, losses, and costs of such inactive employer in the calculation of that manual classification base rate, than the manual classification base rate is when the payroll, losses, and costs of the inactive employer are excluded. For the purpose of determining "significant negative impact," the bureau of workers' compensation shall test each inactive employer separately.

(B) An employer's premium rates shall be the manual classification base rates as provided under rules 4123-17-02, 4123-17-06, and 4123-17-34 of the Administrative Code for each of the employer's manual classifications except as modified by the employer's experience rating, and shall apply for the twelve-month period beginning on the first of July for private employers and for the calendar year beginning on the first of January for public employer taxing districts.

(1) In calculating the manual classification base rate and the expected loss rate under this rule, the bureau shall exclude the experience in a manual classification of an inactive employer if the inclusion of that inactive employer's experience in that manual classification would have a significant negative impact upon the remaining employers in a particular manual classification.

(2) The calculation of the manual classification base rate and the expected loss rate, as modified in paragraph (B)(1) of this rule, shall be applied to all employers reporting payroll in the manual classification.

(C) An experience-rated employer's manual classification experience-modified rate shall be determined by multiplying its experience modification (EM) as defined in paragraph (D) of this rule times the manual classification base rate for each of the employer's assigned manual classifications.

(D) An employer's EM is determined in accordance with the following formula:

TML = Actual losses of the employer for the experience period, limited in accordance with paragraph (E)(1) of this rule.

TLL = Total limited losses = TEL multiplied by LLR

TEL = Total expected losses, determined by applying expected loss rate to the payroll of each manual classification in the employer's experience period, as provided in the appendix to rule 4123-17-05.1 of the Administrative Code for private employers and in the appendix to rule 4123-17-33.1 of the Administrative Code for public employer taxing districts. The total expected losses are then used to determine credibility group, credibility, and the maximum value of a loss.

LLR = Limited loss ratio, calculated for each credibility group within each industry group, as provided in appendix B to rule 4123-17-05 of the Administrative Code for private employers and appendix B to rule 4123-17-33 of the Administrative Code for public employer taxing districts.

C = Credibility given to an employer's own experience, determined by the employer's total expected losses, as provided in the appendix to rule 4123-17-05.1 of the Administrative Code for private employers and in the appendix to rule 4123-17-33.1 of the Administrative Code for public employer taxing districts.

(E) For a private employer that is not an alternate employer organization as defined in section 4133.01 of the Revised Code or a professional employer organization as defined in section 4125.01 of the Revised Code, and who is individually experience rated, individually retrospective rated, group retrospective rated, or in a deductible program under rule 4123-17-72 of the Administrative Code, the employer's EM as calculated in paragraph (D) of this rule is further adjusted by multiplying the EM adjustment factor as provided in appendix A to this rule and the employer's EM.

(F) For a public employer taxing district employer that is not an alternate employer organization as defined in section 4133.01 of the Revised Code or a professional employer organization as defined in section 4125.01 of the Revised Code, and who is individually experience rated, individually retrospective rated, group retrospective rated, or in a deductible program under rule 4123-17-72 of the Administrative Code, the employer's EM as calculated in paragraph (D) of this rule is further adjusted by multiplying the EM adjustment factor as provided in appendix B to this rule and the employer's EM.

(G) An employers' EM shall be subject to the following conditions and limitations:

(1) Actual losses shall include all incurred costs but shall be limited as provided in rule 4123-17-12 of the Administrative Code, and at the claim level to the amounts provided in the appendix to rule 4123-17-05.1 of the Administrative Code for private employers and the appendix to rule 4123-17-33.1 of the Administrative Code for public employer taxing districts according to the total expected losses of an employer; and

(2) An employer shall not be eligible for experience modification of manual classification base rates unless its expected losses are at least the minimum amount as provided in the appendix to rule 4123-17-05.1 of the Administrative Code for private employers and the appendix to rule 4123-17-33.1 of the Administrative Code for public employer taxing districts.

(3) The year-over-year increase in an employer's EM may be limited pursuant to rule 4123-17-03.2 of the Administrative Code.

(4) Actual losses where COVID-19 was contracted by an employee arising during the period between the emergency declared by executive order 2020-01D, issued March 9, 2020 and July 2, 2021 which is fourteen days after the Executive Order was repealed, shall be excluded from employer's experience for the purpose of experience rating calculations.

(5) Actual losses occurring on or after March 23, 2022 where a student is a participant of the work-based learning program shall be excluded from an employer's experience for the purpose of experience rating calculations if both of the following conditions apply:

(a) The employer provides work-based learning experiences for students enrolled in a career-technical education program approved under section 3317.161 of the Revised Code; and

(b) The claim is based on a student's injury, occupational disease, or death sustained in the course of and arising out of the student's participation in the employer's work-based learning experience.

View AppendixView Appendix

Last updated July 13, 2026 at 3:31 PM

History

Effective: February 15, 2025
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-03.2 Experience modification cap.

(A) Definitions.

As used in this rule:

(1) "Experience modification" or "EM" means the experience modification as determined under rule 4123-17-03 of the Administrative Code.

(2) "Eligibility determination date" means the March first immediately preceding the policy year for which the EM is being calculated for private employers, and the September first immediately preceding the policy year for which the EM is being calculated for public employer taxing districts.

(B) Except as provided for in paragraph (D) of this rule, the bureau of workers' compensation shall limit the increase in EM of an employer meeting the eligibility requirements of this rule to twenty-five per cent of the initial EM calculated for that employer in the preceding rating year if the employer is either individually experience rated or base rated in both the current and preceding rating years for any policy years for private employers beginning July 1, 2023 and ending June 30, 2027 or for any policy years for public employer taxing districts beginning January 1, 2023 and ending December 31, 2027.

As of the eligibility determination date:

(1) The employer must be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code;

(2) The employer must not have cumulative lapses in workers' compensation coverage in excess of forty days within the preceding twelve months; and

(D) An employer removed from the EM cap program for failure to meet the criteria set forth in paragraph (C)(3) of this rule will be rerated for the full policy year at the employer's base rate or experience-modified rate as determined by the employer's expected losses for the policy year.

(E) Application of cap to successor policies.

(1) Where a transfer of experience occurs pursuant to rule 4123-17-02 of the Administrative Code, the resulting EM is not subject to limitation under this rule unless one of the following apply:

(a) The transfer is a combination as a result of bankruptcy proceedings, when the transaction is a change in policy number without any change in exposure; or

(b) A base-rated successor wholly or partially succeeds a single policy.

(2) If the criteria in paragraph (E)(1)(a) or (E)(1)(b) of this rule are met, the predecessor's published EM in the preceding rating year will be the EM published for the successor in the same rating year for purposes of determining whether the cap applies under this rule.

Last updated June 30, 2026 at 1:04 PM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-03.3 Employer premium size factors.

(A) The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, hereby sets the premium size factors in the appendix to this rule to be effective July 1, 2024.

(B) A private employer is eligible for the premium adjustment under this rule provided the private employer is not a professional employer organization as defined in section 4125.01 of the Revised Code, and the private employer is individually experience rated, individually retrospective rated, group retrospective rated, or participating in a deductible program under rule 4123-17-72 of the Administrative Code.

(C) The premium size factors in the appendix to this rule will be applied using the following formula to determine an employer's initial premium:

Initial premium equals payroll multiplied by base rate multiplied by EM multiplied by EM adjustment factor where:

Payroll equals the amount of payroll reported by the employer as required under agency 4123 of the Administrative Code;

Base rate equals the rate that an employer who is not experience rated pays as a percentage of their payroll;

EM equals experience modification as defined in rule 4123-17-03 of the Administrative Code; and

EM adjustment factor equals experience modification adjustment factor as defined in rule 4123-17-03 of the Administrative Code.

(D) The following limitations apply to the initial premium calculated in paragraph (C) of this rule:

(1) For an employer that is individually experience rated, group retrospectively rated, or participating in a deductible program under rule 4123-17-72 of the Administrative Code, the initial premium is adjusted by the following formula:

Premium equals initial premium multiplied by premium size factor where:

Initial premium equals initial premium as calculated in paragraph (C) of this rule; and

Premium size factor equals the appropriate premium size factor obtained from the table in the appendix to this rule when applying the initial premium as calculated in paragraph (C) of this rule to the experience rated premium range.

(2) For individual retrospective rated employers, the premium size factors will only apply to the minimum premium and not to any payments on annual evaluation billings made by the employer.

(3) For employers participating in the deductible program, the premium size factors will only apply to the post deductible credited premium and not to any deductible claim cost reimbursement payments made by the employer.

View Appendix

Last updated June 30, 2026 at 12:59 PM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-04 Classification of occupations or industries.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to approve the classification of occupations or industries pursuant to sections 4121.12, 4121.121, and 4123.29 of the Revised Code. The administrator hereby establishes the following classifications of occupations or industries to be effective July 1, 2026, as indicated in the appendix to this rule, the classification of occupations or industries that is based upon the national council on compensation insurance as required by division (A)(1) of section 4123.29 of the Revised Code.

View Appendix

Last updated July 1, 2026 at 7:47 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-05 Private employer industry group and limited loss ratio tables.

View AppendixView Appendix

Last updated July 1, 2026 at 7:47 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-05.1 Private employer experience rating table.

View Appendix

Last updated August 27, 2026 at 8:55 AM

History

Effective: July 1, 2019
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-06 Private employer contributions to the state insurance fund.

View AppendixView Appendix

Last updated July 1, 2026 at 7:47 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-07 Officers of corporations, elective coverage entities, and ministers.

(A) Definitions.

As used in this rule:

(1) "Church" means an established and legally recognized church, congregation, denomination, society, corporation, fellowship, convention, or association that is formed primarily or exclusively for religious purposes.

(2) "Elective coverage persons" means a sole proprietor, a member of a partnership, a member of a limited partnership, an individual incorporated as a corporation with no employees, or an officer of a family farm corporation.

(3) "Elective coverage entity" means a sole proprietorship, a partnership, a limited partnership, an individual incorporated as a corporation with no employees, or a family farm corporation.

(4) "Family farm corporation" has the same meaning as defined in division (E) of section 4123.01 of the Revised Code.

(5) "Minister" means a duly ordained, commissioned, accredited, or licensed minister, member of the clergy, rabbi, priest, or Christian science practitioner.

(B) Officers of corporations.

(1) The actual remuneration of an executive officer of a corporation, such as president, vice president, secretary, treasurer, and any other executive officer enumerated in and empowered by the corporate charter or any regularly adopted bylaws of the corporation and elected or appointed and empowered by the directors to perform duties for the corporation, shall be included in the payroll report of the corporation pursuant to rule 4123-17-14 of the Administrative Code, subject to the weekly minimum and maximum provided in rule 4123-17-30 of the Administrative Code. Such remuneration is to be assigned to the classification code applicable to the duties performed.

(2) Paragraph (B)(1) of this rule does not apply to family farm corporations. The remuneration of the officers of such corporation will not be reported as part of the payroll of such employer, unless such employer elects to include as an "employee," within Chapter 4123. of the Revised Code, any officer of the family farm corporation, in which case the procedure outlined in paragraph (C) of this rule applies.

(1) Remuneration of an elective coverage person shall not be reported as part of the payroll of an elective coverage entity unless that entity elects to include any such person as an employee.

(2) Upon the filing of notice pursuant to paragraph (E) of this rule, the actual remuneration of an elective coverage person shall be reported and included in the payroll report of the employer pursuant to rule 4123-17-14 of the Administrative Code, subject to the weekly minimum and maximum provided in rule 4123-17-30 of the Administrative Code. Such remuneration is to be assigned to the highest rated classification code applicable to the duties performed.

(D) Ministers.

(1) Division (A)(2)(a) of section 4123.01 of the Revised Code excludes from coverage ministers, assistant ministers, or associate ministers in the exercise of their ministry. The remuneration for such persons shall not be reported as part of the payroll of a church employer, unless the church elects to include such persons as employees.

(2) Upon the filing of notice pursuant to paragraph (E) of this rule, the actual remuneration of a minister, assistant minister, or associate minister shall be reported and included in the payroll report of the employer. Such remuneration is to be assigned to the classification code applicable to the duties performed.

(E) An employer may elect to include an elective coverage person or minister, assistant minister, or associate minister as an employee under paragraph (C) or (D) of this rule by notifying the bureau of workers' compensation on a form prescribed by the bureau. After proper election notice, elective coverage persons or ministers, assistant ministers, or associate ministers will be entitled to receive compensation and benefits as provided in Chapter 4123. of the Revised Code.

(1) Coverage for such persons will not be effective until notice has been filed and the mandatory payment made with the bureau. Additional premium for elective coverage must be paid by the due date indicated on the invoice.

(2) Coverage will remain in effect, and the employer will be responsible for the payment of estimated premium thereon, until the bureau receives notice, in writing or by phone, from the employer requesting termination of coverage for the elective coverage persons or ministers, assistant ministers, or associate ministers.

(3) An employer's failure to pay estimated premiums timely will terminate or lapse coverage for its elective coverage persons or ministers, assistant ministers, or associate ministers in accordance with bureau policy. Reinstatement of coverage will also be determined in accordance with bureau policy. No retroactive coverage may be granted except as provided in rule 4123-14-03 of the Administrative Code.

(F) Household workers.

Coverage that is extended to a person who, in his or her household, employs household worker(s) pursuant to section 4123.01 of the Revised Code, does not include such person himself.

Last updated September 4, 2025 at 7:26 AM

History

Effective: September 4, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-08 Classifications according to national council on compensation insurance.

(A) In accordance with division (A)(1) of section 4123.29 of the Revised Code, the purpose of this rule is for the bureau of workers' compensation to conform the classifications of industries according to the categories the national council on compensation insurance (NCCI) establishes that are applicable to employers in Ohio. This rule is based upon "Rule 1, Classification Assignment," effective February 6, 2023, of the classification rules of the NCCI and "Rule 2G, Interchange of Labor." The rule is used with the permission of the NCCI and is modified to conform to the requirements of the Ohio Administrative Code and the bureau of workers' compensation. Where the NCCI scopes of basic classifications contain additional rules and information relating to the reporting of payroll or classification of industries under the classifications, such scopes and rules shall apply under the rules of the bureau of workers' compensation, unless otherwise specifically excepted.

(B) Classification system.

(1) The purpose of the classification system is to group employers with similar operations into classifications so that:

(a) The assigned classification reflects the exposures common to those employers; and

(b) The rate charged reflects the exposure to loss common to those employers.

(2) Subject to certain exceptions, the business of the employer within a state is classified, not separate employments, occupations, or operations within the business.

Classifications are divided into two types - basic classifications and standard exception classifications.

(1) Basic classifications.

Basic classifications describe the business of an employer. This term is applied to all classifications listed in this rule, except for the standard exception classifications. Examples of classifications that describe the business of the employer are provided in table 1 of this rule.

Table 1

| A business... | Example classification type | | --- | --- | | manufactures a product | furniture manufacturing | | performs a process | engraving | | performs construction or erection | carpentry | | is a mercantile business | hardware store | | provides a service | beauty salon |

(2) Standard exception classifications.

Standard exception classifications describe occupations that are common to many businesses. These common occupations are not included in a basic classification unless specified in the classification wording. The standard exception classifications are as follows: clerical office employees not otherwise classified (code 8810); clerical office telecommuter employees (code 8871); drivers, chauffeurs, messengers, and their helpers NOC - commercial (code 7380); salespersons or collectors - outside (code 8742); and automotive salespersons (code 8748).

(a) Clerical office employees not otherwise classified (NOC) (code 8810); and clerical office telecommuter employees (code 8871).

(i) The standard exception classifications are assigned when all the following conditions are met: the basic classification(s) wording applicable to the business does not include clerical office or telecommuting employees; other rules do not prohibit the assignment of code 8810 or code 8871; and the employee meets the duties, site, and other requirements listed as follows.

(ii) Duties.

Duties must be limited to one or more of the following work activities:

(a) Creation or maintenance of employer records, correspondence, computer programs, files;

(b) Telephone duties, including telephone sales;

(d) Copy or fax machine operations, unless the employer is in the business of making copies or faxing for the public; or

(e) General office work similar in nature to those noted in this paragraph.

(iii) Site.

(a) Code 8810. The noted duties must take place in a workstation that is separated from the operative hazards of:

(i) Factories,

(ii) Stores,

(iii) Shops,

(iv) Construction sites,

(v) Warehouses,

(vi) Yards,

(vii) Work or service areas,

(viii) Areas where inventory is located,

(ix) Areas where products are displayed for sale, and

(x) Areas to which the purchaser customarily brings the product from another area for payment.

(b) Workstations as described in paragraph (C)(2)(a)(iii)(a) of this rule must be physically separated by:

(i) Floors,

(ii) Walls,

(iii) Partitions,

(iv) Counters; or

(v) Other physical barriers that protect the clerical employee from the operating hazards of a business.

(c) Code 8871. The noted duties must take place in a clerical work area located within the home of the clerical employee. The clerical work area must be separate and distinct from the location of the employer.

(iv) Other requirements.

(a) Employees who otherwise meet the requirements for code 8810 or code 8871 will not be disqualified from assignment to this classification if they perform certain incidental nonclerical duties directly related to that employee's duties in the office. These duties include:

(i) Depositing funds in a bank;

(ii) Pickup or delivery of mail;

(iii) Purchase of office supplies; and

(iv) Entering an area exposed to the operative hazards of the business for clerical purposes, such as delivering paychecks.

(b) Employees who otherwise meet the requirements for code 8810 or code 8871 are disqualified from assignment to this classification if their duties involve:

(i) Outside sales or outside representation;

(ii) Direct supervision of nonclerical employees that is not performed in an eligible site according to paragraph (C)(2)(a)(iii)(a) of this rule;

(iii) Physical labor; or

(iv) Any work exposed to the operative hazards of the business, such as a stock or tally clerk, that is necessary, incidental, or related to any operations of the business other than a clerical office.

(b) Drivers, chauffeurs, messengers, and their helpers NOC - commercial (code 7380).

This classification is assigned to employees who perform work on or in connection with a vehicle. Messenger and courier deliveries of owned documents or goods made by foot or public transportation are assigned to the governing classification as defined in paragraph (C)(5) of this rule. This code includes garage employees and employees using bicycles as part of their work duties. Duties include, but are not limited to, delivering goods owned by the employer. Code 7380 does not apply when the basic classification wording includes drivers.

This classification is assigned to employees who perform these duties away from the employer's premises. Code 8742 does not apply when the basic classification wording includes outside salespersons, or collectors. This code is not assigned to employees who:

(i) Deliver merchandise;

(ii) Use vehicles to deliver or pick up goods, even if they collect or sell, and these employees must be assigned to the classification applicable to the business for drivers;

(iii) Use public transportation or walk to deliver goods, even if they collect or sell, and these employees must be assigned to the governing classification, as defined in paragraph (C)(5) of this rule, applicable to the business;

(iv) Travel between locations of the employer as district or regional managers to perform various duties not involving outside sales or collection, and for these employees, refer to paragraph (G) of this rule; or

(v) Perform job site measurements or inspections to prepare bids for a job for a construction contractor.

(d) Automotive salespersons (code 8748).

This classification is assigned to employees who perform automotive sales on or away from the employer's premises. These employees are subject to the same rules and treatment as salespersons or collectors - outside (code 8742).

(3) General inclusions.

Some operations appear to be separate businesses but are included within all basic classifications. These are called general inclusions. These operations are not separately classified. They include the following situations that are illustrated through examples. Some employees may perform general inclusion duties for more than one basic classification. In such cases, refer to paragraph (G) of this rule for classification treatment.

(a) Restaurants or cafeterias, stores, or daycare services operated by the employer for employee use.

(i) For example, a bank operates a cafeteria for employer use that is not open to the public. The cafeteria's operations are assigned to the basic classification, which is the appropriate bank classification.

(ii) Exception: if these operations are conducted in connection with construction, erection, lumbering, or mining operations, these operations must be separately classified. For example, a lumber company with a mess tent located on a lumbering job site such as a mountainous or forest-type setting. The mess tent's operations are not assigned to the basic classification. The mess tent's operations are separately assigned to the appropriate restaurant classification.

(b) Manufacture of containers by the employer, such as bags, barrels, bottles, boxes, cans, cartons, or packing cases for sole use in the operations insured by the policy. For example, a fruit juice manufacturer makes plastic bottles for shipping its product. The bottle manufacturing operations are assigned to the basic classification that is the appropriate manufacturing classification of the principal business, which in this example is fruit juice manufacturing.

(c) Hospitals or medical facilities operated by the employer for its employees. For example, a college operates an on-site medical facility for its employees. The medical facility's operations are assigned to the basic classification that is the appropriate college classification.

(d) Maintenance or repair of the employer's buildings or equipment by the employer's employees. For example, an automobile manufacturer has its own janitorial staff and technicians to maintain the assembly line. The janitorial and maintenance operations are assigned to the basic classification that is the appropriate automobile manufacturing classification.

(e) Printing or lithographing by the employer on its own products, packaging, brochures, or promotional materials. For example, a restaurant prints its own menus and takeout price lists. The printing operations are assigned to the basic classification that is the appropriate restaurant classification.

(f) Piloting of unmanned aircraft systems or drone aircraft with a combined weight (including its attached systems, payload, and cargo) of less than fifty-five pounds (24.9 kilograms).

Exceptions include autonomous drone aircraft computer system designers or programmers who qualify as clerical office employees in accordance with paragraph (C)(2)(a) of this rule and do not pilot or operate the drone aircraft are assigned to the appropriate clerical classification; if an employee qualifies as an outside salesperson in accordance with paragraph (C)(2)(c) of this rule, the piloting of a drone aircraft to support their sales duties is included within the classification assigned to the outside salesperson.

(g) Exceptions.

A general inclusion operation must be separately classified if any of the following situations apply.

(i) The operation is conducted as a separate and distinct business of the employer. Refer to paragraph (E)(3) of this rule. For example, if a manufacturer assembles pallets for its own use and sells the pallets to others, pallet manufacturing and sales operations must be separately classified.

(ii) The operation is specifically excluded in the wording of the basic classification. For example, a distillery classified to spirituous liquor distillery (code 2130) has its bottling operation classified to spirituous liquor bottling (code 2131).

(iii) The principal business is described by a standard exception classification. For example, a cafeteria operation in a clerical office is assigned to the appropriate restaurant classification.

(4) General exclusions.

Some operations in a business are so unusual for the type of business described by the applicable basic classification, that they are separately classified even though the operations are not conducted as a secondary business. These operations are called general exclusions. General exclusions are all the following situations.

(a) Aviation. All operations of the flying and ground crews, including piloting of drone aircraft with a combined weight, that is its attached systems, payload, and cargo, of fifty-five pounds (24.9 kilograms) or more. For example, employees of a manufacturing company visit customers' locations. The manufacturing company owns an airplane that is operated by a pilot who transports these employees. The pilot is an employee of the company. The appropriate aviation flying crew classification must be assigned for the pilot.

(b) New construction or alterations. For example, a manufacturing company uses its employees to build a structural addition to the main office building. The appropriate construction classification must be assigned for the employees performing construction duties.

(c) ) Stevedoring. For example, a bulk grain distributor located on a river receives grain from barges. The distributor's employees unload the grain from the barges by using hand trucks. The appropriate stevedoring classification must be assigned for the distributor's employees unloading the grain from the vessel to the dock.

(d) Sawmill operations. For example, a furniture manufacturer receives precut lumber to make products. The company also receives specialty hardwood tree logs that are cut with a band saw by the manufacturer's employees. The sawmill classification must be assigned to the employees sawing the logs.

(5) Governing classification.

The governing classification at a specific job or location is the basic classification, other than a standard exception classification. The governing classification is determined in accordance with table 2 of this rule.

Table 2. Governing Classification Determination Table

| A basic classification produces the greatest amount of payroll | Basic classification | | --- | --- | | A basic classification is applicable but no payroll is assigned | | | Multiple basic classifications apply | Basic classification that is assigned the greatest amount of payroll | | Multiple basic classifications apply but no payroll is assigned to any of the basic classifications | Basic classification that is the highest rated classification | | A basic classification is not applicable | Standard exception classification that is assigned the greatest amount of payroll |

(a) The governing classification is used to determine the classification treatment of:

(i) Miscellaneous employees,

(ii) Local managers, and

(iii) Executive officers who regularly engage in duties that are ordinarily performed by a superintendent, foreperson, or worker.

(b) Examples.

(i) Example of a governing classification. A business has the following payroll amounts assigned to the following classifications: two hundred twenty thousand dollars for code 2003 (bakery); one hundred twenty thousand dollars for code 8017 (store; retail); and two hundred forty thousand dollars for code 8810 (clerical).

The governing code for this business is code 2003 because it is the classification code, other than the standard exception code (code 8810), with the greatest amount of payroll.

(ii) Example of governing classification application for a business that is a restaurant franchise with multiple locations. The business has both restaurant and clerical exposures, and code 9082 (restaurant NOC) is the governing classification. A regional manager travels between the various locations to monitor business operations and sometimes to provide training. The manager is assigned to the governing classification, code 9082 (restaurant NOC).

(6) Principal business.

Principal business is described by the classification, other than a standard exception or general exclusion, with the greatest amount of payroll. If the business is best described by a standard exception operation, and there is no basic classification other than the general inclusion or exclusion operations, then the standard exception operation that produces the greatest amount of payroll for the business is considered the principal business.

(a) Example of principal business determination for businesses involved in multiple operations. A business is involved in two separate operations: the preparation and sale of blasting agents; and blasting excavation. The principal business and the governing classification are determined based on the operation that has the greatest amount of payroll. In this example, based on the information contained in table 3 of this rule, the principal business and the governing classification is code 4777 (explosives distributors and drivers).

Table 3

| Operation | Total payroll | | --- | --- | | Preparation and sale of blasting agents code 4777 (explosives distributors and drivers) | $500,000 | | Blasting operations code 6217 (excavation and drivers) | $200,000 |

(b) Examples for policies that include standard exception classifications. A business is involved in drywall construction and has a clerical office with an office manager and two clerks and total payroll as contained in table 4. In this example, although the standard exception code 8810 (clerical office employees NOC) has more payroll, the governing classification and principal business is code 5445 (wallboard, sheetrock, drywall, plasterboard, or cement board installation within buildings and drivers).

Table 4

| Operation | Total payroll | | --- | --- | | Drywall construction code 5445 (wallboard, sheetrock, drywall, plasterboard, or cement board installation within buildings and drivers) | $50,000 | | Clerical operations code 8810 (clerical office employees NOC) | $75,000 |

(c) Example of principal business determination for policies that include only standard exception and general exclusion classifications. A business classified to the standard exception classification code 8810 (clerical office employees NOC) owns an aircraft and employs a pilot and flying crew to transport employees on business trips. Aviation operations are general exclusions and must be separately classified to the appropriate aviation classifications. In this example, the principal business is the standard exception classification code 8810 (clerical office employees NOC) because the only basic classification of the business is represented by a general exclusion operation.

(d) Example of principal business determination for businesses involved in multiple operations at multiple locations. A business is involved in three operations at two locations as contained in table 5. The governing classification per location is the basic classification with the greatest amount of payroll for that location. The principal business is the basic classification that has the greatest amount of payroll for all operations. In this example, the governing classification for location one is code 2501 (cloth, canvas and related product manufacturing NOC), and the governing classification for location two is code 8010 (store - hardware). The principal business is code 8010 (store - hardware) for all operations of the employer.

Table 5

| Operation | Location 1 | Location 2 | Total payroll | | --- | --- | --- | --- | | Retail shoe store code 8008 (store: shoe -retail) | $250,000 | $0 | $250,000 | | T-shirt manufacturing code 2501 (cloth, canvas, and related products mfg. NOC) | $300,000 | $100,000 | $400,000 | | Hardware store code 8010 (store - hardware) | $0 | $500,000 | $500,000 |

(D) Classification wording.

The following list provides an explanation of classification wording usage.

(1) Classification captions and notes.

(a) The "caption" is the heading or title of the classification.

(b) A "note" is the phrase that follows the caption.

(c) The classification wording as a whole, including the caption and notes, controls, restricts or explains the classification usage. This wording is also referred to as the "phraseology."

(d) Classification captions and notes example. Table 6 of this rule illustrates a caption and a note that provide the complete information using code 3612 (pump mfg.) as an example.

Table 6.

| Part | Classification wording | | --- | --- | | Caption | Pump Mfg. | | Note | Foundry operations are to be separately rated. |

(2) Words and phrases.

(a) "All employees," "all other employees," "all operations," or "all operations to completion."

(i) If a classification includes any of these phrases, no other classification can be assigned unless noted in the classification wording. This applies even if some operations or employees are at a separate location.

(ii) Examples of classifications that include "all employees," "all other employees," all operations," or "all operations to completion."

(a) Code 9186 (carnival, circus or amusement device operator - traveling - all employees and drivers): all employees must be assigned to this classification.

(b) Code 7382 (bus co.: all other employees and drivers): all employees, other than garage employees, must be assigned to code 7382, not code 8385 (bus co.: garage-employees).

(c) Code 5402 (greenhouse erection-all operations): all work for the erection of a greenhouse must be assigned to this classification.

(d) Code 6005 (jetty or breakwater construction-all operations to completion & drivers): all work for the construction of a jetty from the beginning to the end of the project must be assigned to this classification.

(iii) Exceptions.

The following operations within the business must be classified separately even if the classification wording includes "all employees," "all other employees," "all operations," or "all operations to completion":

(a) Construction or erection permanent yard (code 8227);

(b) Contractor-project manager, construction executive, construction manager, or construction superintendent (code 5606);

(c) Classifications describing an operation that is a standard exception unless the basic classification includes the standard exception operation;

(d) Classifications describing an operation that is a general exclusion; and

(e) Any separate and distinct business. Refer to paragraph (E)(3)(c) of this rule.

(b) "Clerical."

"Clerical" means office employees and telecommuter employees.

"Drivers" means drivers, chauffeurs, messengers, and their helpers.

(d) "Includes" or "&."

(i) If the classification wording uses the terms "includes" or "&," the operation or employees cited after those terms must not be assigned to a separate classification. This applies even though the operation or employees may be described by another classification or are at a separate location.

(ii) Examples of classification that include the terms "includes" or "&."

(a) Code 0005 (farm: nursery employees and drivers): all drivers must be assigned to this classification.

(b) Code 4829 (chemical mfg. NOC - all operations & drivers - includes blending or mixing): all drivers and all blending and mixing operations must be assigned to this classification.

(iii) Note: if an employer's operations are assigned to more than one basic classification, an employee's payroll may be allocated among codes appropriate for each operation. This procedure is provided under paragraph (G) of this rule, interchange of labor.

(e) "Local manager."

"Local manager" is an employee, regardless of title, who is in direct charge of the operative procedures in the yard of a business. This employee is subject to the hazards of the business. Therefore, the payroll of the local manager must be assigned to the governing classification unless another basic classification assigned to the business specifically includes this employee.

(f) "No" or "Not."

(i) A classification that includes a restrictive phrase beginning with "no" or "not" must not apply to any employer that conducts any operation described in the restrictive phrase.

(ii) Exception: for mercantile, mining, construction or oil and gas field operations, this rule applies to each job or location.

(iii) Examples of classifications that include the terms "no" or "not."

(a) Code 4611 (medicine, drug or pharmaceutical preparation-no mfg. of ingredients): this code cannot be assigned to a business preparing drugs, medicines, or pharmaceuticals if the business also manufactures the ingredients.

(b) Code 8106 (iron or steel merchant and drivers): this code cannot be assigned to:

(i) Iron or scrap dealers; or

(ii) junk dealers.

(g) "NOC."

(i) "NOC" means "not otherwise classified." If the classification wording uses the term "NOC", that classification applies only if no other classification more specifically describes the employer's business.

(ii) Examples of classification that include the term "NOC":

(a) Code 2688 (leather goods mfg. NOC);

(b) Code 3022 (pipe or tube mfg. NOC and drivers); and

(h) "Or" or "And."

(i) The terms "or" or "and" mean "and/or." This definition applies only to these terms as used in a classification's caption or notes.

(ii) Examples of classifications that include the term "or" or "and."

(a) Code 2586 (cleaning or dyeing & route supervisors, drivers): a business that does cleaning and/or dyeing is classified to this code.

(b) Code 4720 (soap or synthetic detergent mfg.): a business that manufactures soap and/or synthetic detergents is classified to this code.

(c) Code 2883 (furniture manufacturing and cabinet shop - wood NOC): a business that manufactures furniture and/or cabinets is classified to this code.

(i) "Salespersons."

"Salespersons" means salespersons or collectors as defined in paragraph (C)(2)(c) of this rule.

(j) "Stories in height."

Certain classification wording refers to "stories in height." A story is defined as fifteen feet (4.6 meters) in height. The height is measured from the lowest point above ground level to the highest point above ground level.

(k) "To be separately rated."

(i) Certain classification wording contains the phrase "to be separately rated." Operations or employees referenced in those classifications must be separately classified. Rules regarding the assignment of more than one basic classification apply. Refer to paragraph (E)(3) of this rule.

(ii) Examples of classifications that include the term "to be separately rated."

(a) Code 2111 (cannery NOC can mfg. to be separately rated as code 3220): in a business that cans foods, the manufacturing of the cans must separately classified to code 3220.

(b) Code 4131 (mirror mfg.-mfg. of glass, frames, backs, or handles to be separately rated): in a business that makes mirrors, the work of producing glass, or fabricating frames, backs, or handles must be separately classified.

(c) Code 8107 (machinery dealer NOC-store or yard & drivers, operations away from premises, other than demonstration or repair, to be separately rated): in a business that is a machinery dealer, work other than demonstrating or repairing the equipment that is not done at the employer's location must be separately classified.

(l) "Separate and distinct business."

"Separate and distinct business" means an additional operation of the employer that is not included in the basic classification on the policy. Refer to paragraph (E)(3) of this rule.

(E) Classification procedures.

The purpose of the classification procedure is to assign the one basic classification that best describes the business of the employer within a state. Subject to certain exceptions described in this rule, each classification includes all the various types of labor found in a business. The business is classified, not the individual employments, occupations, or operations within the business. Certain exceptions apply as noted below.

(1) Separate legal entities.

Classification rules apply separately to each legal entity operating in a state, even if multiple entities are insured under a single policy.

(2) Businesses not described by a classification.

(a) If no basic classification clearly describes the business, the classification that most closely describes the business must be assigned. All the rules pertaining to the assigned basic classification apply to this operation.

(b) A business not specifically described by a classification is assigned an appropriate classification based on the following factors:

(i) Industry, or the general business activities the business performs, e.g., manufacturing, sales, or administration;

(ii) Product, or whether the business sells goods or sells services; and

(iii) Process, or how the business activities are performed and the materials used.

(c) When a business is not specifically described by a classification, analyzing the business's products and processes is part of determining the appropriate classification to assign. Table 7 provides example considerations.

Table 7

| Industry | Considerations | | --- | --- | | Manufacturing | Raw materials Work processes Customers Products manufactured Uses for the products | | Construction contracting | Type of contractor Work performed Use of specialized equipment Nature of subcontracts | | Merchant sales | Operation: wholesale or retail Merchandise sold Services provided, if any, including delivery | | Service providing | Services performed Location Customers: residential or commercial | | Agriculture or farming | Acreage Crops, if any Livestock, if any Use of machinery or equipment Nature of subcontractors |

(i) Example: A business uses helium-filled airborne turbines attached to tethers that conduct power to a ground station. The turbine is raised several hundred feet in the air. When the wind turns the turbine, electricity is generated, and the electricity produced is provided to customers' power equipment in remote locations. Although the business uses a technology not specifically described by a classification, the business's product is the generation and sale of electrical power. This business is assigned to code 7539 (electric light or power co. NOC-all employees and drivers).

(ii) Example: A business that manufactures helium-filled airborne turbines is not specifically described by a classification. The best match for the manufacture of the airborne turbines is code 3830 (airplane manufacturing) because this code most closely describes the operation.

(3) Assignment of more than one basic classification.

More than one basic classification may be assigned to an employer who meets conditions set forth in paragraphs (E)(3)(a) to (E)(3)(c) of this rule. Operation means activities, enterprises, processes, secondary businesses, or undertakings.

(a) The employer's principal business is described by a basic classification that requires certain operations or employees to be separately rated. Examples include the following.

(i) Code 0251 (irrigation works operation and drivers): operations that are described by code 0251 and the farm classifications must not be assigned to the same employer unless the operations described by these classifications are conducted as separate and distinct businesses. Irrigation system construction is to be separately rated to code 6229.

(ii) Code 5040 (iron or steel erection): frame structures cannot be assigned to the same job or location where code 5059 (iron or steel-erection-frame structures not over two stories in height) applies.

(iii) Code 8265 (iron or steel-scrap dealer and drivers): operations that are described by code 8265 must not be assigned to employers that perform operations described by another classification unless the operations subject to code 8265 are conducted as a separate and distinct business. Salvaging and wrecking are to be separately rated.

(b) The employer conducts one or more of the following operations:

(i) Construction or erection;

(ii) Farming;

(iii) Employee leasing, labor contracting, or temporary labor services;

(iv) Mercantile business; and

(v) Oil and gas field operations.

(i) For purposes of this rule, an employer is conducting more than one operation in a state if portions of the employer's operations in that state are not encompassed by the classification applicable to the employer's principal business. To qualify for a separate classification, the insured's additional operation must:

(a) Be able to exist as a separate business if the employer's principal business in the state ceased to exist;

(b) Be located in a separate building, or on a separate floor in the same building, or on the same floor physically separated from the principal business by structural partitions, and employees engaged in the principal business must be protected from the operating hazards of the separate additional operations; and

(ii) Example of two operations that could qualify as two separate businesses: an employer operates bowling lanes and a movie theater. These distinct operations can qualify as two separate businesses for classification purposes because:

(a) The operations of bowling lanes and movie theaters are not ordinarily conducted as one business, and therefore, are not included within each other's scope; and

(b) Either the bowling lane, if the movie theater ceases to exist, or the movie theater, if the bowling lane ceases to exist, can be expected to continue its operations.

(iii) If the separate additional operation is not encompassed in the classification applicable to the employer's principal business and meets all the conditions listed in paragraph (E)(3)(c)(i) of this rule, the employer is considered to be engaged in an additional operation. A separate basic classification may be assigned to each operation that qualifies as a separate additional operation.

(iv) If the additional operation does not meet all conditions listed in paragraph (E)(3)(c)(i) of this rule, is not encompassed in the classification applicable to the employer's principal business, and has a rate:

(a) Lower than the employer's principal business, assign this operation to the same classification as the employer's principal business.

(b) Higher than or equal to the employer's principal business, assign this operation to the classification that describes the additional operation.

(v) Policies with more than one classification may include employees working under several classifications. Payroll assignment for these employees is subject to the interchange of labor rule. Refer to paragraph (G) of this rule.

(d) Construction, erection, or oil and gas field operations.

(i) Each distinct type of construction, erection, or oil and gas field operation must be assigned to the class that specifically describes the operation only if separate payroll records are maintained for each operation.

(ii) If separate payroll records are not maintained for any construction, erection, or oil and gas field operation, the highest rated classification that applies to the job or location where the operation is performed must be assigned.

(iii) If a construction, erection, or oil and gas field operation is included in the scope of another classification, a separate code must not be assigned.

(iv) Insured subcontractors.

(a) An insured subcontractor who performs a single type of work on a construction, erection, or oil and gas field project or job must be classified based on the classification that describes the particular work involved.

(b) Example of how to classify the work performed by an insured subcontractor: The insured subcontractor who performs only excavation work in connection with the construction of a sewer is classified under code 6217 (excavation) rather than under code 6306 (sewer construction).

(c) Exception: all operations in conjunction with concrete construction including making and erecting forms, placing reinforcing steel and stripping forms, when done by subcontractors, must be assigned to the appropriate concrete construction classification.

(v) Uninsured subcontractors.

(a) Uninsured subcontractors covered under the principal or general contractor's policy are classified on the basis of the classification that would apply if the work were performed by the principal's own employees.

(b) Example of how to classify the work performed by an uninsured subcontractor: The uninsured subcontractor who performs only excavation work but is covered under the policy of the principal contractor who is constructing a sewer, is classified under code 6306 (sewer construction).

(vi) Construction job site salespersons and estimators.

(a) Construction job site salespersons and estimators are separately rated to code 8720, a non-construction code. A division of payroll is not permitted between code 8720 and a construction classification at any single job site. If the construction job site salesperson or estimator also performs construction duties or supervises construction workers at the same job site, the employee's payroll at that job site must be assigned to the appropriate construction classification.

(b) Example of how to classify the work performed by a construction job site salesperson or estimator. A construction job site salesperson who works for a contractor provides sales estimates but does not conduct the actual construction. The construction job site salesperson is assigned to code 8720, (construction-job site salespersons and estimators). The employee may perform measurements or inspections from ground level, in crawl spaces, on ladders, or on roofs. However, the employee's entire payroll at that job site must be assigned to the appropriate construction classification when the employee also performs construction duties or supervises construction workers.

(e) Farm operations.

(i) A farm is defined as any parcel(s) of land used for the purpose of agriculture, horticulture, viticulture, dairying, or stock or poultry raising as a business or commercial venture.

(ii) If separate payroll records are maintained, a division of payroll is allowed for each separate and distinct type of commercial farm operation.

(iii) If payroll records of the farm classification are not clear, and separate payroll records are not maintained, the entire payroll of the farm must be allocated on the basis of proportionate acreages.

(iv) Each farm classification includes:

(a) All employees;

(b) Drivers;

(d) Operations usual and incidental to a farm.

(v) Examples of operations usual and incidental to a farm include:

(a) Maintenance of cows, hogs, or chickens for family use;

(b) A family orchard or truck garden;

(d) Outside domestic workers at the farm location.

(vi) Each farm classification excludes inside domestic workers at the farm location.

(f) Employee leasing firms, labor contractors, professional employer organizations, and temporary labor services.

(i) Workers assigned to clients must be classified the same as direct employees of the client performing the same or similar duties.

(ii) If the client has no direct employees performing the same or similar duties, leased employees are classified as if they were direct employees of the client entity.

(iii) Example of how to classify workers assigned to clients of employee leasing companies, labor contractors, and temporary labor services. The client is a retail store classified to code 8017:

(a) Code 8017 (store-retail) is applicable to the worker assigned as a cashier, just as it is applicable to the client's employee who works as a cashier.

(b) Code 7380 (drivers, chauffeurs, messengers and their helpers-commercial NOC) is applicable to the worker assigned as a delivery truck driver, just as it is applicable to the client's employee who drives a delivery truck.

(g) Mercantile businesses.

(i) A mercantile business is any store or dealer engaged in the sale of goods or merchandise, or in the sale of services.

(ii) For mercantile businesses, the classification is assigned separately for each location.

(iii) Store operations are classified based on the principal type of merchandise sold and whether the operations are wholesale or retail. For purposes of the rule, principal means more than fifty per cent of gross receipts, excluding receipts derived from the sale of lottery tickets.

(iv) The following definitions and instructions must be used to determine the appropriate store classification.

(a) Type of merchandise sold. If a store sells a variety of goods, each of which may be subject to a different classification, the store must be assigned to the classification that best describes the merchandise that generates more than fifty per cent of the gross receipts.

(b) Wholesale versus retail.

(i) Retail applies to the sale of merchandise to the general public for personal or household consumption or use and not for resale.

(ii) Wholesale applies to the sale of merchandise for resale to others; or sale to manufacturers, builders, contractors, or others for use in their business or as raw materials.

(iii) Exception: if a store's sales are clearly retail in nature, the appropriate retail store classification may be assigned regardless of the definition of retail.

(iv) Examples of store sales that are clearly retail in nature:

(A) A store selling artwork in a shopping mall whose majority of sales are for artwork purchased by businesses; and

(B) A store selling art supplies in a shopping mall whose majority of sales are to artists who use the materials in their business.

(c) Combination of retail and wholesale. A store that sells merchandise on a combined wholesale and retail basis must be assigned to the appropriate store classification depending on whether the majority of gross receipts come from wholesale or retail sales.

(4) Standard exceptions.

(a) Standard exception classifications describe occupations that are common to many businesses and are not included in a basic classification unless specified in the classification phraseology. Standard exceptions must be separately classified unless specifically included in a classification assigned to the business. Classifications for standard exceptions apply even if the basic classification includes phrases such as "all employees" or "all operations."

(b) Examples of classifications that do not specifically refer to any standard exception employees.

(i) Code 3383 (jewelry manufacturing): This classification does not specifically include any standard exception employees. Those employees are separately classified to codes 8810, 8871, 8742, and 7380.

(ii) Code 9082 (restaurant NOC): This classification does not specifically include any standard exception employees. Those employees are separately classified to codes 8810, 8871, 8742, and 7380.

Code 5183 (plumbing NOC & drivers): This classification specifically includes drivers. For this type of business, those employees are not separately classified to code 7380.

(d) Examples of classifications that include "all employees" or "all operations" but do not specifically refer to any standard exception employees.

(i) Code 6251 (tunneling - all operations): This classification includes "all operations" but does not specifically include any standard exception employees. Those employees are separately classified to codes 8810, 8871, 8742, and 7380.

(ii) Code 8835 (home, public, and traveling healthcare, all employees): this classification includes "all employees" but does not specifically include any standard exception employees. Those employees are separately classified to codes 8810, 8871, 8742, and 7380.

(e) Examples of classifications inclusive of "all employees" or "all operations" that include standard exception employees.

(i) Code 4361 (photographer - all employees and clerical, salespersons, drivers): This classification includes "all employees" and specifically includes clerical employees, salespersons, and drivers. For this type of business, those employees are not separately classified to code 8810, code 8871, code 8742, and code 7380.

(ii) Code 4828 (chemical blending or mixing NOC - all operations and drivers): This classification includes "all operations" and specifically includes drivers. For this type of business, employees who are drivers are not separately classified to code 7380.

(5) Businesses described by a standard exception classification.

(a) If the principal business is described by a standard exception classification, the operations of all employees not included in the definition of standard exception classification must be assigned to the separate basic classification that most closely describes their operation. This paragraph applies to both an employer's business within a state and to individual jobs or locations where the governing classification is described by a standard exception classification.

(b) Example. The principal business of the employer is a computer system design and programming firm that conducts its business exclusively in an office. The employer owns the office and does not lease space to others. The building maintenance operations are not included in the definition of the standard exception classification. The building maintenance operations must be assigned to the separate basic classification that most closely describes their operations. The business would be classified as follows:

(i) Computer system designers and programmers are assigned to code 8810; and

(ii) Building maintenance operations are assigned to code 9015.

(6) Classifications limited to separate businesses.

(a) The assignment of certain classifications is limited by their classification notes to separate and distinct businesses because the classification notes may describe an operation that frequently is an integral part of a business described by another classification.

(b) Examples of classification notes describing when the classifications are not appropriate for assignment.

(i) Code 8820 (attorney - all employees and clerical, messengers, drivers): Code 8820 must not be assigned to employers that perform operations described by another classification unless the operations subject to code 8820 are conducted as a separate and distinct business.

(ii) Code 8601 (architectural or engineering firm - including salespersons and drivers): Code 8601 applies to employers in the architectural or engineering profession that operate as a separate and distinct business and not in support of an entity's principal business.

(iii) Code 8833 (hospital - professional employees): assign independent medical testing labs that analyze medical specimens to code 4511. Testing labs that are not independent, but part of a hospital, must be classified to code 8833.

(7) Repair operations.

(a) Employers with shop operations that involve the repair of a product for which there is no repair classification are assigned to the classification that applies to the manufacture of the product, unless this repair work is specifically referred to by another classification, footnote, or definition in the manual.

(b) Examples of repair operations that are classified to the manufacturing code.

(i) A pump repair business is assigned to code 3612 (pump mfg.). There is no separate code for pump repair.

(ii) A motor repair business is assigned to code 3643 (electric power or transmission equipment mfg.). There is no separate code for motor repair.

(8) Recycling operations.

(a) The collection, sorting, and handling of recyclable materials for resale to others must be assigned to the appropriate store or dealer classification, or to the classification that most closely describes the business.

(b) Risks with operations that involve the reuse of materials for the production of a new product must be assigned to the classification that applies to the manufacture of the product unless such work is specifically referred to another classification, footnote, or definition.

(F) Miscellaneous employees.

(1) Miscellaneous employees who perform duties that are commonly conducted for separate operations that are subject to more than one basic classification must be assigned to the governing classification.

(2) Examples of miscellaneous employees:

(a) General superintendents, other than construction executives that meet the requirements of code 5606 (contactor - project manager, construction executive, construction manager or construction superintendent);

(b) Maintenance or power plant employees;

(c) Shipping or receiving clerks, and yard workers, other than construction yard employees properly assigned to code 8227 (construction or erection of permanent yard).

(3) Refer to paragraph (E)(5) of this rule if the governing classification is a standard exception.

(4) Examples of classification for miscellaneous employees.

(a) The employer has two separate operations, a machine shop assigned to code 3632 on one floor of the building and a plastics manufacturing business assigned to code 4452 on another floor. If it is determined that code 3632 is the governing classification, all maintenance employees, superintendents, and shipping clerks serving both operations are assigned to code 3632.

(b) The employer is a hair styling salon assigned to code 9586 (hair styling salon, beauty parlor, or barber shop). There is an employee who stands behind a counter and schedules appointments, greets customers, and operates the cash register. This employee is considered a miscellaneous employee and is assigned to the governing classification, code 9586.

(G) Interchange of labor.

Some employees may perform duties directly related to more than one properly assigned classification according to paragraph (E)(3) of this rule. Their payroll may be divided among the properly assigned classifications provided the conditions of paragraphs (G)(1) to (G)(4) of this rule are met.

(1) The classifications can be properly assigned to the employer according to the rules of the classification system.

(2) The employer maintains proper payroll records, which show the actual payroll by classification for that individual employee.

(a) Records must reflect actual time spent working within each job classification and an average hourly wage comparable to the wage rates for such employees within the employer's industry.

(b) Estimated or percentage allocation of payroll is not permitted. If payroll records do not show the actual payroll applicable to each classification, the entire payroll of the individual employee must be assigned to the highest rated classification that represents any part of his or her work.

(3) Some employees qualify for division of payroll between two or more basic classification codes and also engage in operations that are classified by code 8810, 8742, 8748 or 8871. The payroll for these standard exception operations must be allocated to the basic classification code with the largest amount of payroll applicable to that employee.

(4) Instructions when an executive order from the governor requires a business to change its standard means of operations.

(a) For the duration of the executive order, if an employer has employees work from home, the appropriate classification for the operations performed will be assigned to the employer, and a division of payroll will be allowed between two or more classifications including standard exception classifications.

(b) Division of payroll allowed under an executive order.

(i) Any operational employee sent home to telework and performs clerical duties or assigned no duties, all payroll is reported to code 8871.

(ii) When operational employees are sent home and continue to perform the same task or job duty as they performed at their employer's location the classification assigned to those operations does not change and reporting to class code 8871 is prohibited. For example, the employer manufactures surgical masks. The employees are sent home and continue to sew masks to meet customers' needs. The operational classification of code 2501 (cloth, canvas, and related product manufacturing NOC) still applies to these operations. The exposures for the employees do not change.

Code 8810 (clerical office employees), code 8871 (clerical telecommuter employees), code 8742 (salespersons or collectors-outside), and code 8748 (automobile salespersons) are not available for division of payroll under this rule. However, when an interchange of labor exists between code 8810 and code 8871:

(i) Code 8871 will be assigned when the employee spends more than fifty per cent of the time worked telecommuting as described by paragraph (C)(2)(a)(iii)(c) of this rule.

(ii) Code 8810 will be assigned when the employee spends fifty per cent or less of the time worked telecommuting as described by paragraph (C)(2)(a)(iii)(c) of this rule.

(d) The distribution of payroll for the employee may result in no single basic classification code that represents the largest amount of that employee's payroll. In such cases, the payroll included in the standard exception codes, i.e., codes 8810, 8742, 8748, and 8871, will be assigned to the highest rated classification code that represents any part of the employee's work.

(5) This rule does not apply to miscellaneous employees. Refer to paragraph (F) of this rule for these employees.

(6) Examples of instances of interchange of labor where an employee's payroll may be divided between two or more classifications:

(a) In a business that manufactures clocks, all employees must be assigned to either code 3385 (clock mfg.), code 8810 (clerical), code 8742 (salespersons-outside), or code 7380 (drivers). In this example, division of payroll is only allowed for employees whose work is divided between activities described by codes 3385 and 7380. Codes 8810 and 8742 are not eligible for division of payroll.

(b) ) In a business that sells furniture, all employees must be assigned to either code 8044 (store: furniture & drivers), code 8810 (clerical), or code 8742 (salespersons-outside). No division of payroll is allowed in this example, since drivers are already included in the basic classifications. Codes 8810 and 8742 are not eligible for division of payroll.

(c) In a business that manufactures paper and processes this paper into wallpaper, all employees must be assigned to either code 4239 (paper mfg.), code 4279 (wallpaper mfg.), code 8810 (clerical), code 8742 (salespersons-outside), or code 7380 (drivers). A division of payroll is allowed for employees whose work is divided among activities described by codes 4239, 4279, and 7380. Codes 8810 and 8742 are not eligible for division of payroll.

Last updated July 1, 2026 at 7:47 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-09 Clerical office payroll.

Clerical office payroll shall include only the payroll of those employees whose duties are confined to keeping the books and records of the employer, and conducting correspondence, and drafting, or who are engaged wholly in office work where such books and records are kept, having no other duties of any nature in or about the employer's premises.

Last updated July 2, 2024 at 11:25 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-10 Excess premiums.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to approve contributions made to the state insurance fund by employers pursuant to sections 4121.121, 4123.29, 4123.32, and 4123.34 of the Revised Code. Pursuant to sections 4123.29 and 4123.34 of the Revised Code, the administrator is to keep premiums at the lowest level consistent with the maintenance of a solvent state insurance fund and of a reasonable surplus. Pursuant to section 4123.321 of the Revised Code, in the event there is developed as of any given premium rate revision date a surplus of earned premium over all losses which, in the judgment of the bureau's board of directors, is larger than is necessary adequately to safeguard the solvency of the fund, the bureau's board of directors may return such excess surplus to the subscriber to the fund in either the form of cash refunds or a reduction of premiums, regardless of when the premium obligation has accrued. The bureau's board of directors has full discretion and authority to determine whether there is an excess surplus of premium; whether to return the excess surplus to employers; the nature of the cash refunds or reduction of premiums; the employers who are subscribers to the state insurance fund who are eligible for the cash refunds or reduction of premiums; the payroll period or periods for which a reduction of premium has accrued and the premium payment for which the reduction of premium applies; the applicable date of the cash refunds or reduction of premiums; and any other issues involving cash refunds or reduction of premiums due to an excess surplus of earned premium.

Last updated July 27, 2023 at 9:08 AM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-11 Rule of merit rating controlling the employee having but one eye, one hand, etc.

Should any employee having but one hand, arm, eye, foot or leg thereafter lose any one of the foregoing members in an industrial accident or as the result of an occupational disease the same shall be merit-rated, not as a permanent total disability, but as a permanent partial disability, based upon the loss of the last member only. The remaining cost shall not be charged against the accident experience of the employer.

History

Effective: July 1, 1993
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-12 Catastrophe claims.

(A) A "catastrophe" is defined as an occurrence in which two or more employees of one employer are killed or receive injuries resulting in permanent and total disability.

(B) "Catastrophe cost" is defined as the costs enumerated in section 4123.30 of the Revised Code, including reserves for these costs, as a direct result of a catastrophe.

(C) Catastrophe cost in excess of two hundred fifty thousand dollars shall not be included in the experience of a classification code or of an employer.

(D) Catastrophe cost in excess of two hundred fifty thousand dollars for a retrospective policy year as defined in rule 4123-17-41 of the Administrative Code, shall not be included in the annual evaluation or final settlement of that retrospective policy year.

(E) Notwithstanding the provisions of this rule, the administrator of workers' compensation may consider any special circumstances which may affect the determination of a catastrophe.

Last updated July 2, 2024 at 11:26 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-13 Employer application for workers' compensation coverage.

(A) An employer may institute workers' compensation coverage under this rule by submitting an application for coverage that completely provides all the information necessary for the bureau of workers' compensation to establish coverage for the employer.

(1) The application for coverage shall be submitted on a form designated by the bureau that includes, at a minimum, the following information:

(a) The legal name and business entity type, for example corporation, limited liability company, sole proprietorship, or partnership;

(b) Address of the employer;

(d) Information related to the description of the employer's operations, including:

(i) A description of the work done or industry conducted by the employer,

(ii) The estimated average number of employees in each kind of work, and

(iii) The estimated wages of employees in each kind of work over the next twelve months.

(e) Information related to whether the applicant for coverage has purchased an existing business or has another associated policy;

(f) Name of the owners or corporate officers, and, where applicable for elective coverage, the name and necessary identifying information of the sole proprietor, partners, ministers, or officers of the family farm corporation;

(g) Signature of the person completing the application for coverage; and

(h) A non-refundable application fee equal to the minimum administrative annual charge set forth in rule 4123-17-26 of the Administrative Code.

(2) If the bureau receives an application for coverage that does not contain all of the information specified by paragraph (A)(1) of this rule, the bureau will attempt to contact the employer to obtain the necessary information. If the applicant does not provide the necessary information, the bureau will deny the employer's application for coverage based upon the employer's failure to provide all the information specified by paragraph (A)(1) of this rule.

(3) When an applicant fails to provide the information specified by paragraph (A)(1) of this rule and has employed one or more persons, the employer may be considered a non-complying employer under rule 4123-14-01 of the Administrative Code, and the bureau may recover premium and penalties from the employer under rule 4123-14-02 of the Administrative Code.

(B) Upon receipt of the application, the bureau will assign payroll to the classification codes applicable to the duties performed. The bureau will provide the employer notice of its determination regarding the employer's classification codes and division of the employer's payroll within those classification codes, the rates for those classification codes, and estimated premium due for the remainder of the policy year in which the employer applies for initial coverage.

(C) If the bureau determines, after reviewing the information submitted with the application provided for in paragraph (A) of this rule, that the employer was subject to division (B)(2) of section 4123.01 of the Revised Code but failed to comply with the law in matters of workers' compensation coverage, the bureau will notify the employer in writing of such a finding and request any additional information necessary to make a determination of the period for which the employer was not in compliance with the law. Upon such determination, the bureau will notify the employer of the premium and assessments due for the period of noncompliance.

(D) If the bureau determines, after reviewing the information submitted with the application provided for in paragraph (A) of this rule, that the employer is essentially the same employer, regardless of entity type for which workers' compensation coverage previously had been provided, the bureau may do either of the following:

(1) Transfer the prior policy to the employer, and if necessary reactivate a previously cancelled policy in order to complete the transfer, pursuant to rule 4123-17-02 of the Administrative Code, and the employer will assume any outstanding obligations under the prior policy; or

(2) Deny or rescind the application, and the employer will maintain the prior or existing policy.

(E) Upon receipt of the application fee, the bureau will issue a notice of workers' compensation coverage pursuant to section 4123.83 of the Revised Code. The notice will indicate that coverage is contingent on payment of estimated premium and assessments due.

(F) Upon receipt of the application fee,, the employer's coverage begins.

(1) Unless the provisions of paragraph (D) of this rule apply, such coverage is effective from the date of receipt of the application for coverage pursuant to paragraph (A) of this rule.

(2) A credit in an amount equal to the application fee will be applied to the employer's account upon receipt of the first estimated premium payment.

(3) If the first estimated premium payment is not made, the employer's coverage will lapse back to the effective date of the policy.

Last updated July 27, 2023 at 9:08 AM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-14 Reporting of payroll and reconciliation of premium due.

(A) Definitions.

(1) As used in this chapter of the Administrative Code:

(a) "Applied EM" means the experience modification, or "EM," as set forth in rule 4123-17-03 of the Administrative Code, except where such EM is modified by participation in the group experience rating program set forth in rules 4123-17-61 to 4123-17-66 of the Administrative Code, the claim impact reduction program set forth in rule 4123-17-71 of the Administrative Code, or the EM cap program set forth in rule 4123-17-03.2 of the Administrative Code. In such cases, "applied EM" means the experience modifier resulting from participation in those programs.

(b) "Current" with respect to payments due the bureau of workers' compensation means not more than forty-five days past due.

(c) "Payments due the bureau" means any premiums, administrative costs, assessments, fines or monies otherwise due to any fund administered by the bureau for which the employer has not submitted a dispute of the obligation to the bureau's adjudicating committee as set forth in rule 4123-14-06 of the Administrative Code.

(d) "Payroll" or "wages" means the entire remuneration allowed by an employer to employees in the employer's service for the applicable period.

(e) "Public employer taxing district" means an employer that is not the state itself and subject to the provisions of sections 4123.38 and 4123.39 of the Revised Code.

(f) "Remuneration" has the same meaning as defined in division (H) of section 4141.01 of the Revised Code.

(i) The definition of remuneration applies to all persons of such employers considered to be employees under the statutes or rules of the bureau, regardless of whether the employer is required to report payroll or remuneration to the Ohio department of job and family services under Chapter 4141. of the Revised Code or whether the employer reports payroll or remuneration to the Ohio department of job and family services for such persons considered to be employees by the bureau.

(ii) For employees who customarily receive tips or gratuities, remuneration includes all actual wages paid and all tips and gratuities.

(2) All other terms have the same meaning as prescribed in section 4123.01 of the Revised Code.

(B) Private employers: notice of estimated premium.

(1) Except as otherwise provided in paragraph (E) of this rule, the bureau will notify private employers of the development of estimated premium no later than the first day of May preceding the policy year for which such premium is due.

(2) The bureau will provide all of the following:

(a) The estimated payroll used by the bureau to calculate the employer's estimated premium due;

(b) The classification codes in which the employer's payroll is allocated and the base rates for each of the classification codes identified;

(d) The employer's estimated premium due for the applicable policy year.

(3) An employer may revise the estimated payroll amount used to calculate estimated premium due for the policy year for good cause shown, as determined by bureau policy.

(a) The estimated premium will be revised for the policy year and the balance of installments for the remainder of the policy year will be adjusted to reflect the new estimated premium amount.

(b) Requests will not be accepted to revise payroll for a policy year after the last business day of March in that policy year; the adjustment to premium due will be upon the employer's report of actual payroll pursuant to paragraph (D) of this rule.

(1) Except as otherwise provided in paragraph (E) of this rule, the bureau will provide private employers with an invoice for estimated premium no later than the first day of June immediately preceding the policy year for which the estimated premium is charged. The bureau will provide subsequent invoices according to a schedule made available with the notice of estimated premium.

(2) Payment of invoices will be due no later than the date indicated on each invoice.

(3) The administrator of workers' compensation may assess penalties and late fees on payments received after the deadlines set forth in paragraph (C)(2) of this rule, pursuant to rule 4123-17-16 of the Administrative Code.

(D) Private employers: payroll report and reconciliation of premium due.

(1) Except as otherwise provided in paragraphs (D)(5) and (E) of this rule, after the conclusion of each policy year, every private employer shall submit a payroll report to the bureau containing the number of employees employed within each of the employer's assigned classification codes and the aggregate amount of wages paid to such employees over the relevant time period.

(2) The bureau will establish an electronic payroll reconciliation process to address the difference between estimated gross payroll and actual gross payroll immediately upon the filing of the payroll report.

(3) The payroll report shall report data for the full policy year. The report must be filed by, and any payment due the bureau paid by the fifteenth day of August, and effective the policy year beginning July 1, 2024, by the thirty-first day of August, immediately following the conclusion of the policy year. Any balance due the employer will be credited to the employer's account.

(4) An employer may elect to provide payment other than through the electronic reconciliation process, provided payment is received by the fifteenth day of August, and effective the policy year beginning July 1, 2024, by the thirty-first day of August, immediately following the conclusion of the policy year.

(5) The administrator may waive the provisions of paragraph (D)(1) of this rule for private employers who:

(a) Are not an alternate employer organization ("AEO") as defined in section 4133.01 of the Revised Code or a professional employer organization ("PEO") as defined in section 4125.01 of the Revised Code;

(b) Do not have any employees in the policy year, including no employees subject to rule 4123-17-07 of the Administrative Code; and

(E) Alternate employer organizations and professional employer organizations.

(1) Each employer that is recognized by the administrator as an AEO or as a PEO shall submit a monthly payroll report.

(2) The AEO or the PEO shall electronically report data for each month no later than the fifteenth day after the last day of the month for which payroll is being reported and pay all monthly premium and assessments concurrently with the filing of the monthly payroll report.

(3) If an AEO or a PEO fails to make timely payment of premiums and assessments pursuant to this rule, coverage will lapse, and the administrator will proceed to revoke the registration of the AEO or the PEO pursuant to rule 4123-17-15.7 of the Administrative Code.

(4) The administrator may waive the provisions of paragraph (D)(1) of this rule for a client employer of an AEO or a PEO if the client employer:

(a) meets all of the criteria of paragraphs (D)(5)(a) and (D)(5)(b) of this rule;

(b) has been in an AEO agreement or a PEO agreement for the entire policy period; and

(F) Public employer taxing districts: notice of estimated premium.

(1) The bureau will notify public employer taxing districts of the development of estimated premium due no later than the last day of October preceding the start of the policy year.

(2) The bureau will provide all of the following:

(a) The estimated payroll used by the bureau to calculate the employer's estimated premium due;

(b) The classification codes in which the employer's payroll is allocated and the base rates for each of the classification codes identified;

(d) The employer's estimated premium due for the applicable policy year.

(3) An employer may revise the estimated payroll amount used to calculate estimated premium due for the policy year for good cause shown, as determined by bureau policy.

(a) The estimated premium will be revised for the policy year and the balance of installments for the rest of the year will be adjusted to reflect the new estimated premium amount.

(b) Requests will not be accepted to revise payroll for a policy year after the last business day of September in that policy year; the adjustment to premium due will be upon the employer's report of actual payroll pursuant to paragraph (H) of this rule.

(G) Public employer taxing districts: invoice and estimated premium payments.

(1) The bureau will provide public employer taxing districts with an invoice for estimated premium no later than the first day of December immediately preceding the policy year for which the estimated premium is charged. The bureau will provide subsequent invoices according to a schedule made available with the notice of estimated premium.

(2) Payment of invoices will be due no later than the date indicated on each invoice.

(3) The administrator may assess penalties and late fees on payments received after the deadlines set forth in paragraph (G)(2) of this rule pursuant to rule 4123-17-16 of the Administrative Code.

(H) Public employer taxing districts: payroll report and reconciliation of premium due.

(1) After the conclusion of each policy year, every public employer taxing district shall submit a payroll report to the bureau containing the number of employees employed within each of the employer's assigned classification codes and the aggregate amount of wages paid to such employees over the policy year.

(2) The employer shall submit its payroll report electronically and remit any payments due the bureau no later than the fifteenth day of February, and effective the policy year beginning January 1, 2025, no later than the last day of February, immediately following the conclusion of the policy year. Immediately upon receipt of the payroll report, the bureau will adjust the premium and assessments charged to each employer for the difference between estimated gross payrolls and actual gross payrolls. At the conclusion of the payroll and premium reconciliation, each employer shall remit any payments due the bureau. If the reconciled premium results in a credit, the bureau will post such credit to the employer's account.

(I) Allocation of payroll.

(1) If an employer elects under section 4123.292 of the Revised Code to obtain other-states' coverage directly from an other-states' insurer for employment relationships localized in Ohio, the employer shall notify the bureau of the election on a form prescribed by the bureau and provide the bureau with a copy of the other-states' coverage policy.

(2) An employer that elects to obtain other-states' coverage directly from an other-states' insurer under section 4123.292 of the Revised Code shall include on the payroll report required by this rule only the remuneration for work the employees performed in Ohio and other work not covered by the other-states' policy. The employer will maintain documentation of the amount of remuneration paid to its employees for work performed outside of Ohio and covered by the other-states' policy and provide it to the bureau upon request.

(3) If an employer employs an employee covered under a federal Longshore and Harbor Workers' Compensation Act policy, the employer shall include on the payroll report the remuneration for work the employees performed in Ohio for which the employees are eligible to receive compensation and benefits under Chapters 4121. and 4123. of the Revised Code. The employer will maintain documentation of the amount of remuneration for work covered by an insurer under the federal Longshore and Harbor Workers' Compensation Act and provide it to the bureau upon request.

Last updated July 2, 2024 at 11:30 AM

History

Effective: July 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-14.1 Misrepresentation of payroll.

(A) No employer shall knowingly misrepresent to the bureau of workers' compensation the amount or classification of payroll upon which the premium under this chapter is based. No self-insuring employer shall knowingly misrepresent to the bureau the amount of paid compensation paid by such employer.

(B) As used in the rule, "knowingly" means that the employer had actual knowledge of the misrepresentation and was aware that the misrepresentation would cause a certain result. An employer will not be deemed to have knowingly misrepresented its payroll, its classification of payroll, or its paid compensation where the employer's determination of how to report was based on:

(1) The employer's reasonable interpretation of a law, rule, or classification code; or

(2) Prior reporting instructions or written advice received from the bureau.

(C) Whenever the bureau finds that an employer violated division (A) of section 4123.25 of the Revised Code by knowingly misrepresenting its payroll or classification of payroll to the bureau, the administrator of workers' compensation or the administrator's designee may impose a penalty that the administrator or the administrator's designee deems appropriate upon the employer based on the following criteria:

(1) Amount of difference between the premium the employer paid and the amount the employer should have paid;

(2) The frequency with which the employer has misrepresented its payroll or classification of payroll to the bureau;

(3) The number of misrepresentations or misclassifications the employer has made to the bureau;

(4) The duration for which the employer made such misrepresentations or misclassifications;

(5) Whether the bureau has found misclassified or underreported payroll in a premium audit on prior occasion; and

(6) Any additional circumstances that warrant consideration in determining the penalty amount.

(D) The penalty imposed under paragraph (C) of this rule will not exceed ten times the amount of the difference between the premium the employer paid and the amount the employer should have paid.

(E) Whenever the self-insuring employers evaluation board finds that a self-insuring employer violated division (B) of section 4123.25 of the Revised Code by knowingly misrepresenting its paid compensation to the bureau, the self-insuring employers evaluation board may impose a penalty upon the employer as provided under section 4123.25 of the Revised Code.

(F) Except for a self-insuring employer, an employer may appeal a penalty imposed under this rule to the adjudicating committee under section 4123.291 of the Revised Code.

Last updated June 30, 2026 at 1:05 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-14.2 Installment payments.

(A) An employer may elect to pay its estimated premium due in equal installments of two, four, six, or twelve in number.

(1) Employers paying in advance of the installment schedule will not incur a penalty for early payment.

(2) Employers paying the minimum administrative charge shall not be eligible for an installment plan.

(B) Initial installment plans.

(1) All eligible private employers will be invoiced on the six-payment installment plan.

(2) All eligible public employer taxing districts will be invoiced on the twelve-payment installment plan.

(1) A private employer must request a change in installment plan no later than the fiftheent day of May preceding the start of the policy year.

(2) A public employer taxing district must request a change in installment plan no later than the fifteenth day of November preceding the start of the policy year.

(D) Each installment shall be due by the date indicated on the invoice.

(E) In making payment arrangements with an employer, the bureau may alter an installment plan if it determines such change is appropriate.

(F) Election of installment payments under this rule shall not disqualify an employer from participation in the rating plans and discount programs established in this chapter, but any lapse periods imposed on an employer for failure to timely pay installments shall be counted toward the maximum number of days during which an employer is permitted to be lapsed in the eligibility criteria for such rating plans and discount programs.

(G) A public employer taxing district may elect to defer payment of installments due prior to April thirtieth in that policy year until April thirtieth. Such election must occur on or before November fifteen of the previous policy year. If an employer makes such election, the bureau will apply a deferment fee of 0.94 per cent to the total amount of the installments that are deferred.

(H) The bureau will grant an early payment discount to an employer that pays the full twelve month estimated annual premium by the due date for the first installment for each policy year. The employer must be in an active policy status as of the due date for the first installment to be eligible for this discount. For purposes of this rule, "active policy status" does not include a policy that is a no coverage policy or a policy that is lapsed. If an employer elects to pay all installments in a single payment, the bureau will grant a discount to the eligible employer for that policy period as set forth in this rule. The discount cannot reduce the total amount due below the minimum required premium as provided in rule 4123-17-26 of the Administrative Code.

(1) A discount of two per cent will be available to private employers for the policy years commencing on July 1, 2017.

(2) A discount of two per cent will be available to public employer taxing districts for the policy years commencing on January 1, 2017.

Last updated June 30, 2026 at 1:05 PM

History

Effective: March 26, 2018
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-15 Alternate employer organizations and professional employer organizations.

(A) Definitions.

As used in rules 4123-17-15 to 4123-17-15.7 of the Administrative Code:

(1) "Alternate employer organization" or "AEO" has the same meaning as defined in section 4133.01 of the Revised Code. "Alternate employer organization" or "AEO" does not include a service agency that is in the business of employing individuals for the purpose of utilizing the services of the individuals for a temporary period of time.

(2) "Professional employer organization" or "PEO" has the same meaning as defined in section 4125.01 of the Revised Code. PEOs that coemploy a part of a client employer's workforce are to comply with the provisions set forth in paragraph (C) of this rule. "Professional employer organization" or "PEO" does not include a service agency that is in the business of employing individuals for the purpose of utilizing the services of the individuals for a temporary period of time.

(3) "Client employer" has the same meaning as defined in section 4125.01 of the Revised Code for client employers of a PEO and section 4133.01 of the Revised Code for client employers of an AEO. "Client employer" does not mean an employer who is a noncomplying employer as defined in rule 4123-14-01 of the Administrative Code.

(4) "AEO agreement" means an alternate employer organization agreement as defined in section 4133.01 of the Revised Code. On entering into an AEO agreement all worksite employees of a client employer are covered under the workers' compensation policy of the AEO.

(5) "PEO agreement" means a professional employer organization agreement as defined in section 4125.01 of the Revised Code.

(6) "PEO reporting entity" means a professional employer organization reporting entity as defined in section 4125.01 of the Revised Code.

(7) "Assurance organization," "coemploy," and "shared employee" have the same meaning as defined in section 4125.01 of the Revised Code.

(8) "Trade secret" has the same meaning as defined in section 1333.61 of the Revised Code.

(9) "Working capital" means the excess of current assets over current liabilities as determined by generally accepted accounting principles.

(10) "Worksite employee" has the same meaning as defined in section 4133.01 of the Revised Code.

(11) "Policy number," is a term synonymous with "risk number," meaning the identification number that the bureau of workers' compensation assigns to an employer.

(B) Where an AEO or a PEO is required to give notice, register, or make a report to the bureau under rules 4123-17-15 to 4123-17-15.7 of the Administrative Code, the AEO or the PEO shall do so on forms prescribed by the bureau. Forms are to be completed in full, as determined by the bureau, for such notice, registration, or report to be effective.

(1) A PEO may enter into a PEO agreement to coemploy part of a client employer's workforce, provided the client employer is not a temporary agency, for workers' compensation purposes only to the extent wages are paid by and reported under the tax identification number of the PEO for federal tax purposes.

(2) Under such partial lease agreement, the PEO shall report under its workers' compensation policy number the payroll associated with the wages paid by and reported by the PEO for federal tax purposes under the PEO's tax identification number. The client employer shall report under its workers' compensation policy number all payroll associated with wages not paid by and not reported under the PEO's tax identification number.

(3) All of a client employer's payroll within a classification code is to be reported in its entirety under either the workers' compensation policy number of the PEO or client employer; such payroll cannot be split between the PEO and client employer.

(D) Obligations of an AEO.

An AEO must perform all of the following functions:

(1) Annually provide written notice to each worksite employee an AEO assigns to perform services to a client employer of the relationship between and the responsibilities of the AEO and the client employer;

(2) Process and pay all wages and applicable state and federal payroll taxes associated with the worksite employee under the federal tax identification tax number of the client employer, either directly by the AEO or through a third party vendor contracted by the AEO that is not a client employer, irrespective of payments made by the client employer, pursuant to the terms and conditions of compensation in the AEO agreement between the AEO and the client employer.

(3) Pay all related payroll taxes associated with a worksite employee under the federal tax identification number of the client employer independent of the terms and conditions contained in the AEO agreement between the AEO and the client employer.

(4) Annually certify to the bureau that all client employer federal payroll taxes have been timely and appropriately paid and provide proof of payment to the bureau upon request.

(5) In any AEO agreement between an AEO and a client employer, list the client employer on the W-2 of all worksite employees, but the AEO remains jointly and severally liable for all applicable local, state, and federal withholding and employer-paid taxes with respect to the worksite employees.

(6) File federal payroll taxes entirely under the tax identification number of the client employer but remain jointly and severally liable for all wages and payroll taxes associated with worksite employees.

(7) If any client employer of an AEO fails to transmit payment to the AEO sufficient to cover payment of all wages and employer-paid taxes, keep a record of the nonpayment or underpayment and a record that the AEO nonetheless paid the wages and taxes owed.

(8) Maintain workers' compensation coverage, pay all workers' compensation premiums, and manage all workers' compensation claims, filings, and related procedures associated with the worksite employee in compliance with Chapters 4121. and 4123. of the Revised Code under the AEO's policy number, except that when worksite employees include elective coverage persons as those terms are defined in rule 4123-17-07 of the Administrative Code, payroll reports are to include the entire amount of payroll associated with those persons and are not subject to the weekly minimum and maximum provided in rule 4123-17-30 of the Administrative Code.

(9) Maintain complete records separately listing the classification codes of each client employer and the payroll reported to each classification code for each client employer for each payroll reporting period during the time period covered in the AEO agreement. Payroll is to be kept in a manner that clearly identifies the appropriate classification codes assigned to each client employer, the payroll reported in each classification code, and the amount of premiums paid for each client employer for each payroll period covered in the AEO agreement.

(10) Maintain a complete record of workers' compensation claims for each client employer, with claims separately identified according to the client employer.

(11) Report individual client employer payroll, claims, and classification data under a separate and unique subaccount to the bureau.

(12) Within fourteen days of receiving notice from the bureau that a dividend, refund, or rebate will be applied to workers' compensation premiums, provide a copy of that notice to any client employer to whom that notice is relevant.

(13) Within thirty days after receiving a dividend, refund, or rebate that is applied to workers' compensation premiums, either fully redistribute or fully credit the client employer to whom that dividend, refund, or rebate is relevant.

(14) Not provide partial or split workers' compensation coverage for worksite employees in which the client employer provides that coverage for some, but not all, of the client employer's worksite employees.

(E) Obligations of a PEO.

A PEO must perform all of the following functions:

(1) Provide written notice to each shared employee it assigns to a client employer of the relationship between and the responsibilities of the PEO and the client employer.

(2) Pay wages and payroll taxes associated with shared employees as established within the PEO agreement, either directly by the PEO or through a third party vendor contracted by the PEO that is not a client employer. The responsibility for making payments under this section is not contingent on receipt of payment from the client employer. Shared employee wages are to be paid by and reported under the tax identification number of the PEO for federal tax purposes. A PEO may only enter into agreements in which all employees of the client employer are shared and reported under the PEO's tax identification number for federal tax purposes, but reported under the client employer's policy number for workers' compensation purposes, when:

(a) The client employer's payroll is wholly reported under the PEO employer's tax identification number for federal tax purposes; and

(b) The client employer's payroll is wholly reported under the client employer's policy number for workers' compensation purposes.

(3) Be responsible for maintaining both adequate and required employment-related records for employees, and for reporting such information as may be required by appropriate governmental agencies.

(4) Comply with applicable state laws regarding workers' compensation insurance coverage.

(5) Maintain complete records, separately listing the payroll and claims of its client employers for each payroll reporting period. Payroll is to be kept in a manner that clearly identifies the appropriate classification codes assigned to each client employer, the payroll reported in each classification code, and the amount of premiums paid for each client employer for each payroll period covered in the PEO agreement. Claims are to be separately identified according to the client employer.

(6) Report individual client employer payroll, claims, and classification data under a separate and unique subaccount to the bureau.

(7) Maintain workers' compensation coverage, pay all workers' compensation premiums and manage all workers' compensation claims, filings, and related procedures associated with a shared employee in compliance with Chapters 4121. and 4123. of the Revised Code, except that when shared employees include ministers or elective coverage persons as those terms are defined in rule 4123-17-07 of the Administrative Code, payroll reports are to include the entire amount of payroll associated with those persons and are not subject to the weekly minimum and maximum provided in rule 4123-17-30 of the Administrative Code. The PEO must maintain workers' compensation coverage under its workers' compensation policy number for all payroll reported under its tax identification number for federal tax purposes, except as provided in paragraph (D)(2) of this rule.

(8) Within fourteen days after receiving notice from the bureau that a dividend, refund, or rebate will be applied to workers' compensation premiums, provide a copy of that notice to any client employer to whom that notice is relevant.

(9) Within thirty days after receiving a dividend, refund, or rebate that is applied to workers' compensation premiums, either fully redistribute or fully credit the client employer to whom that dividend, refund, or rebate is relevant.

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-15.1 AEO agreements and PEO agreements.

(A) Where a client employer enters into an AEO or a PEO agreement:

(1) Each client employer must establish and maintain an individual account with the bureau of workers' compensation.

(2) The AEO or the PEO is considered the succeeding employer, solely for purposes of workers' compensation experience, and is subject to rule 4123-17-02 of the Administrative Code.

(3) If the AEO agreement or the PEO agreement between a client employer and the AEO or the PEO is terminated, or if the AEO or the PEO declares bankruptcy or ceases operation in Ohio, the AEO or the PEO must notify the bureau and each client associated with that AEO or that PEO within thirty days from the effective date of termination, and identify on forms prescribed by the bureau the portion of the experience of the AEO or the PEO related to the client employer that will be transferred to the client employer.

(4) An AEO or a PEO shall report any transfer of employees between related AEO entities, PEO entities or PEO reporting entities to the bureau within fourteen calendar days after the date of the transfer. The AEO, the PEO, or the PEO reporting entity shall include in the report all client payroll and claim information regarding the transferred employees and a notice of all workers' compensation claims that have been reported to the AEO, the PEO, or the PEO reporting entity in accordance with the internal reporting policies of the AEO, the PEO or the PEO reporting entity.

(B) An AEO or a PEO shall notify the bureau within thirty days when entering into an AEO agreement or a PEO agreement, or when changing the type of a PEO agreement. The AEO, or the PEO for payroll reported under the PEO's policy, must list payroll within the existing classification codes of the client employer. If the bureau is not notified within thirty days, the bureau will recognize the AEO agreement or the PEO agreement on the date the bureau receives notice and the client employer is responsible for reporting payroll and claims under the client employer's individual policy until the recognized effective date of the agreement.

(C) An AEO or a PEO which enters into an AEO agreement or a PEO agreement with a noncomplying employer or an AEO or a PEO which fails to comply with rules 4123-17-15 to 4123-17-15.7 of the Administrative Code will not be considered the employer for workers' compensation purposes. In these instances, the payroll of the shared employees is to be reported by the client employer under its workers' compensation policy number for workers' compensation premium and claims purposes, unless barred by federal law. Claims that are filed by the client employer's shared employees will be charged to the experience of the client employer.

(D) The bureau will not recognize an AEO agreement or a PEO agreement between an out of state client employer and an AEO or a PEO where the employees of the out of state client employer do not have sufficient contacts with Ohio to meet the jurisdictional conditions for coverage.

(E) An AEO agreement or a PEO agreement, or a change in an AEO agreement or a PEO agreement, filed with the bureau will have the following effective date with the bureau for workers' compensation premium and claims purposes:

(1) For a self-insured AEO or self-insured PEO entering into an AEO agreement or a PEO agreement, the commencement date of the AEO agreement or PEO agreement; or

(2) For a state fund AEO or state fund PEO entering into an AEO agreement or a PEO agreement or changing an AEO agreement or a PEO agreement, and for a self-insured AEO or self-insured PEO changing an existing AEO agreement or PEO agreement:

(a) If the commencement date of the AEO agreement or the PEO agreement, or change in the AEO agreement or the PEO agreement, is January first or July first, the commencement date; or

(b) If the commencement date of the AEO agreement or the PEO agreement, or change in the AEO agreement or the PEO agreement, is not January first or July first, the next January first or July first, whichever is earlier.

(F) An AEO or a PEO cannot enter any AEO agreement or PEO agreement where the client employer is an AEO or a PEO, and the bureau will not recognize any AEO agreement or PEO agreement where the client employer is an AEO or a PEO.

(G) The following acts are not permitted:

(1) A PEO from entering into an AEO agreement with any client employer, and

(2) An AEO from entering into a PEO agreement with any client employer.

(H) For each occurrence of the following, an AEO or a PEO will be assessed fifty dollars as a late processing fee:

(1) The AEO or the PEO fails to notify the bureau within thirty days when entering into, or changing, an AEO agreement or a PEO agreement;

(2) The AEO or the PEO fails to notify the bureau or client employer within thirty days of termination of an AEO agreement or a PEO agreement;

(3) The AEO or the PEO fails to notify the bureau or a client employer within thirty days of declaring bankruptcy; and

(4) The AEO or the PEO fails to notify the bureau or a client employer within thirty days of ceasing operations in Ohio.

(I) An AEO or a PEO may appeal any late processing fees assessed by the bureau under paragraph (H) of this rule pursuant to the administrative hearing procedure set forth in section 4123.291 of the Revised Code.

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-15.2 Registration and reporting requirements.

(A) The AEO or the PEO shall register with the bureau of workers' compensation no later than thirty days after the formation of the AEO or the PEO. An AEO or a PEO operating in this state shall register annually with the administrator of workers' compensation.

(1) The AEO or the PEO will submit an initial registration fee as set forth in the appendix to this rule with its initial application. The AEO or the PEO will submit an annual renewal fee as set forth in the appendix to this rule to the bureau on or prior to December thirty-first of each year.

(2) The AEO or the PEO will submit the following information when registering with the bureau:

(a) A list of each of the client employers of the AEO or the PEO that is current as of the date of registration for purposes of initial registration or current as of the date of annual registration renewal, or within fourteen days of adding or releasing a client, that includes the client employer's name, address, federal tax identification number, and bureau of workers' compensation policy number;

(b) The name or names under which the AEO or the PEO conducts business;

(c) The address of the principal place of business of the AEO or the PEO and the address of each office it maintains in this state;

(d) The taxpayer or employer identification number of the AEO or the PEO;

(e) A list of each state in which the AEO or the PEO has operated in the preceding five years, and the name, corresponding with each state, under which the AEO or the PEO operated in each state, including any alternative names, names of predecessors, and if known, successor business entities, and whether the entity is an AEO or PEO in the other state(s);

(f) A list of all corporate officers of the AEO or the PEO;

(g) A list of all related corporate entities;

(h) An attestation of the accuracy of the data submissions from the chief executive officer, president, or other individual who serves as the controlling person of the AEO or the PEO;

(i) Security pursuant to sections 4125.05 and 4133.07 of the Revised Code; and

(j) The most recent financial statement prepared and audited in accordance with rule 4123-17-15.4 of the Administrative Code, and such financial statement is to be no older than thirteen months at the time it is submitted to the bureau.

(B) On an annual basis, on a date determined by the bureau, the AEO or the PEO shall provide an annual report of its client employers and total workforce to the bureau. The report will list all individual employees, by client employer. For each employee, the AEO or the PEO will provide employee identification information, quarterly payroll, associated classification code, title or position, and department.

(C) A PEO reporting entity that will complete the financial reporting mandates of this chapter for commonly owned or controlled PEOs must register with the bureau and pay an initial registration fee as set forth in the appendix to this rule.

(1) The PEO reporting entity shall submit the following information when registering with the bureau:

(a) A list of each of the PEOs for which the PEO reporting entity will complete financial reporting mandates;

(b) The name or names under which the PEO reporting entity conducts business;

(c) The address of the PEO reporting entity's principal place of business and the address of each office it maintains in this state;

(d) The PEO reporting entity's taxpayer or employer identification number;

(e) A list of all corporate officers of the PEO reporting entity;

(f) The most recent financial statement prepared and audited in accordance with rule 4123-17-15.4 of the Administrative Code, and such financial statement is to be no older than thirteen months at the time it is submitted to the bureau;

(g) Security pursuant to section 4125.05 of the Revised Code; and

(h) An attestation of the accuracy of the data submissions from the chief executive officer, president, or other individual who serves as the controlling person of the PEO reporting entity.

(2) The PEO reporting entity will renew such registration and pay an annual renewal fee as set forth in the appendix to this rule no later than December thirty-first of each year.

(D) The administrator may grant limited registration to an AEO or a PEO for reasons specified by the administrator in the certificate of limited registration if the AEO or the PEO provides all of the following items:

(1) A properly executed request for limited registration on a form prescribed by the bureau;

(2) A limited registration fee as set forth in the appendix to this rule;

(3) All information set forth in paragraphs (A)(2)(a) to (A)(2)(h) of this rule; and

(4) Information and documentation necessary to show that the AEO or the PEO satisfies all of the following criteria:

(a) The AEO or the PEO is domiciled outside of Ohio and does not maintain an office in the state;

(b) The AEO or the PEO is licensed or registered as an AEO or a PEO in another state;

(c) The AEO or the PEO does not participate in direct solicitations for client employers located or domiciled in Ohio; and

(d) The AEO or the PEO has fifty or fewer shared employees employed or domiciled in Ohio on any given day. For purposes of this paragraph, an AEO or a PEO is not domiciled outside of Ohio if a commonly owned or otherwise related corporate entity is domiciled in Ohio or maintains an office in the state.

(5) The administrator may demand security of the limited registration AEO or the limited registration PEO pursuant to sections 4125.05 and 4133.07 of the Revised Code.

(E) The bureau will maintain a list of AEOs, PEOs, and PEO reporting entities registered under this rule that is readily available to the public.

(F) The following acts are not permitted:

(1) Beginning on and after January 1, 2022, an AEO, that is currently registered in Ohio under this rule, owning, co-owning, or commonly controlling an AEO, a PEO, or a PEO reporting entity that is registered in Ohio under this rule, and

(2) Beginning on and after January 1, 2022, a PEO or a PEO reporting entity, that is currently registered in Ohio under this rule, owning, co-owning, or commonly controlling an AEO that is registered in Ohio under this rule.

(G) Except to the extent necessary for the administrator to administer the statutory duties of the administrator and for employees of the state to perform their official duties, all records, reports, client lists, and other information obtained from an AEO, a PEO or a PEO reporting entity under this rule are confidential and are considered trade secrets and will not be published or open to public inspection.

View Appendix

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-15.4 Financial mandates.

(A) An AEO, a PEO, or a PEO reporting entity shall prepare financial statements in accordance with generally accepted accounting principles and submit them electronically for registration and registration renewal pursuant to sections 4125.05 and 4133.08 of the Revised Code.

(1) The financial statements shall be audited by an independent certified public accountant authorized to practice in the jurisdiction in which that accountant is located.

(a) The resulting report of the auditor is not to include either of the following:

(i) A qualification or disclaimer of opinion as to adherence to generally accepted accounting principles; or

(ii) A statement expressing substantial doubt about the ability of the AEO, the PEO, or the PEO reporting entity to continue as a going concern.

(b) If an AEO or a PEO does not have at least twelve months of operating history on which to base financial statements, the financial statements are to be reviewed by a certified public accountant.

(2) A PEO reporting entity may submit a combined or consolidated financial statement for its member PEOs to satisfy this paragraph. If the combined or consolidated financial statement includes entities that are not PEOs or that are not in the PEO reporting entity, the controlling entity of the PEO reporting entity that is submitting the consolidated or combined financial statement shall guarantee that the PEOs of the PEO reporting entity have completely satisfied paragraph (B) of this rule.

(B) An AEO, a PEO, or a PEO reporting entity is obligated to maintain positive working capital at initial or annual registration, as reflected in the financial statements submitted to the bureau of workers' compensation under paragraph (A)(2)(j) of rule 4123-17-15.2 of the Administrative Code. If a deficit in working capital is reflected in the financial statements submitted to the bureau, the AEO, the PEO, or the PEO reporting entity shall:

(1) Submit to the bureau a quarterly financial statement for each calendar quarter during which there is a deficit in working capital, accompanied by an attestation of the chief executive officer, president, or other individual who serves as the controlling person of the AEO, the PEO, or the PEO reporting entity that all wages, taxes, workers' compensation premiums, and employee benefits have been paid by the AEO, the PEO, or members of the PEO reporting entity.

(2) Obtain a bond, irrevocable letter of credit, or securities with a minimum market value in an amount sufficient to cover the deficit in working capital. Such security is to be held by a depository designated by the administrator of workers' compensation to secure payment by the AEO, the PEO, or the PEO reporting entity of all taxes, wages, benefits, or other entitlements due or otherwise pertaining to shared employees, if the AEO, the PEO, or the PEO reporting entity does not make those payments when due.

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-15.5 Self-insured AEOs and PEOs.

(A) An AEO or a PEO registered with the bureau of workers' compensation under rule 4123-17-15.2 of the Administrative Code may apply to pay compensation directly as a self-insuring employer.

(1) The AEO or the PEO must meet all eligibility criteria set forth in section 4123.35 of the Revised Code.

(a) The AEO or the PEO will provide five years of financial records as set forth in division (B)(1)(e) of section 4123.35 of the Revised Code. The administrator of workers' compensation cannot waive this mandate.

(b) Worksite employees of an AEO and shared employees of a PEO will be considered employees of the AEO or the PEO for the purposes of meeting the provisions of division (B)(1)(a) of section 4123.35 of the Revised Code only if the following criteria are met:

(i) An AEO will demonstrate to the bureau that it is in compliance with all of the following:

(a) The duties of organization regarding worksite employees set forth in section 4133.03 of the Revised Code, as amplified in paragraph (D) of rule 4123-17-15 of the Administrative Code;

(b) The provisions of section 4133.07 of the Revised Code; and

(c) The provisions of section 4133.10 of the Revised Code, as amplified by paragraphs (A)(3) and (A)(4) of rule 4123-17-15.1 of the Administrative Code;

(ii) A PEO will demonstrate to the bureau that it is in compliance with all of the following:

(a) The duties of organization regarding shared employees set forth in section 4125.03 of the Revised Code, as amplified by paragraphs (C) and (E) of rule 4123-17-15 of the Administrative Code;

(b) The provisions of section 4125.05 of the Revised Code; and

(c) The provisions of section 4125.07 of the Revised Code, as amplified by paragraphs (A)(3) and (A)(4) of rule 4123-17-15.1 of the Administrative Code.

(iii) Client employer wages.

(a) For an AEO, all of the client employer's wages for worksite employees are paid and reported under the tax identification number of the client employer for federal tax reporting purposes as stated in section 4133.03 of the Revised Code and paragraph (D) of rule 4123-17-15 of the Administrative Code.

(b) For a PEO, all of the client employer's wages are paid and reported under the tax identification number of the PEO for federal tax reporting purposes.

(2) Any AEO or PEO application for self-insured status will be referred to the self-insured review panel pursuant to paragraph (F)(1) of rule 4123-19-14 of the Administrative Code.

(3) Any application to add an AEO or a PEO to an existing self-insured entity will be referred to the self-insured review panel pursuant to paragraph (F)(1) of rule 4123-19-14 of the Administrative Code.

(B) An AEO or PEO granted the privilege of self-insured status must do all of the following:

(1) If determined necessary by the bureau, furnish security, in the amount, and in the form of a letter of credit from a federally insured financial institution or other security approved by the bureau, as provided by paragraphs (F), (G), and (H) of rule 4123-19-03 of the Administrative Code.

(a) The amount of security deemed necessary will be as determined by the bureau.

(b) The AEO or the PEO is not permitted to use an assurance organization to meet its security obligations under this rule.

(c) The bureau may, pursuant to paragraph (N) of rule 4123-19-03 of the Administrative Code, demand the AEO or the PEO to furnish additional security within thirty days of receiving the notice issued pursuant to this rule.

(2) Submit to the bureau every two years, or upon the bureau's request, an actuarial estimate of the unpaid loss and loss adjustment expense liabilities of the AEO or the PEO performed by an independent actuary with a fellow of the society of actuaries or casualty actuary society credential.

(3) Make contribution to the self-insuring employers' guaranty fund as set forth in rule 4123-19-15 of the Administrative Code. For purposes of this rule, the premium as reported on the total of the last two full six-month semi-annual payroll reports will include the premium of the AEO or the PEO and all its client employers.

(4) Pay all assessments levied upon self-insuring employers under rule 4123-17-32 of the Administrative Code.

(5) Reimburse the bureau for disabled workers' relief fund payments on claims for which the AEO or the PEO, or its client employers are employer of record, pursuant to paragraph (B) of rule 4123-17-29 of the Administrative Code.

(6) Make a quarterly report to the bureau that details the active clients, all claims, and the claim reserves for each claim of the AEO or the PEO.

(C) For purposes of this rule, "paid compensation" means all amounts paid by the AEO or the PEO and its client employers for living maintenance benefits, all amounts for compensation paid pursuant to sections 4121.63, 4121.67, 4123.56, 4123.57, 4123.58, 4123.59, 4123.60 and 4123.64 of the Revised Code, all amounts paid as wages in lieu of such compensation, all amounts paid in lieu of such compensation under a nonoccupational accident and sickness program fully funded by the AEO or the PEO, or its client employers, and all amounts paid by an AEO or a PEO and its client employers for a violation of a specific safety standard pursuant to Section 35 of Article II, Ohio Constitution and section 4121.47 of the Revised Code. Any reimbursement received from the surplus fund pursuant to section 4123.512 of the Revised Code by the AEO or the PEO, or its client employers for any such payments or compensation paid is to be applied to reduce the amount of paid compensation reported in the year in which the reimbursement is made. Any amount recovered by the AEO or the PEO, or its client employers under section 4123.931 of the Revised Code and any amount that is determined not to have been payable to a claimant in any final administrative or judicial proceeding will be deducted, in the year collected, from the amount of paid compensation reported.

(1) For an AEO or a PEO that is a self-insuring employer for which paragraph (I) of rule 4123-17-32 of the Administrative Code is applicable, paid compensation includes any amounts paid by the state insurance fund for claims directly attributable to the AEO or the PEO and any client employers of the AEO or the PEO. In determining the applicability of paragraph (I) of rule 4123-17-32 of the Administrative Code to an AEO or a PEO, the bureau will use the date on which the AEO or the PEO was added to the self-insured policy if such date is after the effective date of the self-insured policy.

(2) If a client employer enters into a new AEO agreement with an AEO, or a new PEO agreement with a PEO, that is self-insured risk which paragraph (I) of rule 4123-17-32 of the Administrative Code is applicable, paid compensation includes any amounts paid by the state insurance fund for claims directly attributable to that client employer.

(D) An AEO or a PEO granted the privilege of self-insured status cannot:

(1) Enter into AEO agreements or PEO agreements to provide workers' compensation coverage through the state insurance fund; or

(2) Enter into a partial-lease agreement.

Last updated June 8, 2026 at 8:06 PM

History

Effective: June 8, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-15.6 Client employer information.

(A) An AEO or a PEO shall provide a list of all of the following information to the client employer upon the written request of the client employer:

(1) All premiums and payroll associated with that client employer;

(2) All workers' compensation claims, and the compensation and benefits paid, and reserves established for each claim; and

(3) Any other information available to the AEO or the PEO from the bureau of workers' compensation regarding that client employer.

(B) The AEO or the PEO will provide the information pursuant to paragraph (A) of this rule in writing to the requesting client employer within forty-five days after receiving a written request from the client employer. An AEO or a PEO has provided this information to the client employer when:

(1) The information is received by the United States postal service; or

(2) When the information is personally delivered, in writing, directly to the client employer. For purposes of this rule, a communication sent via electronic mail is personally delivered at the time the communication was sent by the AEO or the PEO to a valid electronic mail address for the client employer.

(C) If an AEO or a PEO fails to comply with a client employer's written request for information, the client employer may submit a complaint to the bureau.

(1) The bureau will investigate the complaint to determine whether the AEO or the PEO has complied with this rule.

(2) If the bureau finds the AEO or the PEO has failed to comply with this rule:

(a) The bureau will provide the requested information to the client employer. All administrative costs associated with investigation and providing the information to the client employer will be assessed to the AEO or the PEO; and

(b) The bureau will provide the client employers of the AEO or the PEO with notification of the failure to comply with the rule and advise the client employers of their ability to request information under this rule.

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-15.7 Denial or revocation of AEO or PEO registration.

(A) The administrator of workers' compensation shall deny or revoke the registration of an AEO, a PEO, or a PEO reporting entity if it fails to comply with the provisions of rule 4123-17-15.4 of the Administrative Code.

(B) The administrator may deny or revoke the registration of an AEO, a PEO, or a PEO reporting entity upon finding that the AEO, the PEO, or the PEO reporting entity has done any of the following:

(1) Obtained or attempted to obtain registration through misrepresentation, misstatement of a material fact, or fraud;

(2) Misappropriated any funds of a client employer;

(3) Used fraudulent or coercive practices to obtain or retain business or demonstrated financial irresponsibility;

(4) Failed to appear, without reasonable cause or excuse, in response to a subpoena lawfully issued by the administrator; or

(5) Failed to comply with the provisions of rules 4123-17-15 to 4123-17-15.5 of the Administrative Code.

(C) Concurrent with, or upon, the denial or revocation of the registration of an AEO, a PEO, or a PEO reporting entity, the administrator may deny or revoke the registration of any AEO, PEO, or PEO reporting entity, that is majority owned or commonly controlled by the same entity, parent, or controlling person.

(D) An AEO or a PEO may appeal a denial or revocation of status under this rule pursuant to the administrative hearing procedure set forth in Chapter 119. of the Revised Code.

(E) The administrator's decision to deny or revoke an AEO's registration or a PEO's registration is stayed pending the exhaustion of all administrative appeals by the AEO or the PEO. The bureau of workers' compensation may notify client employers of the administrator's decision to deny or revoke the registration of the AEO or the PEO upon issuance of the administrator's decision, provided the bureau also notifies client employers that the AEO or the PEO has the right to appeal the administrator's decision.

(F) Upon revocation of the registration of an AEO or a PEO, each client employer associated with that AEO or PEO will file payroll reports and pay workers' compensation premiums directly to the administrator on its own behalf at a rate determined by the administrator based solely on the claims experience of the client employer.

(G) If pursuant to this rule the administrator has denied or revoked the registration of an AEO or a PEO, or a PEO reporting entity, then any of the following are ineligible to reapply as an AEO or a PEO, or a PEO reporting entity for a period of two years from the date of denial or revocation of the registration, and rescission of the PEO or PEO reporting entity's status as a coemployer:

(1) The former AEO, the former PEO, or the former PEO reporting entity; or

(2) Any applicant that is majority owned, or commonly controlled, by the same entity, parent, or controlling person of the former AEO, former PEO, or former PEO reporting entity.

(H) When an employer contacts the bureau to determine whether a particular AEO or PEO is registered, if the administrator has denied or revoked that AEO's registration or that PEO's registration, and if all administrative appeals are not yet exhausted when the employer inquires, the appropriate bureau personnel will inform the inquiring employer of the denial, revocation, or rescission and the fact that the AEO or the PEO has the right to appeal the administrator's decision.

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-16 Penalties: late payment and reporting.

(A) Definitions.

As used in this rule:

(1) "Annual payroll report" means the report of the employer's actual payroll expenditures submitted pursuant to section 4123.26 of the Revised Code for private employers, section 4123.41 of the Revised Code for public employers, and under rule 4123-17-14 of the Administrative Code.

(2) "Payments" means premiums, administrative costs, assessments, fines or monies otherwise due to any fund administered by the bureau of workers' compensation, including amounts due for retrospective rating.

(B) Premium payments are due by the date indicated on the invoice provided by the bureau pursuant to rule 4123-17-14 of the Administrative Code. Other payments and reports pursuant to Chapter 4123. of the Revised Code will be considered late if not received by the bureau on the due date specified by statute or administrative rule implementing such statute. If statute and rule do not specify a date for a payment, such payments will be considered late if not received by the bureau by the due date on the invoice issued by the bureau.

(1) The administrator of workers' compensation may establish a grace period during which a penalty will not be assessed on late payments or late reporting.

(2) If the bureau imposes a lapse in coverage on an employer's policy for failure to make premium payments within a grace period established by the administrator pursuant to paragraph (B)(1) of this rule, such lapse will be effective from the first day of the month which falls nearest the due date of the payment.

(1) If an employer fails to pay premium and assessments when due, the administrator may assess a penalty at the interest rate established by the state tax commissioner pursuant to section 5703.47 of the Revised Code.

(2) If an employer recognized by the administrator as an alternate employer organization as defined in section 4133.01 of the Revised Code, or a professional employer organization, as defined in section 4125.01 of the Revised Code, fails to make timely payment of premiums and assessments in accordance with rule 4123-17-14 of the Administrative Code, the administrator will revoke the alternate employer organization's registration or the professional employer organization's registration pursuant to rule 4123-17-15.7 of the Administrative Code.

(D) Penalties for failure to file or pay amounts due under the annual payroll report.

(1) If an employer fails to file or pay amounts due under the annual payroll report within the grace period established by the administrator pursuant to paragraph (B)(1) of this rule:

(a) The employer will be removed from all rating plans and discount programs for the policy year immediately following the policy year to which the annual payroll report pertains. Unless otherwise specified in the rules of the program, such employer will be base-rated or experience-rated, as determined by the expected losses of the employer pursuant to rules 4123-17-33 and 4123-17-34 of the Administrative Code, and

(b) The premium and assessments due from the employer for the policy year to which such report pertains will be calculated based on the estimated payroll of the employer used in calculating estimated premium due, increased by ten per cent.

(2) The bureau will not impose a lapse in coverage on an employer that is current with its estimated premium payments for failure to file an annual payroll report for the preceding policy year.

(E) Certification of past-due amounts to the attorney general.

Pursuant to sections 131.02 and 4123.323 of the Revised Code, the bureau will certify past due amounts to the attorney general according to the following schedule:

(1) Premium payments: seventy-five days after the annual payroll report for the policy year to which the premium payments pertain is due under rule 4123-17-14 of the Administrative Code.

(2) Penalties for failure to make estimated premium payments: seventy-five days after the annual payroll report for the policy year to which the premium payments pertain is due under rule 4123-17-14 of the Administrative Code.

(3) All other assessments and penalties thereon: forty five days after the due date set forth in paragraph (B) of this rule.

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-17 Auditing and adjustment of payroll reports.

(A) Every employer amenable to the workers' compensation law shall keep, preserve, and maintain complete records showing in detail all expenditures for payroll reportable to Ohio and the division of such expenditures in the various divisions and classification codes of the employer's business. If an employer elects under section 4123.292 of the Revised Code to obtain other-states' coverage, the employer shall also keep records of all payroll reported to the other-states' insurer for work performed outside of Ohio. Both types of payroll records shall be preserved for at least five years after the respective time of the transaction upon which such records are based.

(B) All books, records, papers, and documents reflecting upon the amount and the classification codes of the payroll expenditures of an employer shall be kept available for inspection at any time by the bureau of workers' compensation or any of its assistants, agents, representatives, or employees. If any employer fails to keep, preserve, and maintain such records and other information reflecting upon payroll expenditures, or fails to make such records and information available for inspection, or fails to furnish the bureau or any of its assistants, agents, representatives, or employees, full and complete information in reference to expenditures for payroll when such information is requested, the bureau may determine upon such information as is available the amount of premium due from the employer, and the bureau's findings shall constitute prima facie evidence of the amount of premium due from the employer.

(C) The bureau shall have the right at all times to inspect, examine, or audit any or all books, records, papers, documents, and payroll of an employer for the purpose of verifying the correctness of reports made by employers as required by law.

(1) The bureau shall have the right to make adjustments as to classification codes, allocation of wage expenditures to classification codes, amount of wage expenditures, premium rates, or amount of premium.

(2) Except as provided in rules 4123-17-14 and 4123-17-28 of the Administrative Code, adjustments in an employer's account which result in changes to the amount of premium due from an employer for a policy year shall be limited to the annual or adjustment periods ending within twenty-four months immediately prior to:

(a) The date when such error affecting the reports and the premium are brought to the attention of the bureau by an employer through written application for adjustment, or

(b) The date that the bureau provides written notice to the employer of the bureau's intent to inspect, examine, or audit the employer's records.

(D) Where the bureau has assigned two or more classification codes for an employer's operations, the employer shall keep an appropriate record showing a correct and verifiable segregation of all payroll into such classification codes. If it is found that the employer has failed to keep such record, the part of the payroll which cannot be reasonably determined by the bureau as belonging to any other classification codes shall be placed by the bureau under the assigned classification code having the highest rate, and the employer will be assessed premium accordingly.

Last updated July 2, 2024 at 11:33 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-19 Employer contribution to the marine industry fund.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to establish contributions made to the marine industry fund by employers pursuant to sections 4121.121 and 4131.14 of the Revised Code. The administrator hereby sets the premium rates per one hundred dollar unit of payroll to be effective July 1, 2026 as indicated in the appendix to this rule.

View Appendix

Last updated July 1, 2026 at 7:47 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-20 Employer contribution to the coal-workers pneumoconiosis fund.

The administrator of workers' compensation, with the advice and consent of the workers' compensation board of directors, has authority to establish contributions made to the coal-workers pneumoconiosis fund by employers pursuant to sections 4121.121 and 4131.04 of the Revised Code. The administrator hereby sets the premium rates per one hundred dollar unit of payroll, as indicated in the appendix to this rule.

View Appendix

Last updated July 2, 2024 at 11:33 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-22 Traveling expense.

Where employees who travel in the course of their employment are required to pay their travel expenses out of their remuneration, the employer, in submitting payroll reports of the earnings of such employees, may deduct from the remuneration an amount representing actual travel expenses, not exceeding an amount equal to one-third of the remuneration, provided the employer maintains complete detailed records documenting the travel expenses.

Last updated July 2, 2024 at 11:34 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-23 Duties outside the state.

(A) The entire remuneration of employees whose employment involves activities both within and outside the borders of Ohio, and where the supervising office of the employer is located in Ohio, shall be included in the payroll report. However, if the employer elects to obtain other-states' coverage under section 4123.292 of the Revised Code directly through an other-states' insurer the employer shall report payroll as set forth in paragraph (I) of rule 4123-17-14 of the Administrative Code.

(B) The remuneration of employees of other than Ohio employers, who have entered into a contract of employment outside of Ohio to perform transitory services in interstate commerce only, both within and outside of the boundaries of Ohio, shall not be included in the payroll report.

(C) The bureau of workers' compensation respects the extraterritorial right of the workers' compensation insurance coverage of an out-of-state employer for its regular employees who are residents of a state other than Ohio while performing work in the state of Ohio for a temporary period not to exceed ninety days. While temporarily within this state the rights of the employee and the employee's dependents under the laws of the other state are the exclusive remedy against the employer on account of injury, disease or death pursuant to division (H)(5) of section 4123.54 of the Revised Code and remuneration for such employees shall not be included in the payroll report. However, if a temporary period exceeds ninety consecutive days the out-of-state employer shall include in the payroll report the remuneration for work the employees perform in Ohio beyond that ninety day period.

(D) Employees hired to work specifically in Ohio must be reported for workers' compensation insurance under the Ohio fund, regardless of where the contracts of hire were entered.

(E) When an Ohio employer hires an employee to perform transitory work outside of Ohio and the employee is not covered by the workers' compensation laws of the state of residence for claims arising outside that state because the contract of employment was not entered into in the state of residence, the employer and his employee, if the employment relationship maintains sufficient contacts with the Ohio location to be covered by Ohio workers' compensation law, may mutually agree to be bound by the workers' compensation laws of the state of Ohio by executing form C-110, or mutually agree to be bound by the workers' compensation law of some other state by executing form C-112, such forms to be obtained from and filed with the bureau of workers' compensation within ten days after execution.

History

Effective: July 19, 2015
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-24 Other states coverage policy.

(A) Definitions.

For purposes of this rule:

(1) "Other states coverage policy (OSCP)" is the policy offered by the bureau of workers' compensation under section 4123.292 of the Revised Code to provide optional coverage to eligible Ohio employers for workers' compensation exposures in states other than Ohio.

(2) "Contracting carrier" means the insurer providing other states coverage through the bureau.

(3) "Limited other states coverage" is insurance coverage for eligible Ohio employers who have employment relationships localized in Ohio but whose employees have incidental exposures in jurisdictions outside Ohio.

(4) "Other states coverage" is insurance coverage for eligible Ohio employers who have regular or full time employment exposure in jurisdictions outside of Ohio.

(B) OSCP application.

(1) An employer wishing to obtain an OSCP will complete and submit an application to the bureau, and if the employer has an existing other states policy, the employer will provide any declaration page or certificate of coverage of any existing other states policy. Declaration pages or certificates of coverage for previous policy years may be requested as deemed appropriate by the bureau.

(2) The bureau will only process a complete application, and no application will be deemed complete until all information requested by the bureau in connection with the application is supplied.

(3) The bureau may make reasonable inspections of an applicant's place of business and of any records applicable to ensuring proper classification code assignment to the policy or to review loss prevention or safety programs prior to reaching a decision regarding an application for coverage. The bureau will provide advanced notice to the employer of any such inspection.

(4) Only employers meeting the following criteria are eligible for an OSCP:

(a) The employer is headquartered, primarily located, or has a history of predominant business operations in Ohio;

(b) The employer has an active state fund workers' compensation policy with the bureau;

(c) The employer cannot have cumulative lapses in workers' compensation coverage in excess of forty days within the prior twelve months; and

(d) The employer's Ohio policy cannot have past due balances at the time of application or renewal.

(5) The bureau will establish underwriting guidelines for determining whether to approve or deny an application. In addition to the criteria set forth in paragraph (B)(4) of this rule, the bureau's underwriting guidelines may consider the following:

(a) The applicant's history with the bureau, including compliance with applicable workers' compensation laws and rules, payment of premiums and assessments, claims history, safety record, and experience ratings; and

(b) The applicant's history with coverage through any insurer for worker's compensation in any jurisdiction other than Ohio, including premium payment records, claims history, safety record, and experience modification history, if any.

(6) The following employers are not eligible for an OSCP:

(a) Self-insuring employers providing compensation and benefits pursuant to section 4123.35 of the Revised Code;

(b) Temporary employment agencies or other staffing entities;

(c) Professional employer organizations as defined in Chapter 4125. of the Revised Code, and each of the professional employer organization's client employers; and

(d) Alternate employer organizations as defined in Chapter 4133. of the Revised Code, and each of the alternate employer organization's client employers.

(7) The bureau has the authority, in the administrator of workers' compensation's discretion, to approve or deny an OSCP application. The decision of the administrator is final.

(a) In the event that an employer is denied an OSCP, the bureau will provide written documentation of the reason for denial; and

(b) An employer may reapply once the reason for denial is remedied.

(1) An employer whose application for coverage is approved by the bureau will receive a quote for the cost of coverage. If the employer elects to obtain coverage, the bureau will issue an OSCP only after the following:

(a) The bureau's receipt of premium payment for the OSCP; and

(b) If an employer has previously had a policy covering its exposure out of state, submission of proof of cancellation of the existing policy or the expiration date of the previous policy.

(2) Coverage under an OSCP will be effective when the OSCP is issued.

(a) The bureau will issue the policy within five business days of receipt of premium if cancellation notices and other information necessary from the policyholder to issue the OSCP are provided; and

(b) Coverage becomes effective per the effective date of the policy as issued by the contracting carrier.

(D) OSCP renewal.

(1) An employer wishing to renew its OSCP may complete the renewal application, which will be provided by the bureau. The bureau will establish a deadline for the renewal application.

(2) If the renewal application is not completed by an employer, the renewal quote will be based upon the previous policy year's information.

(3) The bureau will non-renew an employer's OSCP if the employer is not eligible for coverage under this rule at the time of renewal.

(4) The premium for the OSCP renewal period has to be received by the bureau prior to the expiration of the previous policy period.

(5) If the renewal premium is not received by the expiration of the previous policy, notice of the policy cancellation for non-payment will be sent to the insured employer under the laws and procedures of the jurisdiction from which coverage is provided. If the bureau received an insured employer payment late, the bureau may, in the administrator's discretion, reinstate the coverage or may require the employer to submit a new OSCP application.

(6) The bureau has the authority, in the administrator's discretion, to non-renew an employer's OSCP. The decision of the administrator is final.

(E) Audits and inspection.

(1) An OSCP will expire per the terms of the policy issued by the contracting carrier, unless otherwise canceled as set forth in this rule.

(2) An employer with an OSCP will have to complete a final audit at the conclusion of each OSCP term and upon cancellation pursuant to the terms of the OCSP.

(3) In the event of a claim filed in a jurisdiction outside Ohio, the bureau may make reasonable inspection of an applicant's place of business and of any records necessary to secure information for the purpose of determining compensability of such claim.

(4) Any audit will be conducted in accordance with rule 4123-17-17 of Administrative Code.

(5) Adjustments to premium may be made based on the results of any audit. The employer will have to pay any balance due within the timelines established by the bureau.

(6) If the employer refuses or otherwise fails to cooperate with an audit by the bureau, the bureau may estimate the insured's payroll. Any estimated payroll pursuant to this section may result in an adjustment of premium.

(7) In the event of an audit dispute, the bureau will make reasonable efforts with the insured to resolve the disputed findings.

(8) If resolution between the bureau and the insured cannot be made, the audit findings can be appealed to the extent allowable under the laws and procedures of the jurisdiction for which coverage is being provided.

(F) Policy cancellation.

(1) An OSCP may be canceled for any of the following reasons:

(a) At the written request of the employer;

(b) Employer misrepresentation regarding its operations;

(d) Employer failure to complete a final audit or pay any amounts due as a result of a final audit;

(e) Any past due balance owed for the OSCP;

(f) Refusal on the part of the insured to permit reasonable audits or inspections; or

(g) Any reason the contracting carrier is authorized to cancel a policy, as established by the laws of the jurisdiction for which coverage is being provided.

(2) An OSCP may be canceled under the laws and procedures of the jurisdiction for which coverage is being provided.

(a) Notice of cancellation will be provided in accordance with the laws and procedures of the jurisdiction for which coverage is being provided; and

(b) A policy cancellation can be appealed to the extent allowable under the laws and the procedures of the jurisdiction for which coverage is being provided.

(G) Assignment of payroll.

(1) If an employer is issued an OSCP for limited other states coverage, the bureau may assign payroll in the event of a claim to the jurisdiction where the claim is filed. The payroll amount will not exceed one hundred per cent of the injured workers' wages for one year.

(2) The assignment of payroll may result in a premium adjustment for the OSCP. The employer will have to pay any balance due within the timelines established by the bureau.

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-25 Military and naval service.

Remuneration given by employers to employees while engaged in active military or naval service of the United States of America shall be excluded from the payroll reports which the employers are required to submit to the bureau of workers' compensation for premium purposes unless the employees are also required to render services to the employers while engaged in active military or naval service.

Last updated July 2, 2024 at 11:34 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-26 Minimum annual administrative charge.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to calculate contributions by employers pursuant to sections 4121.121, 4123.341, and 4123.342 of the Revised Code. The administrator hereby establishes that in cases where an employer reports no payroll for a payroll reporting period the employer shall pay a minimum annual administrative charge at a rate of one hundred twenty dollars annually. In cases where an employer reports payroll resulting in a premium of less than the minimum administrative charge, the employer shall pay the one hundred twenty dollar minimum annual administrative charge.

Last updated July 2, 2024 at 11:34 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-27 Protest of an employer's experience.

A protest of an employer's experience is to be submitted in writing, which includes by e-mail. Only the employer or a representative with a permanent authorization from that employer can file a protest. A protest will be considered on its merits only if the protest is timely received by the bureau of workers' compensation. A protest is timely filed if the date of receipt by the bureau is within two years of the initial effective date of the basic rate(s) on which the protested experience is predicated.

Last updated July 14, 2023 at 1:20 PM

History

Effective: July 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-28 Correction of inaccuracies affecting employer's premium rates.

(A) Whenever the bureau of workers' compensation detects an inaccuracy in the recording or processing of data, records, payroll, claims, or other pertinent items affecting the employer's status, experience modification, or premium, the bureau will correct such discrepancy . This correction will be accomplished regardless of whether this entails increasing or decreasing the employer's experience modification or premium rate. The employer or its representative will be advised of any correction and the effect thereof made under the authority of this rule.

(B) Any correction made pursuant to the provisions of paragraph (A) of this rule will be applied to the current rating year, the rating year immediately preceding the current rating year, and to all rating years subsequent to the current rating year as of the date on which the error was discovered by the bureau or reported to the bureau, whichever date is earlier, except in matters involving disability relief and service-connected disabilities and cases covered by rules 4123-17-02, 4123-17-17, and 4123-19-03 of the Administrative Code. In cases where two or more employers may be affected by such correction, the same period of adjustment will be applied to all affected employers.

(C) Notwithstanding paragraphs (A) and (B) of this rule or paragraphs (C) and (D) of rule 4123-17-17 of the Administrative Code, the bureau may adjust the employer's account or experience for a period in excess of twenty-four months immediately prior to the beginning of the current payroll reporting period for the following circumstances:

(1) If the bureau determines that the employer misrepresented payroll or failed to submit payroll for any period, the bureau may adjust the employer's account or experience resulting in an increase in any amount of premium above the amount of contributions made by the employer to the fund for the entire period the employer misrepresented payroll or the entire period the employer failed to submit payroll, regardless of when the misrepresentation of payroll or failure to submit payroll occurred.

(2) If the bureau excluded any claim costs from the employer's account or experience because the costs were subject to an appeal to court under section 4123.512 of the Revised Code and by a final adjudication it is determined that the claim costs are to be charged to the claim, the bureau may adjust the employer's account or experience resulting in an increase in any amount of premium above the amount of contributions made by the employer to the fund for the entire period affected by the addition of the claim costs to the employer's account or experience.

Last updated April 3, 2024 at 1:28 PM

History

Effective: April 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-17-29 Disabled workers' relief fund; employers' assessments and self-insurers' payments.

(A) State fund employers.

(1) In order to make disabled workers' relief fund (DWRF) payments to claimants having dates of injury or disability prior to January 1, 1987, assessments shall be levied in the following manner for so long as payments to such claimants are required:

(a) Private state fund employers: zero cents per one-hundred-dollar unit of payroll, effective July 1, 2016;

(b) Public employer taxing districts: zero cents per one-hundred-dollar unit of payroll, effective January 1, 2016;

These assessments shall be billed at the same time state insurance fund premiums are billed and payments shall be credited to the DWRF.

(2) In order to make DWRF payments to claimants having dates of injury or disability on or after January 1, 1987, assessments shall be levied in the following manner for so long as payments to such claimants are required:

(a) Private state fund employers: zero per cent of premium, computed at basic rate, effective July 1, 2015;

(b) Public employer taxing districts: zero per cent of premium, computed at basic rate, effective January 1, 2015;

These assessments shall be billed at the same time state insurance fund premiums are billed and payments shall be credited to the DWRF.

(B) Self-insuring employers.

(1) Each self-insuring employer shall reimburse the bureau for DWRF payments made in claims in which it is the employer of record, without regard to the date the employer was granted the privilege to pay compensation directly, for all DWRF payments made on or after August 22, 1986.

(2) Self-insuring employers shall be billed on a semi-annual basis for the DWRF payments made pursuant to this rule.

(3) Upon default and a finding of noncompliance by the administrator of workers' compensation, reimbursement shall be made from the self-insuring employers' guaranty fund.

Last updated March 22, 2024 at 11:13 AM

History

Effective: July 1, 2022
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-30 Payroll limitations for corporate officers, sole proprietors, an individual incorporated as a corporation with no employees, members of partnerships, and family farm corporations.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to establish the total payroll reportable by employers pursuant to sections 4121.12 and 4123.29 of the Revised Code. The administrator hereby sets the total payroll limitations for executive officers of corporations, sole proprietors, members of partnerships, an individual incorporated as a corporation with no employees, and officers of family farm corporations as provided in this rule.

(A) For executive officers of corporations, the payroll reportable shall be the actual payroll received by the executive officers of the corporation, but not less than an average weekly wage equal to fifty per cent of the statewide average weekly wage as defined in division (C) of section 4123.62 of the Revised Code, but shall not exceed an average weekly wage equal to one hundred fifty per cent of the statewide average weekly wage as defined in division (C) of section 4123.62 of the Revised Code. The minimum reportable payroll for executive officers of corporations shall apply only to active executive officers of corporations. As used in this rule, "active executive officer" means an officer engaged in the decision making and day to day operations of the corporation.

(B) For sole proprietors, members of partnerships, an individual incorporated as a corporation with no employees, and officers of family farm corporations who elect to include themselves as employees under the workers' compensation act and comply with rule 4123-17-07 of the Administrative Code, the payroll reportable shall be the actual payroll received by the sole proprietor, member of partnership, an individual incorporated as a corporation, and officer of a family farm corporation, but not less than an average weekly wage equal to fifty per cent of the statewide average weekly wage as defined in division (C) of section 4123.62 of the Revised Code, nor more than an average weekly wage equal to one hundred fifty per cent of the statewide average weekly wage as defined in division (C) of section 4123.62 of the Revised Code.

Last updated July 2, 2024 at 11:35 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-32 Self-insuring employer assessment based upon paid compensation.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to determine and levy against self-insuring employers amounts to be paid to support the safety and hygiene fund, the administrative cost fund, the portion of the surplus fund that is mandatory and the portion of the surplus fund used for claims reimbursement for self-insuring employers under division (H) of section 4123.512 of the Revised Code, pursuant to sections 4121.12, 4121.37, 4121.66, 4123.34, 4123.342, and 4123.35 of the Revised Code in conjunction with rule 4123-19-01 of the Administrative Code. The administrator hereby sets the self-insuring employer assessments to be effective July 1, 2026, for the period July 1, 2026, to June 30, 2027, payable in two equal remittances by February 28, 2027, and August 31, 2027, as follows:

(A) The assessments shall be on the basis of the paid compensation attributable to the individual self-insuring employer as a fraction of the total amount of paid compensation for the previous calendar year attributable to all amenable self-insuring employers.

(B) Paid compensation means all amounts paid by a self-insuring employer for living maintenance benefits, all amounts for compensation paid pursuant to sections 4121.63, 4121.67, 4123.56, 4123.57, 4123.58, 4123.59, 4123.60 and 4123.64 of the Revised Code, all amounts paid as wages in lieu of such compensation, all amounts paid in lieu of such compensation under a non-occupational accident and sickness program fully funded by the self-insuring employer, and all amounts paid by a self-insuring employer for a violation of a specific safety standard pursuant to section 35 of article II, Ohio Constitution and section 4121.47 of the Revised Code. Any reimbursement received from the surplus fund pursuant to section 4123.512 of the Revised Code by a self-insuring employer for any such payments or compensation paid shall be applied to reduce the amount of paid compensation reported in the year in which the reimbursement is made. Any amount recovered by the self-insuring employer under section 4123.931 of the Revised Code and any amount that is determined not to have been payable to a claimant in any final administrative or judicial proceeding shall be deducted, in the year collected, from the amount of paid compensation reported.

(C) The assessments shall be computed for all self-insuring employers operating in Ohio by multiplying the following rates by the individual self-insuring employer's paid compensation for calendar year 2025:

(1) Safety and hygiene fund: 0.0030.

(2) Administrative cost fund, BWC: 0.0873.

(3) Administrative cost fund, IC: 0.1333.

(4) Surplus fund (mandatory): 0.0500.

(D) The assessment to fund the portion of the surplus fund that is used for claims reimbursement for all self-insuring employers operating in Ohio who have not made an election to opt out of the right to reimbursement under the provisions of division (H) of section 4123.512 of the Revised Code shall be computed by multiplying the following rate by the individual self-insuring employer's paid compensation for calendar year 2025:

Surplus fund (disallowed claims reimbursement): 0.0090.

(E) An employer who no longer is a self-insuring employer in Ohio or who no longer is operating in this state shall continue to pay assessments for administrative costs and for the portion of the surplus fund that is mandatory. The assessments shall be computed by such employer by multiplying the following rates by the individual employer's paid compensation for calendar year 2025:

(1) Administrative cost fund, BWC: 0.0873.

(2) Administrative cost fund, IC: 0.1333.

(3) Surplus fund (mandatory): 0.0500.

(F) If the paid compensation for a self-insuring employer for calendar year 2025 is less than ten thousand nine hundred sixty-four dollars and ninety-one cents, the minimum assessments shall be paid as follows:

(1) Safety and hygiene fund: $32.89.

(2) Administrative cost fund, BWC: $957.24.

(3) Administrative cost fund, IC: $1,461.62.

(4) Surplus fund (mandatory): $548.25.

An employer who no longer is a self-insuring employer in Ohio or no longer is operating in this state and who has less than ten thousand nine hundred sixty-four dollars and ninety-one cents in paid compensation for calendar year 2025 shall have a reduced minimum assessment. The minimum assessment shall be ninety per cent of the above minimum assessments in this paragraph in the year after becoming inactive, eighty per cent in the following year, seventy per cent in the following year, and so forth, being reduced ten per cent each year, until the assessment is phased out over ten years. The bureau may, in its discretion, permit an employer to pay its total assessment obligation under this paragraph in a single payment, discounted for present value at a rate determined by the bureau. An employer electing to pay its assessment obligations in a single payment must continue to administer self-insured claims and pay compensation and benefits pursuant to paragraph (C) of rule 4123-19-05 of the Administrative Code.

(G) If an individual self-insuring employer has become self-insured in the last five years (on or after July 1, 2021), paid compensation shall be as defined in paragraph (B) of this rule and shall additionally include compensation paid in calendar year 2025 by the state insurance fund for claim costs directly attributable to the employer prior to becoming self-insured.

(H) The initial assessment to a self-insuring employer in its first calendar year of operation as a self-insuring employer shall be prorated to cover the time period that self-insurance was in effect, but shall not be less than the minimum assessment for a self-insuring employer as provided in paragraph (F) of this rule.

(I) Pursuant to rule 4123-19-15 of the Administrative Code, the following assessment, to be billed and payable in two equal remittances by February 28, 2027, and August 31, 2027, shall be computed for all self-insuring employers by multiplying the following rate by the individual self-insuring employer's paid compensation for calendar year 2025:

Self-insuring employer guaranty fund: 0.0797.

(J) All self-insuring employers must pay assessments under this rule using the online payment offering on the bureau's website. The bureau may waive the online payment requirement with written justification and supporting documentation, satisfactory to the bureau, from the self-insuring employer and filed with the bureau by the payment due date on the assessment remittance. The written justification and supporting documentation must demonstrate the self-insuring employer's inability to remit payment through the online payment offering on the bureau's website.

(K) If an employer fails to pay the assessment when due, the administrator may add a late fee penalty of not more than five hundred dollars to the assessment plus an additional penalty amount as follows:

(1) For an assessment from sixty-one to ninety days past due, the prime interest rate, multiplied by the assessment due;

(2) For assessment from ninety-one to one hundred twenty days past due, the prime interest rate plus two per cent, multiplied by the assessment due;

(3) For an assessment from one hundred twenty-one to one hundred fifty days past due, the prime interest rate plus four per cent, multiplied by the assessment due;

(4) For an assessment from one hundred fifty-one to one hundred eighty days past due, the prime interest rate plus six per cent, multiplied by the assessment due;

(5) For an assessment from one hundred eighty-one to two hundred ten days past due, the prime interest rate plus eight per cent, multiplied by the assessment due;

(6) For each additional thirty-day period or portion thereof that an assessment remains past due after it has remained past due for more than two hundred ten days, the prime interest rate plus eight per cent, multiplied by the assessment due.

For purposes of this paragraph, "prime interest rate" means the average bank prime rate, and the administrator shall determine the prime interest rate in the same manner as a county auditor determines the average bank prime rate under section 929.02 of the Revised Code.

Last updated July 10, 2026 at 7:51 AM

History

Effective: July 10, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-33 Public employer taxing district industry group and limited loss ratio tables.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to calculate contributions made to the state insurance fund by employers pursuant to section 4121.121 of the Revised Code. The administrator hereby sets the industry group assignments and limited loss ratio tables for public employer taxing districts as indicated in appendices A and B to this rule.

View AppendixView Appendix

Last updated July 1, 2026 at 8:59 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-33.1 Public employer taxing districts experience rating table.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to calculate contributions made to the state insurance fund by employers pursuant to section 4121.121 of the Revised Code. The administrator hereby sets the public employer taxing district experience rating table part A, "credibility and maximum value of a loss," to be effective January 1, 2021, for public employer taxing districts as indicated in appendix A to this rule.

View Appendix

Last updated June 30, 2026 at 1:05 PM

History

Effective: January 1, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-34 Public employer taxing districts contribution to the state insurance fund.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to approve contributions made to the state insurance fund by employers pursuant to section 4121.121 of the Revised Code. The administrator hereby sets base rates and expected loss rates to be effective January 1, 2026 applicable to the payroll reporting period January 1, 2026 through December 31, 2026 for public employer taxing districts as indicated in the appendix to this rule.

View AppendixView Appendix

Last updated January 5, 2026 at 10:30 AM

History

Effective: January 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-35 Public employer state agency contribution to the state insurance fund.

View Appendix

Last updated July 1, 2026 at 7:48 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-35.1 Public employer state agency lump sum settlement program.

(A) Public employer state (PES) agency that is not currently participating in a settlement payment program may participate in the lump sum settlement (LSS) direct reimbursement rating and payment program. A PES agency participating in this program will have the LSS payments excluded from the bureau's rate calculation process.

(1) Requirements.

(a) A PES agency shall make a three-year minimum commitment to the LSS direct reimbursement payment and rating program.

(b) The earliest beginning date of the LSS program is July 1, 2004.

(c) A PES agency shall notify the bureau of its desire to participate in the LSS direct reimbursement and payment program before the first day of the second month following any quarter ending date to be effective the following quarter. For example, if the PES agency chose to participate in the LSS program beginning April 1, 2016, the request must be submitted before February 1, 2016. The notification shall be made on the form provided by the bureau and signed by the PES agency's designee.

(d) A PES agency currently participating in a settlement program is not eligible to participate in the LSS direct reimbursement payment and rating program.

(2) LSS rate calculation.

(a) All LSS payments will be treated the same whether the result of a court-ordered settlement, an agency-negotiated settlement or any other type of settlement.

(b) Once a PES agency begins participating in the LSS direct reimbursement and rating program, all LSS payments will be excluded from the losses used to calculate the contribution rate for future policy years.

(c) When an agency terminates a LSS direct reimbursement and rating program, the contribution rate will include all LSS payments that were made by the bureau and not reimbursed by the PES agency.

(3) LSS reimburseemnt payments.

(a) A LSS will be billed in the next month following the date the LSS warrant was cashed.

(b) The bureau will bill a structured settlement to the PES agency as the warrant is cashed.

(d) If the PES agency fails to pay a LSS monthly bill within thirty days, the bureau will remove the PES agency from the LSS direct reimbursement rating and payment program and the bureau will include the outstanding LSS payments in the rate calculation.

(e) A PES agency may settle permanent total disability (PTD) and death benefit claims in which the present value was previously used in the rate calculations.

PES agencies will not be billed for the settlement costs of PTD and death benefit claims in which the present value of both medical and indemnity costs was included in contribution rate calculations. These claims would likely be death benefit claims awarded before January 1, 2001 and PTD claims awarded before January 1, 1996.

For PTD claims awarded between January 1, 1996 and December 31, 2000 and where the present value of the future indemnity cost was previously included in the development of the agency's contribution rates, the bureau will include only the medical portion of the settlement amount in the quarterly billings.

(f) A PES agency shall file any dispute in writing, specifying the agency's objections to the billing, with the bureau's direct billing department. The filing of a dispute does not relieve or suspend the agency's obligation to pay the obligation. Questions concerning the rate calculations should be directed to the bureau's actuarial division.

(4) Change in status.

(a) When a PES agency combines with another PES agency, the succeeding agency's participation in this program will not be affected.

(b) A PES agency that is participating in a program and transfers a portion of its operations to another agency shall continue to participate in the program. Participation in this program by the agency to which the operations were transferred will not be affected.

(c) Where a PES agency participating in a LSS direct reimbursement rating and payment program becomes self-insured, the bureau will calculate a buyout and any obligations owed by the PES agency under the program will be included in the buyout.

(B) Terminating a LSS program.

(1) A PES agency may request, in writing, to terminate a LSS program after the three year minimum commitment period has been completed. The agency's participation in the program will automatically be renewed for another three years unless the written request is submitted.

(2) A PES agency shall submit a request to terminate a program before the first day of the second month of the quarter the three year commitment ends. For example, if the PES agency started participating in the LSS program or its participation was renewed for the policy year beginning July 1, 2013, the request must be submitted before May 1, 2016.

(3) Once a PES agency terminates a LSS program, the agency is no longer eligible to participate in this program.

Last updated June 30, 2026 at 1:05 PM

History

Effective: July 1, 2016
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-36 Administrative cost contribution.

(A) The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to calculate contributions for administrative costs attributable to the activities of the industrial commission, the bureau of workers' compensation board of directors, and the bureau of workers' compensation pursuant to sections 4121.121, 4123.341, and 4123.342 of the Revised Code. The administrator hereby sets administrative cost contributions for public employer state agencies as indicated in paragraph (D) of this rule for the bureau of workers' compensation and the bureau of workers' compensation board of directors. Based upon the information provided to the administrator by the industrial commission pursuant to section 4123.342 of the Revised Code, the administrator, with the approval of the chairperson of the industrial commission, hereby sets administrative cost contributions for public employer state agencies as indicated in paragraph (E) of this rule for the industrial commission.

(B) The administrative cost contributions due for each employer, except for self-insuring employers, are set in accordance with section 4123.341 of the Revised Code.

(C) Whenever administrative cost contributions established under this rule and rule 4123-17-32 of the Administrative Code prove inadequate or excessive, the same may be adjusted at any time during the biennial period.

(D) Administrative cost contributions for the bureau of workers' compensation and bureau of workers' compensation board of directors for public employer state agencies are 19.43 per cent of premium effective July 1, 2026.

(E) Administrative cost contributions for the industrial commission for public employer state agencies are 7.81 per cent of premium effective July 1, 2026.

Last updated July 1, 2026 at 7:48 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-37 Employer contribution to the safety and hygiene fund.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to approve contributions to the state insurance fund by employers pursuant to sections 4121.121 and 4121.37 of the Revised Code. The administrator hereby establishes the amount of premium to be set aside to fund the division of safety and hygiene to be one per cent of paid premium for public employer taxing districts effective January 1, 2027, one per cent of paid premium for public employer state agencies effective July 1, 2026, and one per cent of paid premium for private employers effective July 1, 2026.

Last updated July 1, 2026 at 7:48 AM

History

Effective: July 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-40 Self-insured buy-out factors.

The administrator of workers' compensation, with the advice and consent of the bureau of workers' compensation board of directors, has authority to establish factors for the purpose of implementing the procedure for self-insurance buy-outs. The administrator hereby adopts factors to establish the liability of a private employer or a public taxing district employer requesting to transfer from state insurance fund coverage to self-insurance with the buy-out calculated upon the pure premium paid by the employer on payroll for a seven calendar year period, as provided in paragraph (M) of rule 4123-19-03 of the Administrative Code. The factors indicated in attached appendix A shall apply to all applications.

View Appendix

Last updated July 2, 2024 at 11:36 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-41 Retrospective rating definitions applicable to any employer.

Rules 4123-17-41 to 4123-17-54 of the Administrative Code apply to individual employer retrospective rating. As used in rules 4123-17-41 to 4123-17-54 of the Administrative Code:

(A) "Minimum premium" means the fixed cost chargeable to an employer, independent of the claims costs of the employer during the year of experience.

(B) "Maximum premium" means the employer's experience-rated premium multiplied by the maximum premium percentage selected by the employer.

(C) "Per claim limit" means the maximum chargeable costs for each claim incurred during the retrospective-rated period, as selected by the employer.

(D) "Retrospective policy year" or "policy year" means the fiscal year beginning July first for private employers and the calendar year beginning January first for public employer taxing districts.

(E) "Evaluation period" means the ten-year period beginning with the first day of the policy year. Annual evaluations will occur throughout the evaluation period. At the end of the evaluation period, final settlement will be made.

(F) "Final settlement" means the final determination of premium for a policy year including any remaining reserves for claims occurring in the policy year. This determination will occur at the end of the evaluation period and will terminate the plan for that policy year.

(G) "Annual evaluation" means a statement of claim costs and premium. This information will be posted to the employer's online bureau account.

(H) "Incurred losses" are compensation payments, medical payments, and reserves, excluding any losses defined in paragraphs (G)(4) and (G)(5) of rule 4123-17-03 of the Administrative Code. Reserves will be assigned at the end of the evaluation period.

(I) "Retrospective premium" means the compilation of minimum premium, all medical costs, indemnity, and any remaining reserves at the end of the ten-year evaluation period.

Last updated March 22, 2024 at 11:19 AM

History

Effective: July 3, 2022
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-42 Eligibility for retrospective rating.

(A) An employer that is either a private or a public employer taxing district as defined in division (B)(1) of section 4123.01 of the Revised Code may be eligible for either the tier I or tier II retrospective rating plan depending upon satisfying the eligibility requirements for either the tier I or tier II retrospective rating plan as described in this rule.

(B) For both the tier I and tier II retrospective rating plans, the employer must satisfy the following requirements as of the application deadline:

(1) The employer must be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code.

(2) The employer cannot have cumulative lapses in workers' compensation coverage in excess of fifteen days within the last five rating years.

(3) The employer must report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year no later than the date set forth in rule 4123-17-14 of the Administrative Code. An employer will be deemed to have met this requirement if the bureau receives the payroll report and the employer pays premium associated with such report before the expiration of any grace period established by the administrator pursuant to paragraph (B) of rule 4123-17-16 of the Administrative Code.

(4) The employer must be in an active policy status. The administrator may waive this requirement for a new business entity moving into Ohio. For purposes of this rule, "active policy status" does not include a policy that is a no coverage policy or a policy that is lapsed.

(5) The employer's estimated experience-rated premium for the retrospective rating year must be greater than or equal to the minimum experience-rated premium threshold listed on the employer's retrospective rating minimum premium percentages table, contained in the appendices to rule 4123-17-53 of the Administrative Code. If estimated premium is less than the minimum experience-rated premium threshold listed on the employer's retrospective rating minimum premium percentages table, the bureau will reject the application. In the event the estimated experience-rated premium is equal to or greater than the minimum premium threshold but the actual premium is less than the minimum experience-rated premium threshold, the retrospective rating plan remains in effect for that risk and the minimum premium is based on the minimum experience-rated premium threshold multiplied by the appropriate minimum premium percentage for the hazard group and the claim limit/maximum premium percentage selected.

(C) In addition to the requirements of paragraph (B) of this rule, for the tier I retrospective rating plan, a private employer must submit audited financial statements prepared in accordance with generally accepted accounting principles (GAAP) to satisfy the following requirements:

(1) The employer must satisfy financial standards demonstrating strength and stability. In reviewing the financial requirements of the employer, the bureau shall consider, but is not limited to, the following criteria, as applicable:

(a) The employer's trend of operating profit for a minimum of three years;

(b) The employer's trend of net income for a minimum of five years;

(d) Significant asset size of the employer in the state of Ohio;

(e) A total liabilities/equity ratio of no greater than four to one;

(f) The employer's debt structure, including but not limited to current versus long term debt and recent drastic changes in debt;

(g) The employer's retained earnings trend;

(h) Whether the employer has significant fluctuations in specific balance sheet numbers from one year to the next; and

(i) The employer's bond rating.

(2) The employer shall demonstrate the ability to maintain its financial viability and to cover all costs of the retrospective rating plan through closure, in the event of a catastrophic or severe workers' compensation loss.

(3) The employer cannot have entered into a part-pay agreement for payment of assessments due the state insurance fund for the past three rating years preceding the beginning date of the retrospective policy year.

Alternatively, the employer may provide a letter of credit that is equal to the maximum premium for the applicable policy year.

(D) In addition to the requirements of paragraph (B) of this rule, for the tier I retrospective rating plan, the bureau will obtain a public employer taxing district's audited or reviewed financial statements prepared in accordance with generally accepted accounting principles (GAAP) that are available on the state of Ohio auditor's website. The bureau reserves the right to obtain additional financial information from the public employer taxing district. The bureau will review the public employer taxing district's financial statements to satisfy the following requirements:

(1) The public employer taxing district must satisfy financial standards demonstrating strength and stability. In reviewing the financial requirements of the public employer taxing district, the bureau shall consider, but is not limited to, the following criteria, as applicable:

(a) Significant asset size of the public employer taxing district in the state of Ohio;

(b) The public employer taxing district's debt structure, including but not limited to current versus long term debt and recent drastic changes in debt;

(c) Whether the public employer taxing district has significant fluctuations in amounts reported on the balance sheet and statement of operations from one year to the next; and

(d) The public employer taxing district's underlying or uninsured bond rating.

(2) The public employer taxing district shall demonstrate the ability to maintain its financial viability and to cover all costs of the retrospective rating plan through closure, in the event of a catastrophic or severe workers' compensation loss.

(3) The public employer taxing district cannot have entered into a part-pay agreement for payment of assessments due the state insurance fund for the past three rating years preceding the beginning date of the retrospective policy year.

(4) The public employer taxing district in making its initial application for retrospective rating, cannot be under fiscal watch or fiscal emergency pursuant to section 118.022, 118.04 or 3316.03 of the Revised Code as of the application deadline for retrospective rating.

(E) In addition to the requirements of paragraph (B) of this rule, for the tier II retrospective rating plan:

(1) A private employer must submit audited financial statements prepared in accordance with generally accepted accounting principles (GAAP).

(2) The bureau will obtain a public employer taxing district's audited or reviewed financial statements prepared in accordance with GAAP or other comprehensive basis of accounting as permitted in Ohio auditor of state bulletin 2005-002 from the state of Ohio auditor's website. The bureau reserves the right to obtain additional financial information from the public employer taxing district.

(3) For a private employer that does not demonstrate the ability to satisfy the financial criteria of paragraph (C) of this rule, or a public employer taxing district that does not demonstrate the ability to satisfy the financial criteria of paragraph (D) of this rule, the financial statements provided by the employer must demonstrate the ability to sustain losses that are at the maximum claim limit for the retrospective rating plan and still maintain its financial viability.

Last updated July 27, 2023 at 8:44 AM

History

Effective: July 1, 2023
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-43 Application for retrospective rating plan.

(A) All operations of an employer electing retrospective rating are subject to retrospective rating.

(B) The application must be filed on a bureau application form for the retrospective rating plan. The application must be completed in its entirety, including but not limited to the selection of a per-claim limit and maximum premium per cent. The absence of pertinent information will result in the application being rejected.

(C) The application and all other required information must be filed by the application deadline. An application for a retrospective rating plan is applicable to only one policy year. Continuation of a plan for subsequent years is subject to filing of an application on a yearly basis and the meeting of eligibility requirements each year.

(D) All changes to the original application must be filed on another application form for the retrospective rating plan prior to the filing deadline. Any changes made must be completed in writing and signed by an officer of the company and filed prior to the filing deadline. Any changes received by the bureau after the filing deadline will not be accepted. The latest application form or rescission received by the bureau prior to the filing deadline will be used in determining the premium obligation.

Last updated February 18, 2022 at 11:48 AM

History

Effective: June 12, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-44 Minimum retrospective premium.

(A) The minimum annual premium due shall not be less than the minimum experience-rated premium threshold times the minimum premium percentage for the employer's hazard group, claim limit, and maximum premium percentage for the applicable policy year. The premium will be subject to the premium sized adjustment described in rule 4123-17-03.3 of the Administrative Code.

(B) If estimated experience-rated premium is greater than or equal to the minimum experience-rated premium threshold listed on the employer's retrospective rating minimum premium percentages table, contained in the appendices to rule 4123-17-53 of the Administrative Code, but actual experience-rated premium is less than the minimum experience-rated premium threshold listed, the minimum premium due is the minimum experience-rated premium threshold times the minimum premium percentage for the employer's hazard group, claim limit, and maximum premium percentage.

(C) The minimum annual premium is due and payable even if the employer has no claims costs during the evaluation period for the applicable policy year.

(D) The minimum premium will be recalculated at the time the employer submits actual payroll pursuant to rule 4123-17-14 of the Administrative Code.

Last updated February 18, 2022 at 11:48 AM

History

Effective: June 12, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-45 Initial computation.

(A) The hazard group for an employer shall be determined as follows:

(1) The employer's experience-rated premium is totaled for each hazard group for the most recently completed policy year. The employer's hazard group is the group with the highest percentage of premium for the recently completed policy year;

(2) For an employer new to Ohio without a reported payroll, the hazard group is based on the employer's application for workers' compensation coverage;

(3) Hazard groups are defined as follows:

(a) For private employers, appendix C to rule 4123-17-72 of the Administrative Code; and

(b) For public employer taxing districts, appendix E to rule 4123-17-72 of the Administrative Code.

(B) The bureau shall notify the employer of the estimated minimum premium percentage based on the limits selected by the employer and the payroll of the employer. The premium rates on the payroll reports received by the employer for the policy year will be calculated using the minimum premium per cent and the premium sized adjustment described in rule 4123-17-03.3 of the Administrative Code.

Last updated February 18, 2022 at 11:48 AM

History

Effective: June 12, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-46 Premium adjustments.

(A) Upon completion of a policy year and annually throughout the evaluation period, the employer's aggregate retrospective-rated premium for the policy year will be determined based on the incurred losses and on the audited payrolls of the employer. The bureau shall annually send the employer an annual evaluation within approximately four months following the end of the policy year.

(B) Incurred losses will be based on compensation payments and medical payments, as defined in rule 4123-17-41 of the Administrative Code. The cost of permanent total disability claims and death claims will be charged to the employer as the payments are made, and the reserve will be billed in the final settlement.

(C) If the retrospective premium due is less than the retrospective premium paid as of the prior evaluation date, the difference, subject to the minimum premium, less assessments due any fund administered by the bureau will be refunded to the employer.

(D) If the retrospective premium due is greater than the retrospective premium paid as of the prior evaluation date, the difference must be paid to the bureau within forty-five days after the due date of the invoice billing the additional retrospective premium, or the employer will be subject to penalties as provided in rule 4123-17-48 of the Administrative Code.

(E) Values used in an annual evaluation will not be revised for any reason other than clerical error. The bureau must be notified of any such errors, in writing, within sixty days after the due date on the invoice billing the retrospective premium.

(F) Premiums are subject to minimum and maximum premium limitations as selected by the employer.

Last updated November 2, 2021 at 10:12 AM

History

Effective: November 1, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-47 Final settlement.

(A) At the end of the tenth-year determination of retrospective premium, the plan for that retrospective policy year shall terminate.

(B) As part of the final determination of retrospective premium, the bureau will evaluate the employer's claims and establish reserves. Reserves will be developed for claims, other than allowed permanent total disability claims and allowed death claims, using the balance sheet reserve table in effect as of the ending date of the evaluation period.

(D) The final settlement calculated, subject to the minimum and maximum premium of the plan selected, shall be paid to the bureau within forty-five days after the due date the the additional retrospective premium.

(E) The final determination of a retrospective premium will not be revised for any reason other than clerical error.

Last updated February 18, 2022 at 11:48 AM

History

Effective: June 12, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-48 Penalties.

Any retrospective-rated employer failing to file a report of payroll expenditures or failing to pay premium when due, as prescribed in rules 4123-17-14, 4123-17-14.2, 4123-17-46, and 4123-17-47 of the Administrative Code, will be penalized in accordance with paragraph (C) of rule 4123-17-16 of the Administrative Code . All premium due as a result of the selection of retrospective rating, including the minimum premium and premium as a result of annual evaluations, shall be included as premium as used in this rule.

Last updated February 18, 2022 at 11:48 AM

History

Effective: June 12, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-49 Disability relief.

Disability relief, as permitted under section 4123.343 of the Revised Code and rule 4123-3-35 of the Administrative Code, will be applied to reducible claims costs as limited by the per-claim limit selected by the employer.

Last updated April 2, 2024 at 9:08 AM

History

Effective: April 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-51 Termination and transfers.

(A) A risk may not retroactively include claims experience in a plan, exclude claims experience from a plan nor voluntarily terminate a plan during the evaluation period.

(B) Successor: retrospective-rated predecessor: experience-rated, base-rated, non-complying or self-insured

Where one legal entity that has established coverage and is a retrospective-rated employer wholly succeeds one or more legal entities having established coverage and the predecessor entities are either experience-rated, base-rated, non-complying or self-insured at the date of succession, the costs incurred and payroll reported by the predecessor from the date of succession to the end of the policy year, shall be included in the successor's retrospective rating plan. The successor remains liable for any and all charges associated with the predecessor. If the predecessor had at any time participated in a retrospective policy plan, the successor remains liable for any and all charges associated with the retrospective policy plans. The adjustment for combinations in the experience rating system will follow the same rules that are in effect as of the date of succession.

Where one legal entity that has established coverage and is a self-insured employer wholly succeeds one or more entities that are retrospective-rated, the retrospective-rated predecessor's plan(s) shall terminate as of the ending date of the evaluation period. Payroll reported and claims incurred on or after the date of succession will be the responsibility of the successor. The successor shall remain responsible for all liabilities of the predecessor, including but not limited to costs associated with any retrospective policy years still in the evaluation period. The minimum premium for the current policy year will be based on the predecessor's annualized payroll.

(D) Successor: experience-rated or base-rated predecessor: retrospective-rated

Where one legal entity that has established coverage and is an experience-rated or based-rated employer wholly succeeds one or more entities that are retrospective-rated, the retrospective-rated predecessor's plan(s) shall terminate as of the ending date of the evaluation period. Payroll reported and claims incurred on or after the date of succession will be the responsibility of the successor under its experience rated plan. The successor shall remain responsible for all liabilities of the predecessor, including but not limited to costs associated with any retrospective policy years still in the evaluation period. The minimum premium for the current policy year will be based on the predecessor's annualized payroll.

(E) Successor: retrospective-rated predecessor: retrospective-rated

If the successor and the predecessor are retrospective-rated employers for the current policy year, the successor shall be retrospective-rated based on the combined experience of the predecessor and the successor. The successor remains liable for any and all retrospective-rated premiums or other charges associated with the predecessor. The adjustment for combinations in the experience rating system will follow the same rules that are in effect as of the date of succession.

(F) Successor: entity not having coverage predecessor: retrospective-rated

When an entity not having coverage wholly succeeds a retrospective-rated entity, the experience of the predecessor shall be transferred to the successor-employer effective as of the actual date of succession. The successor remains liable for any and all open retrospective-rated premium or other charges associated with the predecessor. The successor entity will become retrospective-rated as of the date of succession until the end of the policy year, with the same plan parameters chosen by the predecessor risk. The adjustment for combinations in the experience rating system will follow the same rules that are in effect as of the date of succession.

(G) Successor: cancels coverage predecessor: no predecessor

If a current or previously retrospective-rated employer cancels coverage and does not transfer or combine operations with another entity, all open retrospective policy years will be terminated as of the date of cancellation. If the employer was retrospective-rated during the two most recent rating years, the final premium for each of those years will be the maximum premium for the plan selected by the employer. The maximum premium for the current year will be based on the employer's annualized payroll. If the employer was retrospective-rated in other years of the evaluation period, the final premium for each of those years will be calculated as stated in rule 4123-17-47 of the Administrative Code.

(H) Successor: files a petition for bankruptcy predecessor: no predecessor

If a current or previously retrospective-rated employer with open policy year(s) files a petition for bankruptcy under chapter 7 or chapter 11 of the Federal Bankruptcy Law, that employer shall notify the bureau's law section by certified mail within five working days from the date of the bankruptcy filing. The bureau will petition the bankruptcy court to take appropriate action to protect the health of the state insurance fund and other related funds.

(I) Successor and/or predecessor: open retrospective-rated policy years in the evaluation period.

If the successor and predecessor employers are not currently retrospective-rated but either or both have open retrospective-rated policy years in the evaluation period, the successor shall be liable for any and all retrospective-rated premiums or other charges associated with the predecessor. The adjustment for combinations in the experience rating system will follow the same rules that are currently being used.

(J) Partial transfer

If an entity partially succeeds another entity and the predecessor entity has any retrospective policy years in the evaluation period, the predecessor entity remains liable for all premium associated with claims incurred prior to the date of the partial transfer. If the financial capability of the predecessor entity is not sufficient to cover the costs of the retrospective rating plan, the successor shall be liable for all unpaid costs of the predecessor's retrospective rating plan through closure. If the successor is retrospective-rated in the current policy year and the effective date of the partial transfer is other than the beginning of the rating year, the successor will continue to be rated in the same manner as prior to the transfer. The successor will be liable for any payroll and/or claims incurred from that part of the predecessor entity which was transferred, beginning on the date of the transfer. If the successor has retrospective policy years in the evaluation period, the successor remains liable for all charges associated with retrospective rating plan(s), whether or not the successor is retrospective rated as of the effective date of the partial transfer. The adjustment for partial transfers in the experience rating system will follow the same rules that are in effect as of the date of succession.

(K) Transfer or sale of assets only

In the case of the transfer or sale of assets without transfer of liability or stock, the transferor who is now retrospective-rated or has been retrospective-rated with policy year(s) still in the evaluation period shall notify the bureau's actuarial section by certified mail within five working days of the date of transfer. The bureau shall schedule and hold a hearing within sixty days of such notification, or in the event of no notification, within sixty days of receiving information which indicates such a transfer may have occurred. At this hearing the bureau shall determine and set responsibility for funding the as yet unpaid costs associated with the retrospective policy year(s) still in the evaluation period.

Last updated February 18, 2022 at 11:48 AM

History

Effective: June 12, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-52 Parameters of the retrospective rating plan.

(A) An employer participating in retrospective rating will pay the following:

(1) Minimum premium. The minimum premium depends on the assigned hazard group, the per claim limit selected by the employer, the maximum premium limit selected by the employer, and the employer's base-rated premium or experience-rated premium. The employer's base-rated premium or experience-rated premium is assumed to be at least the minimum experience-rated/base-rated premium threshold listed on the employer's retrospective rating minimum premium percentages table contained in the appendices to rule 4123-17-53 of the Administrative Code. The minimum premium includes employer contributions to cover safety and hygiene costs, surplus costs, and the cost of losses exceeding the per claim and the maximum premium limitations and those health partnership program costs associated with the losses exceeding the per claim and the maximum premium limitations. The minimum premium is subject to the premium sized adjustment described in rule 4123-17-03.3 of the Administrative Code.

(2) Premium based on paid losses. The employer will pay for any compensation payments, including death and permanent total disability, and medical payments made in covered claims. Billings to the employer will be sent annually for ten years to collect for these medical and compensation payments.

(3) Premium based on claim reserves. The employer will pay the value of reserves on claims evaluated as of the end of the tenth year.

(4) Premium for health partnership program costs on retained losses. In each evaluation period associated with a policy year, the employer will pay an additional premium based on a percentage, known as the loss conversion factor applied to the paid losses and claims reserves to cover the associated health partnership program costs of those paid losses or claims reserves. Each policy year will have a specific loss conversion factor, determined before the start of the policy year, which will apply for the ten year retrospective period.

(B) Surplus charges in claims will not be charged to the employer.

(C) Individual claims costs will be limited to the per claim limit selected by the employer. The usual experience rating limitations will not apply.

(D) The employer's maximum premium will be limited to a percentage of its base-rated or experience-rated premium as selected by the employer. That is, premiums based on losses, reserves and health partnership program costs charged to the employer cannot exceed the maximum premium minus the minimum premium. The maximum premium is subject to the premium sized adjustment described in rule 4123-17-03.3 of the Administrative Code

(E) The premium for health partnership program costs on retained losses is an aggregate calculation made on the total billings to an employer for either paid losses or reserves. As such, premiums associated with health partnership program costs are not allocated to individual claims, and therefore are not considered when evaluating whether an individual claim has reached the per claim limit.

(F) When an employer leaves a retrospective rating program and returns to the state fund program, the employer shall be subject to all of the provisions of rule 4123-17-03 of the Administrative Code, classification rates.

(G) An employer removed from retrospective rating for failure to comply with paragraph (B) of rule 4123-17-42 of the Administrative Code will be required to pay:

(1) Claims costs according to this rule for all injuries incurred from the beginning of the policy year in which the employer participated in retrospective rating through the date of removal from the program.

(2) Full experience-rated premium from the date of removal from retrospective rating through the remainder of the policy year.

Last updated February 18, 2022 at 11:48 AM

History

Effective: June 12, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-53 Private employer retrospective rating plan minimum premium percentages.

The administrator hereby sets the private employer retrospective rating plan minimum premium percentages to be effective July 1, 2024, as indicated in the appendixes A, (Tier I, tables A, B, C, D, E, F, and G) and B (Tier II, tables A, B, C, D, E, F, and G) to this rule.

The administrator hereby sets the private employer loss conversion factors to be applied to losses associated with policy years beginning on or after July 1, 2015, as indicated in appendix C to this rule.

View AppendixView AppendixView Appendix

Last updated July 2, 2024 at 11:37 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-54 Public employer retrospective rating plan minimum premium percentages.

The administrator hereby sets the public employer taxing districts retrospective rating plan minimum premium percentages to be effective January 1, 2025, as indicated in appendixes A (Tier I) and B (Tier II) to this rule.

The administrator hereby sets the public employer loss conversion factors to be applied to losses associated with policy years beginning on or after January 1, 2016, as indicated in appendix C to this rule.

View AppendixView AppendixView Appendix

Last updated January 2, 2025 at 10:02 AM

History

Effective: January 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-55 Transitional work development grant and transitional work bonus program.

(A) Definitions.

As used in this rule:

(1) "AEO" and "PEO" have the same meaning as defined in rule 4123-17-15 of the Administrative Code.

(2) "Application deadline" means the applicable application deadline set forth in appendix A or in appendix B to rule 4123-17-74 of the Administrative Code.

(3) "Client employer" has the same meaning as defined in rule 4123-17-15 of the Administrative Code.

(4) "Program period" means the policy year for which the employer elects to participate in the transitional work program.

(5) "Transitional work" has the same meaning as defined in rule 4123-6-01 of the Administrative Code.

(6) "Transitional work developer" means the provider who develops the employer's transitional work program. A transitional work developer shall:

(a) Meet the minimum credentials designated in rule 4123-6-02.2 of the Administrative Code for one of the following provider types:

(i) A vocational rehabilitation case manager,

(ii) An occupational therapist, or

(iii) A physical therapist; and

(b) Complete bureau of workers' compensation sponsored transitional work development training prior to delivering transitional work programs and at two-year intervals.

(B) Eligibility requirements.

(1) To receive benefits under this rule, the employer must meet the following criteria as of the application date for the grant or the application deadline for the transitional work bonus:

(a) The employer must be current with respect to all payments due the bureau, as defined in rule 4123-17-14 of the Administrative Code.

(b) The employer must not have cumulative lapses in workers' compensation coverage in excess of forty days within the preceding twelve months.

(c) The employer must be in an active policy status. For purposes of this rule, "active policy status" does not include a policy that is a no coverage policy or a policy that is lapsed.

(d) The employer must report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year no later than the application deadline.

(2) The following employers shall not be eligible for either a transitional work program development grant or a transitional work bonus under this rule:

(a) Employers paying the minimum administrative charge for the applicable payroll reporting period as set forth in rule 4123-17-26 of the Administrative Code;

(b) State agencies; and

(3) The following employers shall not be eligible to receive a transitional work program development grant under paragraph (C) of this rule:

(a) Employers who have elective coverage only; and

(b) Sole proprietors with zero payroll.

(4) An employer that is found to be ineligible for participation in the program may reapply for a subsequent program period.

(1) An employer interested in obtaining a transitional work program development grant shall apply to the bureau on a form provided by the bureau. In signing the application form, the chief executive officer or designated management representative of the employer is certifying to the bureau that the employer will comply with all program requirements.

(2) The bureau shall evaluate each application to determine the employer's eligibility to receive a transitional work program development grant and shall have the final authority to approve a grant for an eligible employer and to determine the amount of the grant. If, upon review of an application, the bureau determines that it can assist the employer in developing a transitional work program, the bureau may deny the grant and provide assistance to the employer directly.

(3) Transitional work program development grant awards expire five years from the date of the mailing of the notice of approval of the grant. Upon expiration of the grant, the employer loses any remaining grant funds that were awarded but unspent. However, the employer may apply for a new transitional work program development grant.

(4) An employer is eligible for no more than one transitional work program development grant per policy number every five years, calculated from the date of the mailing of the notice of approval of the previous transitional work program development grant. The bureau shall provide assistance to employers as needed to update transitional work programs developed with previous grants.

(5) Grant amounts will be determined by the bureau based on employer size and the complexity of services needed for transitional work services. Factors which may determine appropriate grant amounts may include the employer's:

(a) Payroll;

(b) Job classifications;

(d) Collective bargaining agreements.

(6) The bureau shall not reimburse an employer for costs associated with a transitional work developer's preparing and submitting a proposal to an employer and shall not reimburse for costs determined by the bureau to be ineligible or unnecessary. The bureau may monitor the content and implementation of transitional work services.

(7) The employer shall have and maintain continuous active state fund coverage for a period of one year from the date the bureau disburses the grant funds to the employer. The bureau may recover the entire grant if the bureau determines the employer has failed to maintain coverage as required by this rule.

(D) Transitional work bonus program.

An employer who has developed and implemented a transitional work program may be eligible to receive a transitional work bonus as provided in this rule.

(1) The employer must report actual payroll due upon reconciliation of estimated premium and actual premium for the program period no later than the date set forth in rule 4123-17-14 of the Administrative Code. An employer will be deemed to have met this requirement if the bureau receives the payroll report, and the employer pays premium associated with such report, before the expiration of any grace period established by the administrator of workers' compensation pursuant to rule 4123-17-16 of the Administrative Code.

(a) Failure to comply with paragraph (D)(1) of this rule shall immediately remove the employer from the transitional work bonus program for the current program period, and the employer shall not be eligible for a transitional work bonus for the current program period.

(b) Should an employer fail to comply with paragraph (D)(1) of this rule, the employer may reapply to the transitional work bonus program subject to the eligibility requirements of paragraph (B) of this rule for the next program period.

(2) An employer interested in participating in the transitional work bonus program shall apply to the bureau on a form provided by the bureau. In signing the application form, the chief executive officer or designated management representative of the employer is certifying to the bureau that the employer will comply with all program requirements.

(3) The bureau shall evaluate each application to determine the employer's eligibility to participate in the transitional work bonus program at the time of the application. The bureau shall have the final authority to approve an eligible employer for participation in the transitional work bonus program.

(4) The transitional work program bonus calculation shall occur at six months following the end of the applicable program period. The bureau will evaluate all claims of the employer with injury dates that fall within the applicable program period to determine:

(a) How many of those claims had the potential for transitional work services, and

(b) How many of the claims identified in paragraph (D)(4)(a) of this rule utilized transitional work services.

(5) The bureau will calculate the employer's percentage of claims with potential for transitional work services in which transitional work services were utilized.

(6) The employer will receive a transitional work bonus equal to the percentage calculated pursuant to paragraph (D)(5) of this rule multiplied by a percentage of the employer's pure premium for the applicable program period as set forth in the appendix to rule 4123-17-75 of the Administrative Code. The transitional work bonus will be posted to the employer's account with the bureau.

(7) An AEO or a PEO shall be eligible to receive a transitional work bonus under this rule for claims in which the AEO or the PEO was the employer of record on the date of injury and transitional work services were available under a transitional work program of either the AEO, the PEO or its client employer.

(8) An employer may appeal the bureau's transitional work bonus program application rejection or the bureau's transitional work bonus determination to the bureau's adjudicating committee pursuant to section 4123.291 of the Revised Code and rule 4123-14-06 of the Administrative Code.

(9) Unless an employer notifies the bureau otherwise as outlined below, continued participation in this program for each subsequent program period shall be automatic provided that the employer continues to meet the eligibility requirements set forth in paragraph (B) of this rule.

An employer that elects to opt out of continued participation in this program shall provide written notice to the bureau by the application deadline set forth in this rule.

(10) The transitional work bonus program will gradually be phased out with reductions in the percentage of the empoyer's pure premium for the applicable program period used in the transitional work bonus calculation pursuant to paragraph (D)(6) of this rule and the maximum transitional work bonus per employer, as set forth in the appendix to rule 4123-17-75 of the Administrative Code. The last policy year for the transitional work bonus program will be the policy year beginning July 1, 2025, for private employers, and beginning January 1, 2026, for public employers.

Last updated July 2, 2024 at 11:37 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-56 Safety grant programs.

(A) Pursuant to section 4121.37 of the Revised Code, the administrator of workers' compensation may establish a program of safety grants for safety interventions or research for eligible employers. The safety grant program may provide grant funds to an eligible employer for safety interventions including education, training, research, or purchase of equipment to prevent occupational injuries, illnesses, or fatalities.

(1) The purpose of the safety intervention grant program is for the division of safety and hygiene of the bureau of wokers' compensation to fund employer interventions that reduce the risk of injuries, illnesses, and fatalities in the workplace, investigate the effectiveness of safety interventions in preventing occupational injuries, illnesses, and fatalities and establish safety and health best practices. For this purpose, the bureau may make safety grants to employers as provided in this rule.

(2) If the division of safety and hygiene concludes there are interventions outside the scope of the program, the division of safety and hygiene may establish an unapproved items list to notify employers of specific safety education, training, research, or purchase of equipment that the bureau shall not fund.

(B) The bureau may limit participation in the safety grant program based upon:

(1) The availability of bureau resources for the program;

(2) The merits of the employer's proposal;

(3) The type of employer's policy;

(4) The manual numbers reported under the employer's policy;

(5) The employer's policy history; or

(6) The safety grant program objectives and unapproved items list under paragraph (A) of this rule.

(C) The bureau shall determine whether the employer's policy is eligible for the safety grant program under this rule. The employer must satisfy the following criteria:

(1) The safety grant program is available only to a private state fund employer, a public employer taxing district, a marine industry fund employer, or a coal-workers' pneumoconiosis fund employer;

(2) The employer shall have active state fund-coverage to participate in the safety grant program;

(3) The employer shall have active coverage for one year prior before applying for a safety grant and shall maintain active coverage for the one year after implementation of the safety intervention under the safety grant approved by the bureau;

(4) The employer shall be current with respect to all payroll reporting and required payments due to any fund administered by the bureau;

(5) The employer shall not have more than forty days of cumulative lapses in workers' compensation coverage within the prior twelve months.

(D) The bureau will assess whether the employer's proposed safety intervention is eligible to participate in the safety grant program under this rule.

(1) The employer's proposed safety intervention shall explain how one of the following objectives is attained through receipt of safety grant funds:

(a) Reduction of risk of workplace injuries, illnesses, or fatalities; or

(b) Advancement of research into the prevention of workplace injuries, illnesses, or fatalities.

(2) The owner, chief executive officer, chief financial officer or persons having fiduciary responsibilities with the employer may be required to meet with a bureau consultant to review the safety grant program application.

(3) The bureau shall review and evaluate the safety grant application. The bureau may also assess and evaluate the employer's safety and loss prevention and control programs. If the bureau accepts the employer into the safety grant program, the employer shall submit reports and case studies to the bureau as required by the bureau for a period of one year following the purchase and implementation of the safety intervention.

(4) The bureau and employer shall enter into a written agreement detailing the rights, obligations, and expectations of the parties for performance of the safety grant program.

(5) The employer may not apply for a safety grant for reimbursement of previously purchased safety interventions.

(6) The employer shall agree to not eliminate jobs or reduce employment due to the intervention funded by the safety grant program. If the bureau determines an employer has violated this provision, the employer shall be immediately disqualified from participation in the safety grant program, and the employer shall return all disbursed safety grant funds to the bureau for the intervention that eliminated jobs or reduced employment.

(7) The bureau shall establish policies and processes for adding or removing safety interventions on the unapproved items list. The bureau shall not accept an employer's proposed intervention if the employer's proposed intervention contains any item on the unapproved items list.

(E) The bureau may meet with the owner, chief executive officer, chief financial officer, or persons having fiduciary responsibilities with the employer to evaluate the employer's progress in the safety grant program. The employer shall provide the bureau access to records or personnel to conduct research into the effectiveness of the safety grant program.

(F) An employer who complies with the requirements of the safety grant program under this rule shall be eligible to receive a grant from the bureau as provided in the written agreement.

(1) The bureau may establish by written agreement with the employer the maximum amount of the safety grant funds.

(2) The bureau may establish by written agreement with the employer a requirement for matching funds from the employer in a ratio to be determined by the bureau.

(3) The bureau shall monitor the employer's use of the safety grant program funds. The bureau may recover the entire grant if the bureau determines that the employer has not used the grant for the purposes of the safety grant program or has otherwise violated the written agreement of the safety grant program.

(G) Reconsideration of determination of ineligibility to participate in, or disqualification from, the safety grant program.

(1) An employer may request reconsideration of a decision finding the employer did not meet the requirements provided in paragraph (C) of this rule or disqualifying the employer from continued participation in the safety grant program. The request must be in writing and filed with the superintendent of the division of safety and hygiene within thirty days of the notification of the decision.

(2) The employer may submit a request for reconsideration of the superintendent's decision to the adjudicating committee in accordance with the provisions contained in rule 4123-14-06 of the Administrative Code.

(H) Upon the approval, purchase, and implementation of the safety intervention, the employer shall provide to the bureau sufficient documentation on the use of the funds, including proof of payment, proof of the employer's and bureau's contribution, and proof that the funds were fully applied to the approved safety intervention.

(1) The employer shall purchase, implement, and provide purchase documentation for all approved safety interventions within the time period determined by the superintendent from the date that the bureau disburses safety grant funds to the employer.

(2) The purchase and implementation of the safety intervention can take place only after the approval of the safety grant funds.

(3) The bureau may extend the period defined in paragraph (H)(1) of this rule by up to ninety days in special circumstances where the employer, for reasons beyond their control, experiences delay in purchasing or implementing the approved safety intervention. The employer must request additional time in writing that explains the special circumstances, with any supporting documentation, and specifying the additional time needed. The bureau may grant additional extensions of up to ninety days, pursuant to the same requirements and guidelines for the initial extension, but the cumulative period of all extensions shall not exceed one year.

(I) The bureau shall evaluate the effectiveness of the safety grant program on a periodic basis. The bureau may publish reports of the safety grant program's effectiveness and research findings to assist employers in preventing workplace injuries and illnesses.

(J) Marine industry fund and coal-workers' pneumoconiosis fund safety grants.

(1) A marine industry fund employer or a coal-workers' pneumoconiosis fund employer applying for a safety grant is subject to paragraphs (A) to (I) of this rule.

(2) The bureau's division of safety and hygiene shall determine whether the marine industry fund employer or the coal-workers' pneumoconiosis fund employer is eligible for the safety grant program under this rule. The safety grant program in this rule is available only to a marine industry fund or a coal-workers' pneumoconiosis fund employer that satisfies the following additional criteria:

(a) A marine industry fund employer shall have and shall maintain active state fund coverage under rule 4123-17-19 of the Administrative Code.

(b) A coal-workers' pneumoconiosis fund employer shall have and shall maintain active state fund coverage under rule 4123-17-20 of the Administrative Code.

(c) A coal-workers' pneumoconiosis fund employer may only use the safety grant to purchase equipment to prevent coal workers' pneumoconiosis.

(3) Additional employer responsibilities include:

(a) A marine industry fund employer or a coal-workers' pneumoconiosis fund employer shall contact the local bureau customer service office to schedule a visit by a bureau safety consultant.

(b) A coal-workers' pneumoconiosis fund employer shall also schedule a visit by a mine safety inspector from the Ohio department of natural resources.

Last updated December 11, 2023 at 9:52 AM

History

Effective: December 9, 2023
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-56.1 Workplace wellness grant program rule.

(A) For purposes of this rule:

(1) "Health risk factors" means physical and mental characteristics that can be modified, nearly always with much less cost compared to waiting for sickness and then attempting to treat the disease.

(2) "Employer" or "employer" means a private state fund employer, a public employer taxing district, a marine industry fund employer, or a coal-workers' pneumoconiosis fund employer.

(3) "Workplace wellness program" means a health and wellness program in the workplace which consists of a biometric screening and health risk appraisal, and activities based on the results of the screening, program measurements and policies.

(B) Workplace wellness grant program.

(1) Pursuant to section 4121.37 of the Revised Code, the administrator may establish a program of workplace wellness grants for the prevention of occupational injuries and illnesses for which an employer is eligible under this rule. The workplace wellness grant may include grants to an employer to provide funds to address health risk factors to reduce the number and severity of workplace injuries and illnesses.

(2) The bureau shall determine whether the employer is eligible for the workplace wellness grant program under this rule. The bureau may limit participation in the workplace wellness grant program based upon the availability of bureau resources for the program and upon the merits of the employer's proposal. The bureau shall award grant funds for employers on a first come, first serve basis. The workplace wellness grant program is available to a state-fund employer that satisfies the following criteria:

(a) The employer shall be current with respect to all payroll reporting and payments due to any fund administered by the bureau.

(b) The employer shall not have more than forty days of cumulative lapses in workers' compensation coverage within the prior twelve months.

(d) For grants to an employer for the research and implementation of workplace wellness programs, the employer shall submit to the bureau an application for participation in the workplace wellness grant program. The employer shall demonstrate a need for workplace wellness grant program.

(e) The employer is not eligible for a workplace wellness program grant if the employer has an existing workplace wellness program.

(3) The bureau shall assess the employer's workplace wellness proposal and shall review the workplace wellness grant program application, including the baseline assessment of the worksite provided in the application.

(a) If the bureau accepts the employer into the workplace wellness grant program, the employer shall submit an annual report to the bureau for up to four years following the implementation of the wellness program. The employer shall develop an implementation strategy plan for its workplace wellness grant program.

(b) The bureau and employer shall enter into a written agreement detailing the rights, obligations, and expectations of the parties for performance of the workplace wellness grant program.

(c) The employer shall implement the wellness program within three months from the date that the bureau disburses the grant funds to the employer. The implementation of the workplace wellness program cannot take place before the disbursement of the grant funds.

(4) The employer shall agree to not eliminate jobs or reduce employment due to the implementation of the workplace wellness program.

(5) The bureau may meet with the owner, chief executive officer, chief financial officer, or persons having fiduciary responsibilities with the employer to evaluate the employer's progress in the workplace wellness grant program.

(6) An employer who complies with the requirements of the workplace wellness grant program under this rule shall be eligible to receive a grant from the bureau as provided in the written agreement.

(a) The bureau may establish a limit for the amount of monies it disburses for the workplace wellness grant and this amount shall be established by written agreement with the employer.

(b) The bureau may require that the employer must execute its workplace wellness program through an approved vendor.

(7) Reconsideration of determination of eligibility.

(a) An employer may request reconsideration from a decision finding the employer did not meet the requirements provided in paragraph (B)(2) or (B)(3) of this rule. The request must be in writing and filed with the superintendent of the division of safety and hygiene within thirty days of the notification of the decision.

(b) The employer may submit a request for reconsideration of the superintendent's decision to the adjudicating committee.

(c) The adjudicating committee shall consider the request and make a recommendation on the employer's eligibility to the administrator.

(d) The decision of the administrator shall be final.

(8) Upon the approval of the proposed wellness program, the employer shall provide to the bureau documentation on the use of the funds, including submission of original paid itemized invoices, proof of payment, proof of the employer's contribution, and cancelled checks that demonstrate the employer spent all workplace wellness grant funds toward the approved expenditures.

(9) The bureau shall evaluate the research data from the workplace wellness grant program on a periodic basis. The bureau may publish reports of the research to assist employers in preventing workplace injuries and illnesses.

(1) An employer participating in the workplace wellness grant program shall be eligible to continue participating in the program only if the employer maintains active workers' compensation coverage according to the following standards:

(a) The employer must be current with respect to all payroll reporting and payment due to any fund administered by the bureau.

(b) The employer must not have cumulative lapses in workers' compensation coverage in excess of forty days within the prior twelve months.

(2) After the first year of enrollment, an employer participating in the workplace wellness grant program shall be eligible to renew its application and continue participation at the discretion of the bureau.

(3) Applications submitted for the workplace wellness grant program may be processed and renewed by the bureau on a rolling basis.

(D) Disqualification from the workplace wellness grant program.

(1) An employer shall be immediately disqualified from the participation in the workplace wellness grant program if the employer is found by the bureau to have knowingly misrepresented information on the initial application for employee participation and compliance with program requirements.

As used in this paragraph, "knowingly" means that the employer had actual knowledge of the misrepresentation and was aware that the misrepresentation would cause a certain result.

(2) An employer shall be immediately disqualified from participation in the workplace wellness grant program if the bureau determines the employer has violated any state or federal statutes pertaining to confidential personal information and personal health information, including but not limited to the statutes and rules contained in rule 4123-10-04 of the Administrative Code.

(3) An employer shall be immediately disqualified from participation in the workplace wellness grant program if the bureau determines the employer has coerced employees to participate in the workplace wellness grant program. As used in this paragraph, "coerced" is defined as intimidating an employee to compel the individual to do some act against his or her will by the use of psychological pressure, physical force, or threats. The definition of coercion as stated in section 2905.12 of the Revised Code shall also apply to this paragraph.

(4) An employer shall be immediately disqualified from participation in the workplace wellness grant program if the bureau determines the employer eliminated jobs or reduced employment due to the implementation of its workplace wellness program.

(5) The bureau may disqualify an employer from the workplace wellness grant program if the bureau determines that the employer has not used the grant for the purposes of the workplace wellness grant program or has otherwise violated the written agreement.

(6) An employer shall be disqualified from continued participation in the workplace wellness grant program if the employer violated paragraph (C)(1) of this rule.

(7) An employer that is disqualified from participation in the workplace wellness grant program under the preceding paragraphs shall make restitution of all monies awarded by the bureau for participating in the program.

(8) Reconsideration of disqualification from workplace wellness program.

(a) An employer may request reconsideration from a decision finding the employer is disqualified from the workplace wellness program. The request must be in writing and filed with the superintendent of the division of safety and hygiene within thirty days of the notification of the decision.

(b) The employer may submit a request for reconsideration of the superintendent's decision to the adjudicating committee.

(c) The adjudicating committee shall consider the request and make a recommendation on the employer's eligibility to the administrator.

(d) The decision of the administrator shall be final.

(e) {Enter paragraph text here}

Last updated June 30, 2026 at 1:05 PM

History

Effective: March 26, 2018
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-56.2 Safety council rebate program.

(A) Definitions.

For the purposes of this rule,

(1) "Local safety council" means an entity contracted with the bureau of workers' compensation to provide a safety campaign in accordance with standards set forth by the superintendent of the division of safety and hygiene.

(2) "Program year" means July first to June thirtieth, inclusive.

(3) "Superintendent" means the superintendent of the division of safety and hygiene or the superintendent's designee.

(B) For each program year, the administrator may establish a safety council rebate.

(1) The superintendent shall determine safety council rebate eligibility requirements for each program year, including the enrollment deadline, and publish such program requirements no later than sixty days prior to the start of the program year.

(2) The safety council rebate shall be equal to the amount identified in the appendix to rule 4123-17-75 of the Administrative Code times the employer's pure premium costs during the program year.

(1) To receive a rebate as set forth in paragraph (B) of this rule the employer must meet the following criteria as of the enrollment deadline:

(a) The employer must be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code.

(b) The employer must not have cumulative lapses in workers' compensation coverage in excess of forty days within the prior twelve months immediately preceding the enrollment deadline.

(c) The employer must report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year no later than the date set forth in rule 4123-17-14 of the Administrative Code. An employer will be deemed to have met this requirement if the bureau receives the payroll report and the employer pays premium associated with such report before the expiration of any grace period established by the administrator pursuant to paragraph (B) of rule 4123-17-16 of the Administrative Code.

(2) An employer shall not be eligible to receive a safety council rebate eligibility rebate as set forth in paragraph (B) of this rule if:

(a) The employer is a self-insuring employer providing compensation and benefits pursuant to section 4123.35 of the Revised Code.

(b) The employer is a state agency.

(c) The employer is participating in a program designated as incompatible with the rebate under rule 4123-17-74 of the Administrative Code.

(d) The employer is a client employer of an alternate employer organization (AEO).

(e) The employer is a client employer of a professional employer organization (PEO), to the extent the employer's payroll is reported to the bureau under the PEO's workers' compensation policy.

(f) The employer fails to comply with safety council eligibility requirements contained in paragraphs (B)(1) and (C)(1) of this rule.

(3) An AEO or a PEO shall not be eligible to receive a safety council rebate under this rule unless all of the following requirements are met:

(a) The AEO or the PEO, and each of the client employers of the AEO or the PEO, meet all eligibility and program requirements contained in paragraphs (B)(1) and (C)(1) of this rule.

(b) The AEO or the PEO electronically submits affirmation that the AEO or the PEO, and each of the client employers of the AEO or the PEO, has enrolled in a local safety council as of the enrollment deadline of the applicable program year.

(c) The AEO or the PEO submits a list of each of the client employers with whom it has an agreement as of May first of the applicable policy year.

(i) The list shall be electronically submitted on a form prescribed by the bureau, and shall include each client employer's name, address, federal tax identification number, bureau of workers' compensation risk number; and the amount of payroll, listed by manual class code, reported by the AEO or the PEO on behalf of each client employer.

(ii) If the bureau determines the AEO or the PEO has manipulated the client list for purposes of obtaining a safety council rebate under this rule, the AEO or the PEO shall not be eligible to receive such rebate.

(iii) The bureau shall hold the list required under this paragraph as confidential pursuant to rule 4123-17-15.2 of the Administrative Code.

(4) The forms and deadlines for meeting the requirements of paragraphs (C)(3)(b) and (C)(3)(c) of this rule shall be prescribed by the superintendent.

Last updated May 1, 2026 at 8:20 AM

History

Effective: May 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-57 Premium for construction industry.

(A) As used in this rule:

(1) As defined in division (F)(3) of section 4123.34 of the Revised Code, "construction industry" includes any activity performed in connection with the erection, alteration, repair, replacement, renovation, installation, or demolition of any building, structure, highway, or bridge. The classification codes satisfying this definition are listed in paragraph (E) of this rule.

(2) "Construction industry employer" is an employer that reports payroll of a construction industry employee for work performed in a construction industry classification code as defined in paragraph (E) of this rule.

(3) "Construction industry employee" is any employee as defined in division (A) of section 4123.01 of the Revised Code who performs work and whose payroll is properly reported in a construction industry classification code as defined in paragraph (E) of this rule.

(B) Pursuant to division (F) of section 4123.34 of the Revised Code, the administrator of workers' compensation shall determine the premium rates for construction industry employees for payroll paid beginning January 1, 1995, in accordance with the limitations provided in this rule.

(C) A construction industry employer shall report the actual remuneration paid to its construction industry employees, except that for payroll paid beginning January 1, 1995, the reportable payroll shall not exceed on a weekly basis an amount as provided in division (F) of section 4123.34 of the Revised Code. This limitation applies only to the construction industry employees of the construction industry employer, and does not apply to employees of a construction industry employer whose payroll is not reported in a construction industry classification code as defined in paragraph (E) of this rule.

(D) The construction industry employer shall maintain records to verify the weekly wages paid to construction industry employees. The payroll limitation for construction industry employees shall apply to weekly payroll, regardless of the hourly or daily remuneration. If upon audit the construction industry employer is unable to document payroll records of an employee on a weekly basis, the bureau of workers' compensation shall establish the payroll by the actual remuneration for the payroll reporting period, subject to the maximum limitation as provided in division (F) of section 4123.34 of the Revised Code times the number of weeks in the payroll reporting period.

(E) The payroll limitation of this rule shall apply only to the following construction industry classification codes of a construction industry employer: all of the classification codes in industry group four as provided in the credibility table used for experience rating, table one, part B, of rule 4123-17-05 of the Administrative Code. The bureau shall periodically review the classification codes satisfying the definition of construction industry, and any reclassifications, changes, deletions, or additions to the bureau's classification codes or industry groups may result in additions or deletions of classification codes from this rule.

(F) The payroll limitation of this rule shall apply to premium of the construction industry employer for construction industry employees reported under the classification codes listed in paragraph (E) of this rule. The payroll limitation also applies to the disabled workers' relief fund assessment, and for such purposes the construction industry employer shall report the remuneration of the construction industry employees as provided in paragraph (C) of this rule.

(G) For a construction industry employee who is also an officer of a corporation, a sole proprietor, partnership, or member of a family farm corporation, and whose payroll is subject to a payroll limitation by rules 4123-17-07 and 4123-17-30 of the Administrative Code, any additional payroll limitations of this rule also may apply.

(H) If upon audit or reclassification of payroll the bureau determines that the payroll of an employee has been improperly classified in a construction industry classification code and the new or proper classification code is not a construction industry classification as defined in paragraph (E) of this rule, the bureau shall establish the premium due based upon the full actual remuneration of the employee.

Last updated July 2, 2024 at 11:37 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-58 Substance use prevention and recovery program.

(A) Definitions.

For purposes of this rule:

(1) "AEO" and "PEO" have the same meaning as defined in rule 4123-17-15 of the Administrative Code.

(2) "Application deadline" means the applicable deadline set forth in appendix A or in appendix B to rule 4123-17-74 of the Administrative Code.

(3) "Client employer" has the same meaning as defined in rule 4123-17-15 of the Administrative Code.

(4) "Comparable program" means a program referred to in section 153.03 of the Revised Code.

(5) "Drug-free workplace policy" means an employer's written policy and procedures to prevent and reduce the risk of workplace accidents and injuries attributed to the use and abuse of alcohol and other drugs, including prescription, over-the-counter, and illegal drugs.

(6) "Evaluatoin date" means June first for private employers, and December first for public employer taxing districts, prior to the commencement of the program period.

(7) "Program period" means the policy year for which the employer elects to participate in the substance use and prevention and recovery program.

(8) "Safety-sensitive position or function" means any job position or work-related function or job task designated as such by the employer, which through the nature of the activity could be dangerous to the physical well-being of or jeopardize the security of the employee, co-workers, customers or the general public through a lapse in attention or judgment.

(9) "Substance use prevention and recovery (SUPR) program" means the bureau of workers' compensation's bonus and grant program for employers who implement a program under this rule.

(10) "Supervisor" means an employee who supervises others in the performance of their jobs, has the authority and responsibility to initiate reasonable suspicion testing and recommend or perform hiring or firing procedures.

(B) Eligibility requirements.

(1) To receive benefits under this rule, the employer must, as of the evaluation date:

(a) Be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code;

(b) Not have cumulative lapses in workers' compensation coverage in excess of forty days within the preceding twelve months;

(c) Be in an active policy status, which for purposes of this rule, does not include a policy that is a no coverage policy or a policy that is lapsed; and

(d) Report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year no later than the evaluation date.

(2) The bureau may permit an employer who applies after the application deadline, but before the end of the program period, to participate in the SUPR program. An employer that applied to participate in the SUPR program after the application deadline is not eligible for the bonus for that program period set forth in the appendix to rule 4123-17-75 of the Administrative Code.

(3) The following employers shall not be eligible for benefits under this rule:

(a) State agencies; and

(b) Self-insuring employers providing compensation and benefits pursuant to section 4123.35 of the Revised Code.

(4) An AEO or a PEO shall not be eligible to receive benefits under this rule unless the AEO or the PEO and each of the client employers of the AEO or the PEO meet all eligibility and program requirements.

(5) An employer determined to be ineligible for participation in the SUPR program based on the bureau's review of the employer's submitted application may appeal such determination to the adjudicating committee pursuant to section 4123.291 of the Revised Code.

(6) An employer that is found to be ineligible for participation in the SUPR program may reapply once the reason for the rejection has been resolved.

To implement a basic SUPR program, an employer shall make annual application to the bureau and implement the program elements set forth in paragraphs (C)(1) to (C)(6) of this rule. The requirements and timeframes for completion of each element shall be determined by the bureau.

(1) Safety - Employers participating in the SUPR program shall

(a) Ensure each supervisor completes accident-analysis training; and

(b) Use online accident-analysis reporting on the bureau's website for lost time claims.

(2) Policy - Employers are required to put in place a drug-free workplace policy.

(3) Employee education - The employer's SUPR program shall include annual education for all employees.

(4) Supervisor skill-building training - The employer's SUPR program shall include annual training for all supervisors in support of enforcing the employer's drug-free workplace policy.

(5) Drug and alcohol testing - The employer's SUPR program shall include alcohol and other drug testing which conforms to the federal testing model promulgated by the United States department of health and human services. The employer shall implement and pay for testing required by SUPR program participation but is not required to pay for re-testing requested by an employee and follow-up testing. Testing shall occur as specified by the bureau including, but not limited to the following:

(a) Pre-employment and new-hire drug testing;

(b) Post-accident alcohol and other drug testing;

(d) Return-to-duty and follow-up alcohol and other drug testing.

(6) Employee assistance - The employer's SUPR program shall include an employee assistance plan.

(D) Advanced SUPR program level.

To implement an advanced SUPR program, an employer shall make annual application to the bureau and implement the program elements set forth in paragraphs (D)(1) and (D)(2) of this rule. The requirements and timeframes for completion of each element shall be determined by the bureau.

(1) The employer shall meet all of the requirements of a basic SUPR program as provided in paragraph (C) of this rule.

(2) The employer shall do all of the following:

(a) Ensure that its drug-free workplace policy clearly reflects how random drug testing will be implemented and how additional employee assistance will be provided;

(b) Ensure conducting fifteen per cent or higher random drug testing of the employer's workforce each program period;

(c) Designate at lease one substance use professional in advance to be available for, and pay the costs of, a substance assessment of an employee who tests positive, comes forward voluntarily to indicate he or she has a substance problem, or is referred by a supervisor; and

(d) Commit to not terminate the employment of an employee who tests positive for the first time, who comes forward voluntarily to indicate he or she has a substance problem, or who is referred by a supervisor for an assessment.

(E) Comparable program.

(1) Self-insuring employers and state-fund employers not participating in the SUPR program shall submit an application for approval of a comparable program.

(2) Prior to providing labor services or on-site supervision of such labor services under a public improvement project as defined in division (A)(9) of section 153.03 of the Revised Code, employers participating in the comparable program shall:

(a) Develop, implement, and provide to all employees the written substance use policy required by division (B)(2)(a) of section 153.03 of the Revised Code;

(b) Conduct drug testing on employees, including supervisors, as outlined in paragraph (C)(5) of this rule;

(d) Complete all supervisor training required by division (B)(2)(e) of section 153.03 of the Revised Code.

(F) Progress reporting and renewal requirements.

(1) In order to qualify for renewal in the basic SUPR program, advanced SUPR program, or comparable program, an employer shall have implemented all requirements of its basic SUPR program, advanced SUPR program, or comparable program by the implementation date specified by the bureau.

(2) The employer shall submit an annual report detailing program implementation and reporting annual statistics on a form provided by the bureau. The requirements and timeframes for completion of the annual report shall be determined by the bureau.

(a) If the employer is applying for renewal in the SUPR program, the annual report shall be deemed the employer's annual application, and the employer shall identify which SUPR program level is requested for the following program period;

(b) The employer shall provide any follow-up documentation required by the bureau and shall maintain on-site statistics as required by the bureau;

(c) The report required by this paragraph and any other information submitted by the employer in meeting SUPR program requirements shall be considered part of the annual statement submitted to the bureau as required by section 4123.26 of the Revised Code. The bureau shall hold such information as confidential pursuant to section 4123.27 of the Revised Code.

(3) In conjunction with the annual report required under paragraph (F)(2) of this rule, an AEO or a PEO participating in the SUPR program must submit a client employer list.

(a) The list shall include all client employers with whom the AEO or the PEO had an agreement as of thirty days prior to the filing deadline for the annual report;

(b) The list shall include each client employer's name, address, federal tax identification number, bureau of workers' compensation policy number; and the amount of payroll, listed by classification code, reported by the AEO or the PEO on behalf of each client employer;

(c) If the bureau determines the AEO or the PEO has manipulated the client list for purposes of obtaining benefits under this rule, the AEO or the PEO shall not be eligible to receive such benefits;

(d) The bureau shall hold the list required under this section as confidential pursuant to sections 4125.05 and 4133.07 of the Revised Code.

(G) The bureau may remove an employer from participation in the SUPR program for failure to fully implement a SUPR program in compliance with the approved program level requirements. The bureau shall send written notice of removal to the employer. An employer removed from the SUPR program under this section may reapply for the SUPR program for the next program period. The bureau may deny the application based on circumstances of previous participation.

(H) An employer completing SUPR program requirements may be eligible for a bonus equal to the amount identified in the appendix to rule 4123-17-75 of the Administrative Code times the employer's premium costs during the program period. To be eligible for the bonus, an employer must report actual payroll due upon reconciliation of estimated premium and actual premium for the program participation year no later than the date set forth in rule 4123-17-14 of the Administrative Code. An employer will be deemed to have met this requirement if the bureau receives the payroll report and the employer pays premium associated with the payroll report before the expiration established by the administrator pursuant to rule 4123-17-16 of the Administrative Code. Additional program requirements for bonus eligibility shall be determined by the bureau.

(I) Participation in this program under this rule is voluntary. Nothing contained in this rule shall affect, modify, or amend any collective bargaining agreement or alter the rights or obligations of an AEO, a worksite employee, an employer, an employee, a client employer, a PEO, or a shared employee under applicable federal or state law. Provisions of a collective bargaining agreement that prevent implementation of program criteria will preclude employer participation in the SUPR program.

(J) Pursuant to section 4121.37 of the Revised Code, the administrator may establish a grant program for development and legal review of a drug-free workplace policy, employee education, supervisor skill-building training, drug and alcohol testing, and substance use assessment for eligible employers who participate in the grant program.

(1) To be eligible for the SUPR grant program, an employer must:

(a) Meet the eligibility requirements set forth in paragraph (B) of this rule: and

(b) Have a physical office located in Ohio.

(2) An employer's continued eligibility in the grant program for each subsequent program period shall be automatic provided that the employer continues to meet the eligibility requirements set forth in paragraph (J)(l) of this rule.

(3) The employer must make application for the grant program to the bureau on forms provided by the bureau.

(4) The employer must enter into a written agreement with the bureau detailing the rights, obligations, and expectations of the parties for performance during participation in the SUPR grant program.

(5) The bureau shall evaluate each application to determine the employer's eligibility to receive a grant and shall have the final authority to approve a grant for an eligible employer and the amount of the grant.

(6) The bureau will only reimburse for drug testing if:

(a) The employer's drug-free workplace policy meets requirements as specified by the bureau: and

(b) The employer submits reimbursement requests for the types of alcohol and drug testing set forth under this rule or section 153.03 of the Revised Code.

(7) The employer must pay for eligible expenses and apply to the bureau for reimbursement.

(a) Reimbursement is available on a first come, first served basis while funding and bureau resources are available. The grant program or funding may be suspended at any time.

(b) The employer must provide the bureau documentation of itemized expenses and proof of payment. The bureau has sole discretion in determining whether documentation provided by the employer is sufficient for reimbursement, and the bureau may require additional documentation from the employer as deemed necessary to process the employer's request for reimbursement.

(c) The bureau shall reject any expense filed for reimbursement that is not submitted to the bureau within one year of the date of service.

(8) The bureau reserves the right to audit the employer's use of program funds and to recover any overpaid, misappropriated, or improperly expended funds.

Last updated July 30, 2025 at 7:53 AM

History

Effective: July 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-59 Fifteen thousand dollar medical-only program.

(A) Any employer who is paying premiums to the state insurance fund and whose coverage is in force may elect to participate in the fifteen thousand dollar medical-only program as provided in section 4123.29 of the Revised Code. No formal application is required; however, an employer must elect to participate. Once an employer has elected to participate in the program, the employer will be responsible for all bills in all medical-only claims with a date of injury the same or later than the election date, and the employer agrees to pay bills within thirty days of receipt of the bill, unless the employer notifies the bureau of workers' compensation within fourteen days of receipt of the notification of a claim being filed that it does not wish to pay the bills in that claim, or the employer notifies the bureau that the fifteen thousand dollar maximum has been paid, or the employer notifies the bureau of the last day of service on which it will be responsible for the bills in a particular medical-only claim.

(B) Employers may pay bills only on any alleged medical-only injury. The provisions of this program and rule shall not apply to claims in which an employer with knowledge of a claimed compensable injury or occupational disease, has paid wages in lieu of compensation or total disability. Payment of a bill by an employer does not waive the bureau's right to adjudicate the claim, nor does it waive the employer's right to contest the claim should a claim be filed.

(C) This program in no way supersedes the right of any injured worker to file a workers' compensation claim with the bureau.

(D) An employer or its agent may elect to pay to the injured worker, or the provider on behalf of the injured worker, the first fifteen thousand dollars of a medical-only claim. Employers may elect which medical-only claims they do not wish to cover under this program.

(1) An employer electing to pay bills in its employees' medical-only claims is responsible for all bills in a claim until the fifteen thousand dollar maximum is reached and the employer provides notice to the bureau that the employer has paid the first fifteen thousand dollars of the bills in the claim by providing the bureau the date of service of the bill which reached the fifteen thousand dollar maximum, or the employer provides notice to the bureau that it no longer wishes to be responsible for the bills in a particular claim by providing the bureau the last date of service that it will pay. The bureau will process all related bills received after the withdrawal notification date.

(2) If the fifteen thousand dollar maximum has not been reached and the payment of a bill will exceed the fifteen thousand dollar maximum, the employer should pay that portion of the bill that will bring the payment to the fifteen thousand dollar maximum and inform the provider to bill the bureau for the remainder of the bill. The employer should then notify the bureau that the first fifteen thousand dollars has been paid, and provide proof of such payment and copies of all bills paid, in the proper billing format, to the bureau. The bureau will then be responsible for processing all future bills.

(3) The employer cannot elect to pay only certain bills for a claim and submit other bills in that claim to the bureau for payment.

(4) Once an employer has elected to pay bills in medical-only claims under this program, the employer must pay all bills under this program within thirty days of receipt of the bill. The employer shall provide copies of the bills paid in the claim, in the proper billing format, to the bureau and the injured worker or the injured worker's representative upon request. Upon written request from the bureau, the employer shall provide documentation to the bureau of all medical-only bills that they are paying directly. Such requests from the bureau may not be made more frequently than on a semiannual basis. Failure to provide such documentation to the bureau within thirty days of receipt of the request may result in the employer's forfeiture of participation in the program for such injury.

(E) An employer electing this program must keep a record of the injury to include: name, address, and social security number of the injured worker; date and time of injury; type of injury; part of body injured; and a brief description of the accident. The employer also shall keep a copy of all bills with proof and date of payment under this program. This information will be made available to the bureau and the injured worker or their representative upon request. The information must be kept on file for five years from the last date a bill has been paid by the employer or the information has been received by the bureau.

(1) An employer in the program must notify the bureau within fourteen days of a claim being filed of the employer's intention not to cover the first fifteen thousand dollars of the medical costs of the claim.

(2) The bureau will process all related bills in a filed medical-only claim in the normal manner unless the employer has previously notified the bureau that it has elected to participate in the fifteen thousand dollar program.

(3) In those cases in which the bureau has been properly notified by the employer of the employer's intention to directly pay the bills, the bureau shall not pay any bills submitted to the bureau directly from the provider but will notify the provider that the bill should be submitted to the employer until the provider is notified by the employer that the bureau is responsible for the bills in the claim. No interest shall be paid by the bureau on account of bills not paid within thirty days if such bills are the responsibility of the employer.

(4) All bills submitted to the bureau or the employer for payment must be in the proper billing format and must be received by the bureau or the employer within one year of the date of service on the bill.

(F) An employer electing this program has the responsibility to notify the injured worker and medical provider, in writing, of the acknowledgment of the alleged medical-only injury, that it has elected under section 4123.29 of the Revised Code to pay the first fifteen thousand dollars, that all bills should be submitted to the employer, and that the injured worker and the bureau should not be billed.

(1) Once an employer in this program pays a bill on a work-related injury the bureau will not reimburse that employer.

(2) In the event that a duplicate payment is made, the employer may request reimbursement of such bills from the provider, and the provider shall reimburse the employer where the bureau has paid the bill.

(3) In the event that a medical-only claim changes to a lost time claim, the bureau will not reimburse the employer for bills that have been paid by the employer under this program.

(G) The employer shall pay all bills as billed or agree upon an appropriate reimbursement level with the provider for claims with a date of injury prior to June 30, 2009. Providers must accept the bureau fee schedule as payment in full for claims with a date of injury on or after June 30, 2009. A certified health care provider shall extend to an employer who participates in this program the same rates for services rendered to an employee of that employer as the provider bills the administrator of workers' compensation for the same type of medical claim processed by the bureau and shall not charge, assess, or otherwise attempt to collect from an employee any amount for covered services or supplies that is in excess of that rate. Providers may only balance bill the bureau on the occasion of a bill that would require an employer to exceed the fifteen thousand dollar maximum. The bureau will not mediate fee disputes between the employer and the provider. If an employer elects to enter the program and the employer fails to pay a bill for a medical-only claim included in the program, the employer shall be liable for that bill and the employee for whom the employer failed to pay the bill shall not be liable for that bill.

(H) Payments made by the employer in this program will not be charged to that employer's experience modification; however, if a claim has been filed with the bureau and bills paid by the bureau, these payments will be included in the employer's experience modification. The bureau will not adjust the employer's experience modification to remove such payments unless the employer has complied with this rule and the bureau has made such payments in contravention of this rule. Failure by an employer to make timely payments on all bills will not affect the coverage of that employer and will not obligate the bureau to pay interest to the medical provider; however, the bureau may exclude employers who do not make timely payment on all bills in this program from participation in this program. An employer may appeal a decision of the bureau excluding the employer from this program to the adjudicating committee under rule 4123-14-06 of the Administrative Code.

(I) An employer who elects to participate in this program may cancel its participation in the program at any time by notifying the bureau. The bureau will process all related bills in all medical-only claims against that employer's account after the date of the notification.

Last updated July 2, 2024 at 11:38 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-60 Annuity factors.

View AppendixView AppendixView AppendixView AppendixView AppendixView AppendixView Appendix

Last updated January 5, 2026 at 10:31 AM

History

Effective: January 1, 2026
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-61 Criteria for group experience rating.

(A) The administrator of workers' compensation shall offer a plan that groups employers for rating purposes. Individual employers shall retain their separate risk identity but shall be pooled and grouped for experience rating purposes only.

(B) In establishing a group for group experience rating purposes, the sponsoring group organization or individual employers in the group must satisfy all of the following requirements and must meet all the sponsorship rules as provided in rule 4123-17-61.1 of the Administrative Code:

(1) All of the individual employers within the group must be governing members of the sponsoring organization or the affiliate organization.

(2) An individual employer must have a policy in good standing with the bureau of workers' compensation. "Policy in good standing" means the individual employer is current on all payments due to the bureau and is in compliance with bureau laws, rules, and regulations at the time of enrollment or reenrollment.

(3) The employers' business in the organization must be substantially similar such that the employers which are grouped are substantially homogeneous. A group shall be considered substantially homogeneous if the main operating classification codes of the employers as determined by the premium obligations for the rating year beginning two years prior to the coverage period are assigned to the same or similar industry groups, as determined by appendix A to rule 4123-17-05 of the Administrative Code. Industry groups seven and nine as well as eight and nine, and industry groups two and four as well as four and six, are considered similar.

(a) The bureau may allow an individual employer to move to a more homogeneous group, after September thirtieth for private employer groups and March thirty-first for public employer taxing district groups but before the first day of the policy year, if the individual employer:

(i) Is without a full year of recorded premium;

(ii) Is reclassified as a result of an audit; or

(iii) Fully or partially combines with another employer.

(b) An individual employer member of a continuing group who initially satisfied the homogeneous requirement shall not be disqualified from participation in the continuing group for failure to continue to satisfy such requirement.

(4) The group of employers must consist of at least one hundred individual members or a group where the aggregate workers' compensation premiums of the members are, as determined by the administrator, expected to exceed one hundred fifty thousand dollars during the policy year for which the application for group rating is made.

(5) As of the deadline for application for group experience rating set forth in appendix A and in appendix B to rule 4123-17-74 of the Administrative Code, each individual employer seeking to enroll in a group for workers' compensation coverage must meet the following requirements:

(a) The individual employer must be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code;

(b) The individual employer must be current on the payment schedule of any part-pay agreement into which it has entered for payment of premiums or assessment obligations;

(c) The individual employer cannot have cumulative lapses in workers' compensation coverage in excess of forty days within the prior twelve months; and

(d) The individual employer must report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year.

(6) New employers electing to apply for group experience rating program.

(a) The following definitions apply to this rule,

(i) "New employer" means an employer creating one or more jobs in the state of Ohio for which any of the following is true:

(a) The employer is a new business entity made amenable to Ohio workers' compensation laws by such job creation; or

(b) The employer is an out of state employer that has not had prior operations in Ohio and has not had prior workers' compensation insurance coverage in Ohio.

(ii) "Initial rating year" means the rating year including the date on which the new employer's Ohio workers' compensation coverage becomes effective.

(b) If a new employer elects to apply for the group experience rating program under this rule, the administrator shall waive the application deadlines set forth in appendix A and appendix B to rule 4123-17-74 of the Administrative Code and allow the new employer to apply for the group experience rating program.

(i) To apply for the group experience rating program, the new employer must file an AC-26 form for the group with the sponsoring organization.

(ii) Upon receipt of an AC-26 form from a new employer, a sponsoring organization shall:

(a) Not permit a new employer to participate in a group unless the new employer meets homogeneity requirements set forth in paragraph (B)(3) of this rule:

(b) Notify the bureau of the addition of a new employer to the group within thirty days of the date the bureau assigns a policy number to the new employer; and

(c) Electronically submit to the bureau a new employer's AC-26 form with a statement identifying the group in which a new employer is being placed for the new employer's initial rating year.

(iii) For new employers electing to participate in the group experience rating program between the twenty-ninth day before the applicable group experience rating deadline. as set forth in appendix A and appendix B of rule 4123-17-74 of the Administrative Code. and the last day of the initial rating year. inclusive. the sponsoring organization shall, within thirty days of the date the bureau assigns a policy number to the new employer, and in addition to the requirements of paragraph (B)(6)(b)(ii) of this rule, submit to the bureau a statement identifying the group in which the new employer is being placed for the rating year immediately following the new employer's initial rating year.

(c) The new employer's participation in the group experience rating program in rating years subsequent to the initial rating year for which the new employer was admitted to a group pursuant to the administrator's waiver in paragraph (B)(6)(b) of this rule is subject to all requirements for participation in the group experience rating program set forth in rules 4123-17-61 through 4123-17-68 of the Administrative Code.

(7) Cancellations, transfers, and combinations.

(a) An individual employer whose coverage status becomes cancelled or combined during the rating year may not continue to participate in group experience rating. The effective date of the removal from the group experience rating program shall be on the first day of the next policy year, unless the date of cancellation or combination is determined to be the first day of the policy year, in which case the individual employer shall be removed from group as of the actual date of cancellation or combination. An individual employer who becomes active and obtains coverage after the group experience rating application deadline may not participate in group experience rating for that year except as defined in rule 4123-17-66 of the Administrative Code.

(b) An individual employer that obtains initial coverage after the group experience rating application deadline as set forth in appendix A and in appendix B to rule 4123-17-74 of the Administrative Code and for which a transfer of experience is indicated under rule 4123-17-02 of the Administrative Code may not participate in group experience rating for that year except as defined in rule 4123-17-66 of the Administrative Code.

(8) Payroll reporting and premium reconciliation. An individual employer must report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year no later than the date set forth in rule 4123-17-14 of the Administrative Code. An individual employer will be deemed to have met this requirement if the bureau receives the payroll report and the employer pays premium associated with the payroll report before the expiration of any grace period established by the administrator pursuant to paragraph (B) of rule 4123-17-16 of the Administrative Code.

(a) An individual employer removed from group experience rating for failure to meet these criteria will be rerated for the full policy year at the individual employer's base-rate or experience-modified rate as determined by their expected losses for the policy year.

(b) The group shall retain, for the policy year, the experience of any employer removed from group experience rating for failure to meet these criteria.

(C) In providing employer group plans under section 4123.29 of the Revised Code, the bureau shall consider an employer group as a single employing entity for purposes of group experience rating. No employer may be a member of more than one group for the purpose of obtaining workers' compensation coverage.

Last updated July 2, 2024 at 11:38 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-61.1 Sponsorship certification requirements.

(A) The following certification requirements shall apply to all sponsoring organizations that seek to make application for either the group rating plan, as provided for in rule 4123-17-61 of the Administrative Code, or the group retrospective rating plan as provided in rule 4123-17-73 of the Administrative Code, known collectively as group programs.

(B) The sponsoring organization must have been in existence for at least two years prior to the last date upon which the group's application for coverage may be filed with the bureau of workers' compensation as provided in rule 4123-17-62 of the Administrative Code.

(C) The organization must be formed for a purpose other than that of obtaining group workers' compensation coverage. The bureau shall require the organization to demonstrate this through submission of required evidence and documentation. As long as all of the other criteria of this rule are satisfied, a parent corporation may be a sponsoring organization and, if it qualifies under the criteria of this rule, a member of a group of its subsidiary corporations for purposes of group programs. A sponsoring organization may sponsor more than one group.

(D) The formation and operation of a group program in the organization must substantially improve accident prevention and claims handling for the employers in the group. The bureau shall require the group to document its plan or program for these purposes, and, for groups reapplying annually for group coverage, the results of prior programs.

Following the conclusion of each policy year, the bureau will report annually on the aggregate performance of all groups.

(E) A sponsoring organization shall satisfy all of the requirements for a sponsoring organization as required under section 4123.29 of the Revised Code and in this rule. A sponsoring organization shall submit to the bureau information to demonstrate that the organization meets the requirements for sponsorship. The bureau shall review the information and shall register the sponsoring organization if it meets the requirements. A sponsoring organization shall be registered and be certified by the bureau prior to marketing to or soliciting employers for membership in a group under the group programs.

(1) .Once the bureau certifies a sponsoring organization, the sponsoring organization shall be permitted to sponsor a group retrospective rating program under rule 4123-17-73 of the Administrative Code, as well as groups in the current group experience rating program under this rule beginning the next rating year. The bureau shall review the certification of a sponsoring organization at least once every three years or on a more frequent basis as determined by the bureau.

(2) A sponsoring organization that seeks to be certified by the bureau shall provide to the bureau the following:

(a) The sponsoring organization's workers' compensation policy number and proof of active workers' compensation coverage;

(b) The name of the sponsoring organization's third party administrator, if applicable;

(c) A copy of the sponsoring organization's marketing materials (web site, brochures, etc.), including a description of the services related to group rating as well as other services provided by the sponsor;

(d) A list of all sponsoring organizations affiliated with the sponsoring organization. For the purpose of this rule, an "affiliated" organization is an organization in which members are brokered, borrowed, shared, or co-opted for inclusion in the certified sponsoring organization's group. All affiliated organizations are required to be certified sponsors as provided in this rule.

(e) A copy of the sponsoring organization's articles of incorporation;

(f) A copy of the sponsoring organization's mission statement;

(g) A completed application form, signed by the sponsor, which includes disclosure of nine-hundred-ninety filings with the Internal Revenue Service and counts of all members (both group and non-group);

(h) A copy of the sponsor's safety plan.

(i) With reasonable notice, the bureau may request that a sponsor provide for the bureau's inspection at the sponsor's designated location any of the following: additional financial information, dues structure, revenue sources, a table of organization, a comprehensive membership roster, by-laws, and/or a list of corporate officers.

(F) The sponsoring organization shall provide to the bureau a signed statement certifying the accuracy of the information provided to the bureau. A sponsoring organization's failure to provide accurate information or submission of false information may be grounds for the bureau to refuse to certify the sponsoring organization or to decertify the sponsoring organization. The bureau reserves the authority to use all the listed information above and any other information available to make the certification approval.

(G) Should the bureau deny the certification of the sponsoring organization, the applicant may appeal to the bureau adjudicating committee. After exhausting all administrative appeals and correction of sponsorship requirement deficiencies, the applicant may reapply one year after the latest certification denial.

(H) The bureau will collect this information and retain it or ask that a sponsoring organization maintain the information for bureau inspection upon request.

(I) The sponsoring organization shall be in compliance with all bureau rules. A sponsoring organization's non-compliance may result in decertification.

(J) The sponsoring organization, or their authorized representative, shall have the capability to send and receive secure electronic (FTP - file transfer protocol) files.

(K) Group marketing.

(1) A sponsoring association, affiliate, or representative, including, but not limited to, a third-party administrator, broker, or marketer may not offer a discount to either a private or public employer either seeking to participate in a group-experience rating plan or that exceeds the combined result of the lowest experience modifier and its associated break-even factor for the future policy year until those factors are approved by the bureau's board of directors. Those parties also may not provide marketing material that is either false or unattainable relating to the process of forming groups under the group-retrospective rating plan for a future policy year. Prohibited marketing material under this rule is any communication that:

(a) Instructs prospective participants to provide false information on forms used for purposes of group formation, including the AC-3, the AC-26, and the U-153.

(b) Claims the sponsoring association, affiliate, or representative is endorsed by the bureau or the state of Ohio.

(c) Offers or estimates specific discounts or refunds that are unattainable to prospective participants in either group-experience rating or group-retrospective rating.

(i) For group-experience rating, "unattainable" is defined as exceeding the maximum discount when combining the lowest experience modifier and its associated break-even factors as approved by the bureau of workers' compensation board of directors.

(ii) For group-retrospective rating, "unattainable" is defined as quoting a specific refund amount that exceeds the maximum possible refund when considering the basic premium factor for the maximum premium ratio selected as approved by the bureau of workers' compensation board of directors.

(2) The bureau may apply the following sanctions upon its determination of a violation of this rule:

(a) For a violation of paragraph (K)(1)(c) of this rule the bureau may place that group sponsor at capacity for the an upcoming policy year.

(i) For sponsors that filed group rosters with the bureau for the policy year, "capacity" is defined as prohibiting a sponsoring association from exceeding the total number of employers in their current or most recent groups, adding new employers for groups they may form in the policy year of the sanction, and affiliating with any other group sponsors for the policy year of the sanction.

(ii) For sponsors that have not filed group rosters with the bureau for the current policy year, "capacity" means they will not be able to form groups and cannot affiliate with other group sponsors for the upcoming policy year.

(b) For a violation of paragraph (K)(1)(a) or (K)(1)(b) of this rule, along with any action that results in knowingly falsifying information on forms submitted to the bureau, the bureau shall immediately revoke the sponsor's certification for the upcoming policy year.

(3) The bureau will provide the bureau of workers' compensation board of directors a report by no later than the April board meeting each year regarding sanctions rendered under this paragraph and corrective actions taken by the bureau with respect to this rule.

Last updated June 30, 2026 at 1:05 PM

History

Effective: July 1, 2010
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-62 Application for group experience rating.

(A) Sponsoring organization requirements.

(1) A sponsoring organization shall make annual application for group experience rating by submitting an employer roster for group rating plan (AC-25) for each group it sponsors. Each AC-25 shall:

(a) Be signed each year by an officer of the sponsoring organization to which the members of the group belong;

(b) Identify each individual employer to be included in the group policy year for which the group application is made; and

(i) Enrolled in the same group,

(ii) Not enrolled in the same group, but enrolled in a different group sponsored by the sponsoring organization, or

(iii) Not enrolled in the same group, and not enrolled in a different group sponsored by the sponsoring organization.

(2) In the manner specified by the bureau of workers' compensation, the sponsoring organization shall annually identify all employers that were enrolled in the group in the previous policy year but are not enrolled in the group for the policy year for which the current application is made and specify whether the employer is enrolled in another group of the same sponsoring organization.

(3) The bureau may request from individual employers or the sponsoring organization any additional information necessary for the bureau to rule upon the application for group experience rating. Failure or refusal of the sponsoring organization to provide the requested information in the manner requested by the bureau shall be sufficient grounds for the bureau to reject the application and refuse the group's participation in group experience rating.

(4) A sponsoring organization's application for group experience rating is effective for a single policy year. Continuation of a group for subsequent years requires timely filing of an application on a yearly basis and meeting eligibility requirements set forth in rule 4123-17-61 of the Administrative Code.

(B) Employer requirements.

An employer electing to participate in group experience rating must file an application for group rating (AC-26) with the sponsoring organization of the group in which the employer seeks to participate. If the sponsoring organization elects to include the employer in its group, the sponsoring organization must file the AC-26 form electronically with the bureau by the group experience rating application deadline set forth in the appendices to rule 4123-17-74 of the Administrative Code.

(1) An employer's AC-26 shall remain in effect for all subsequent policy years when the employer remains in the same group or another group sponsored by the same sponsoring organization.

(2) The employer must file an AC-26 if the employer applies for group experience rating with a different sponsoring organization or was not group-experience rated in the previous rating year.

(3) When an employer files a new AC-26 or multiple AC-26 forms during the application period, the latest-filed AC-26 shall establish the employer's intentions for group experience rating. The employer's AC-26 shall remain effective until any of the following occurs:

(a) The employer timely files a subsequent AC-26 indicating the desire to participate in a group with a different sponsor for the upcoming policy year;

(b) The sponsoring organization for the group does not include the employer on the group roster (AC-25);

(c) The group does not reapply for group experience rating or is rejected for failure to meet group eligibility requirements; or

(d) The employer fails to meet individual eligibility requirements set forth in paragraph (B) of rule 4123-17-61 of the Administrative Code.

(C) For private employers, the sponsoring organization shall file applications on or before the date identified in appendix A to rule 4123-17-74 of the Administrative Code. For public employers, the sponsoring organization shall file applications on or before the date identified in appendix B to rule 4123-17-74 of the Administrative Code.

(1) Except as provided in paragraph (B)(6) of rule 4123-17-61 of the Administrative Code, the sponsoring organization may not add an employer to a group after the application deadline. The sponsoring organization will be permitted to correct a clerical error that results in an employer being omitted from a group roster if:

(a) The sponsoring organization has made an error in reporting the name or policy number of the employer on the sponsoring organization's AC-25; or

(b) The sponsoring organization included the employer on the sponsoring organization's AC-25 but failed to file the employer's AC-26 with the bureau prior to the application deadline. The sponsoring organization must provide sufficient documentation, as determined by the bureau, that the employer timely filed its AC-26 with the sponsoring organization.

(2) A sponsoring organization that has applied for group experience rating may not voluntarily terminate the application during the bureau's evaluation period.

(3) Any changes to the sponsoring organization's original application must be filed in a manner prescribed by the bureau prior to the application deadline. Any rescissions made must be completed in writing and signed by an officer of the sponsoring organization to which the members of the group belong. Any changes received by the bureau after the application deadline will not be honored. The latest application form or rescission received by the bureau prior to the application deadline will be used to determine the premium obligation for the group.

(D) A sponsoring organization shall notify an employer that is participating in a group of that sponsoring organization if the employer will not be included in a group by that sponsoring organization for the next rating year.

(1) For private employer groups, the sponsoring organization shall notify the employer in writing prior to the last business day of October of the year of the group application deadline set forth in appendix A to rule 4123-17-74 of the Administrative Code.

(2) For public employer taxing district groups, the sponsoring organization shall notify the employer in writing prior to the last business day of April of the year of the group application deadline set forth in appendix B to rule 4123-17-74 of the Administrative Code.

(3) If an employer notifies the bureau that a sponsoring organization has not complied with this paragraph, and the sponsoring organization fails to prove that the notice was provided in a timely manner, the bureau will, without the approval of the sponsoring organization, allow the employer to remain in the group for the rating year for which the notice was required. If that group no longer exists the bureau will, without the approval of the sponsoring organization, place the employer in a homogeneous group with the same sponsoring organization or take other appropriate action.

(E) When the bureau determines that individual employers in a proposed group do not meet the eligibility requirements set forth in rule 4123-17-61 of the Administrative Code, the bureau will notify the individual employers and the sponsoring organization of its determination. The sponsoring organization may continue in its application for group coverage without the disqualified employers, but the group must meet minimum requirements of rule 4123-17-61 of the Administrative Code.

(F) A sponsoring organization may request that an employer be removed from its group for a gross misrepresentation made on the employer's application to the group.

(1) "Gross misrepresentation" is an act by the employer that would cause financial harm to the other members of the group, and is limited to any of the following:

(a) The sponsoring organization discovers that the employer applicant for group experience rating has recently merged with one or more entities without disclosing such merger on the employer's application for membership in the group, and such merger adversely affects the experience modification (EM), as defined in rule 4123-17-03 of the Administrative Code, of the group.

(b) The sponsoring organization discovers that the employer applicant for group experience rating has failed to disclose the true nature of the employer's business pursuit on its application for membership in the group, and this failure adversely affects the EM of the group.

(2) Requests for removal of an employer pursuant to this paragraph must be submitted within thirty days of the bureau's notification to the sponsoring organization that a rate adjustment has occurred. The sponsoring organization must notify the employer of its request to remove the employer from the group for gross misrepresentation.

(3) The sponsoring organization must provide sufficient documentation, as determined by the bureau, to support its request to remove an employer from a group.

(4) The employer shall be removed from the group only with the bureau's approval.

Last updated July 2, 2024 at 11:39 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-63 Eligibility for group experience rating-size criteria.

(A) To be eligible for group experience rating, the group taken as a whole must include at least one hundred employers, each employer being identified as a separate employer for state fund identification purposes, or the group taken as a whole must be of sufficient size that the premiums of the members, as determined by the administrator of workers' compensation, are expected to exceed one hundred fifty thousand dollars during the coverage period, except as provided by paragraph (C) of this rule. The administrator may determine the aggregate premium of the members based upon the historical premium experience of the members, projected payroll, and anticipated premium rates. The evaluation period for determining aggregate premium shall be the rating year beginning two years prior to the coverage period.

(B) For a group of less than one hundred members, the premium requirement shall be deemed to have been satisfied if the aggregate premium to the state insurance fund for the members of the group for the rating year beginning two years prior to the coverage period exceeded one hundred fifty thousand dollars, except as provided by paragraph (C) of this rule. Failure to reach one hundred fifty thousand dollars in premium during the coverage period shall not negate the group coverage.

(C) The bureau of workers' compensation shall calculate the premium based upon the actual experience modified premium of the member employers during the evaluation period, including any modification due to group rating. The administrator may waive the requirement that premiums exceed one hundred fifty thousand dollars during the coverage period for a continuing group of substantially similar membership if the sole reason that the premium fails to exceed one hundred and fifty thousand dollars is due to the premium modification discounts earned by the group as a direct result of safety operations of the group rating program, and not due to other factors, such as a departure of members from the group or a reduction in payroll for members of the group.

Last updated July 2, 2024 at 11:39 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-64 Group experience rate calculations.

(A) A group meeting all the requirements for group rating shall be considered as a single employing entity for purposes of group experience rating. The eligibility of data for use in the group shall be the same as the eligibility of data for use in the individual employer's rate calculation. Credibility limits and all factors based upon credibility will apply at the group level. For catastrophe claims, the definition of a catastrophe under paragraph (A) of rule 4123-17-12 of the Administrative Code must be satisfied by an individual employer in the group to be eligible for catastrophe claim cost relief, although more than one individual employer in the group may qualify for catastrophe relief from the same catastrophe occurrence. Disability relief charges to surplus shall be applied at the group level.

(B) All operations or classification codes of an employer electing group rating are subject to group experience rating.

(C) Except with respect to mergers or transfers of the operations of a business, an employer's experience may be combined once during a policy year to create an experience modification for multiple employers grouped together for experience rating purposes.

(D) Employers participating in a group rating plan may implement the drug-free safety program.

(E) An employer that is in a cancelled coverage status, for at least one full rating year as of the date that the experience modification of a group of which it had been a member is recalculated, will not be liable for any obligation, nor will such employer receive the benefit of any credit, associated with the recalculation.

Last updated April 2, 2024 at 9:08 AM

History

Effective: April 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-64.2 Public employer taxing district group rating break even factor.

The administrator will apply an adjustment factor to all public empoyer taxing district group rated employer experience modifiers (EM) as indicated in appendix A to this rule.

View Appendix

Last updated February 3, 2025 at 6:28 AM

History

Effective: January 1, 2021
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-65 Experience retention for group experience rate calculation purposes.

If an individual employer is a member of a group for group experience rating and leaves the group, the experience of that individual employer shall be used in experience-rating calculations for the group to impact only the rating years that the employer was a member of the group. The individual employer leaving the group retains its own experience rating incurred while a member of the group for the balance of the standard experience period. The group shall not be liable for claims experience incurred by an individual employer for claims occurring after the employer has left the group.

Last updated July 2, 2024 at 11:40 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-66 Termination and transfers for group experience rating.

This rule on termination and transfer of group experience rating shall apply at the group level after the bureau of workers' compensation applies the applicable individual rules on transfer of experience.

(A) A group formed for the purpose of group experience rating may not retroactively include experience in a plan, exclude experience from a plan, or voluntarily terminate a plan during the policy year. A change in the name of the group will not constitute a new group. A change of the organization sponsoring a group or moving a group to a new sponsoring organization shall constitute a new group and the members of the new group must meet the homogeneity requirement of paragraph (B)(3) of rule 4123-17-61 of the Administrative Code. A group will be considered a continuing group if more than fifty per cent of the members of the group in the previous rating year are members of the group in the current rating year.

(B) Successor: Files petition for bankruptcy

Predecessor: No predecessor

An individual employer which is a member of a group for the purpose of experience rating and which becomes a debtor-in-possession during the policy year shall remain a member of the group for the entire policy year.

Predecessor: Group rated with employees and reported payroll

Where one legal entity not having coverage in the most recent experience period wholly or partially succeeds another legal entity in the operation of a business, and the predecessor entity was a member of a group for experience rating, the successor shall be considered a member of the group, and the successor entity's rate shall be based on the group's experience, as long as the successor employer is homogeneous to the group. For a partial transfer, the effective date of the group experience transfer shall be on the first day of the next payroll reporting period (January first or July first).

(D) Successor: Group rated

Predecessor: Experience rated (either individually or in a different group), or non-group base rated

Where a legal entity having established coverage is a member of a group for experience rating and wholly succeeds another legal entity, the successor entity shall remain a member of the group for experience rating, and the experience of the predecessor shall be included with the experience of the group for the purpose of experience rating.

(E) Successor: Non-group rated

Predecessor: Group rated

Where a legal entity having established coverage is a member of a group for the purpose of experience rating and is wholly succeeded by another legal entity which is not a member of the group, the successor entity shall not become a member of the group.

(F) Successor: Group rated

Predecessor: Group rated

Where a legal entity which is a member of group for the purpose of experience rating wholly succeeds another legal entity which is also a member of the same group for the purpose of experience rating, the successor entity shall remain a member of the group for the purpose of experience rating.

(G) Successor: Group rated

Predecessor: Self-insured

When an individual employer which has returned to the state insurance fund from self-insured status and has used the self-insured experience in calculating the experience rate becomes a member of a group for the purpose of experience rating, the self-insured experience shall be included in the experience of the group for experience rating purposes. Upon returning to the state insurance fund the employer shall provide the bureau with a payroll, a list of all claims incurred while the employer was self-insured, all payments made with respect to those claims, and any additional information required by the bureau to calculate the employer's experience.

(H) Successor Group rated

Predecessor: Non-group rated

Where a legal entity succeeds in the operation of a portion of a business of another legal entity and the successor entity is a member of a group for experience rating, the successor entity shall remain a member of the group for experience rating, and the experience of the predecessor shall be included with the experience of the group for the purpose of experience rating. The effective date of the group experience transfer shall be on the first day of the next payroll reporting period (January first or July first).

(I) Successor: Non-group rated

Predecessor: Group rated

Where a legal entity having established coverage succeeds in the operation of a portion of a business of another legal entity, and the successor entity is not a member of a group and the predecessor is a member of a group for experience rating, the successor entity will not become a member of the group for experience rating, and the predecessor will remain a member of the group.

(J) Successor: entity not having coverage

Predecessor: Group rated with no employees and no reported payroll

(K) When any combination or transfer of experience is indicated, the effective date of such combination or transfer shall be the beginning date of the next following payroll reporting period. In cases where an entity not having coverage wholly succeeds another entity, the effective date shall be the actual date of succession.

(L) An individual employer which is a member of a group for the purpose of experience rating may not participate in a retrospective rating plan during the policy year in which the employer is a member of the group.

Last updated July 2, 2024 at 11:40 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-67 Representation for group experience rating.

(A) A group that has been established and has been accepted by the bureau of workers' compensation for the purpose of group experience rate calculation shall have no more than one permanent authorized representative for representation of the group and the individual employers of the group before the bureau and the industrial commission in any and all employer-related matters pertaining to participation in the state insurance fund.

(B) The selection of an authorized group representative must be made by submission of a completed form AC-24, and any change or termination of the authorized group representative can be made only by a subsequent submission of form AC-24. Only an officer of the group may sign an AC-24.

(C) Notwithstanding the provisions of paragraph (A) of this rule, an individual employer in a group may retain the services of an attorney or other authorized representative for claims-related matters, such as representation at claims hearings before the bureau and the industrial commission, through submission of the appropriate authorization for representation in such individual claim files. The bureau will recognize only one authorized representative for notice and appeal purposes.

Last updated July 2, 2024 at 11:40 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-68 Group experience and group retrospective safety program requirements.

(A) The purpose of this rule is to establish minimum safety requirements for group experience and group retrospective rating as provided by section 4123.29 of the Revised Code.

(B) The bureau safety and hygiene division, upon the request of the sponsoring organization, shall provide assistance with implementing all of the provisions of this rule.

(C) The primary or affiliated sponsoring organization of a group experience or group retrospective plan shall document its program to improve accident prevention and claims handling for the members in the group with the group application, and, for an existing group reapplying for group coverage annually, shall document the effectiveness of prior programs and any proposed improvements to these programs. This analysis shall include identification of the most common injuries among group members and strategies aimed at increasing awareness and prevention of these injuries.

(1) A bureau division of safety and hygiene loss prevention representative shall review the sponsor's safety requirements annual report within sixty days of receipt. The safety and hygiene representative shall contact the primary or affiliated group sponsor or its authorized representative to assist in further developing appropriate safety strategies if there are deficiencies in the report. All primary and affiliated sponsoring organizations shall be required to sponsor a minimum of eight hours of safety training during the rating year for members of their group. Training shall be hosted by the sponsor or the sponsor's third party administrator. Training should be designed in increments of at least two hours. Training should be industry specific where possible. Webinars and online training hosted by the sponsor will qualify to fulfill this requirement. The sponsor must document the number of employers in attendance at safety training with a goal of at least fifty per cent membership attendance. If the same agenda is offered repeatedly in different regional sites, hour to hour credit will be granted. A bureau representative may attend training to ensure the requirement is being met.

(2) If an employer that participates in group rating or group retrospective rating plan sustains a claim within the "green period," the employer shall complete either of the following:

(a) The bureau's online accident analysis form and the bureau's associated online safety class, or

(b) Two hours of safety training approved by the bureau. Such training can be offered by the sponsoring organization, the sponsoring organization's third party administrator, or the bureau.

The sponsor will notify members of this requirement and maintain recordkeeping to track completion of this requirement. The sponsor will submit to the bureau a list of members completing the training required by this rule. The bureau shall reserve the right to request additional information from the sponsor to ensure compliance.

(3) The bureau safety and hygiene division shall make a recommendation to the bureau employer programs unit on whether the group's safety requirements annual report is acceptable for the following policy year. A copy of the recommendations and findings of the safety and hygiene division shall be communicated to the sponsoring organization or its authorized representative at the same time. The employer programs unit shall consider this recommendation in making its decision whether to approve the group rating application and at the time of sponsor recertification.

(4) The bureau safety and hygiene division shall evaluate the sponsor's safety requirements annual report at the sponsoring organization level and not at the individual member level. The bureau safety and hygiene safety representative may conduct member visits to confirm the sponsoring organization requirements are met.

(5) If the bureau's employer programs unit does not approve a group for group rating based upon the sponsor's safety activities, the sponsoring organization may request a hearing before the adjudicating committee pursuant to rule 4123-14-06 of the Administrative Code.

(6) Primary and affiliated sponsoring organizations shall publish in the first quarter of the rating year, for the knowledge of the members in their group, a safety accountability letter outlining the group rating safety requirements and responsibilities of all associated parties.

(D) The sponsoring organization shall provide information regarding safety resources to members in their group. Communication and education strategies of the sponsoring organization may include use of the following strategies: web sites, webinars, claims review and analysis, newsletters, seminars, professional consultants, videos, personal contact, brochures, booklets, manuals, identifying key personnel and training in safety management for the sponsoring organization staff and/or its members. The bureau safety and hygiene division representative will be added to all member distribution lists to monitor safety education activity.

(E) Linkage of the group-sponsoring organization with the division of safety and hygiene may include the following strategies:

(1) The bureau shall link each sponsoring organization with a service representative from safety and hygiene.

(2) Safety and hygiene shall assist the group with its development of safety strategies.

(3) Safety and hygiene and the sponsoring organization may sponsor joint seminars.

(4) The safety and hygiene representative shall provide a list of resources and expertise within each region upon request.

(5) The sponsoring organization shall promote bureau safety and hygiene services to its members.

(6) Safety and hygiene may provide training sessions and written safety and health materials.

(7) Bureau safety and hygiene division consultation services may be utilized by member companies for customized safety management assistance.

(8) Safety and hygiene and the sponsoring organization may develop joint programs in response to member needs.

(F) The division of safety and hygiene shall schedule annual regional training seminars for sponsoring organizations. Each sponsoring organization must send at least one representative to the seminar. Additionally, the division of safety and hygiene shall develop a list of publications and support materials that assist the sponsoring organization in reinforcing the safety guidelines of this rule.

History

Effective: July 1, 2015
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-71 Claim impact reduction program.

(A) Definitions.

As used in this rule:

(1) "Claim impact reduction program" or "CIRP" means the bureau of workers' compensation's voluntary rate program which offers a private employer or a public employer taxing district employer the opportunity to mitigate the impact of a significant claim that will enter the employer's experience for the first time.

(2) "Program eligibility period" means the four policy years in which an employer has a significant claim in its experience period.

(3) "Significant claim" means a claim whose total value or maximum claim value, whichever is lower, will be greater than the employer's total limited losses ("TLL") as defined in rule 4123-17-03 of the Administrative Code. Effective July 1, 2020, for private employers whose expected losses fall below the minimum expected loss provided in appendix A to rule 4123-17-05.1 of the Administrative Code, a TLL of three hundred dollars shall be used; for public employer taxing districts whose expected losses fall below the minimum expected loss provided in appendix A to rule 4123-17-33.1 of the Administrative Code, a TLL of five hundred fifty dollars shall be used.

(4) "Minor claim" means a medical-only or lost-time claim whose total value or maximum claim value, whichever is lower, will be less than the employer's TLL as defined in rule 4123-17-03 of the Administrative Code, subject to the TLL provisions of a significant claim that became effective July 1, 2020.

(B) Application and withdrawal processes.

(1) An employer's participation in the CIRP is voluntary. The employer shall apply to participate in the CIRP for their initial year of program eligibility by the application deadline set forth in appendix A and appendix B to rule 4123-17-74 of the Administrative Code. For subsequent years of eligibility, if an employer meets the requirements of paragraph (C) of this rule as of the application deadline set forth in appendix A and appendix B to rule 4123-17-74 of the Administrative Code, and the employer has not withdrawn from the CIRP pursuant to paragraph (B)(2) of this rule, the bureau will renew the employer in the CIRP without requiring the employer to file a renewal application. The bureau shall have the final authority to approve an eligible employer for initial and continued participation in the CIRP.

(2) An employer may withdraw from the CIRP under this rule at any time. The employer must notify the bureau in writing that the employer no longer desires to participate in the CIRP. An employer that withdraws from the CIRP after receiving a discount will return to its own individual experience rating for that policy year.

(3) If the employer withdraws from the CIRP and has any remaining years in the program eligibility period, the employer may reapply for the CIRP under the provisions of paragraph (A) of this rule and designate the same claim as the significant claim.

At the time of an employer's initial application for the CIRP, the employer must be enrolled in the group experience rating program. At the time of initial application and each renewal application deadline as set forth in appendix A and appendix B to rule 4123-17-74 of the Administrative Code, the employer must:

(1) Be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code;

(2) Be current on the payment schedule of any part-pay agreement into which it has entered for payment of premiums or assessment obligations;

(3) Not have cumulative lapses in workers' compensation coverage in excess of forty days within the prior twelve months;

(4) Be enrolled in the group experience rating program; and

(5) Have reported actual payroll for the preceding policy year and have paid any premium due upon reconciliation of estimated premium and actual premium for that policy year.

(D) General program requirements.

(1) In signing the application form, the chief executive officer or designated management representative of the employer is certifying to the bureau that the employer will comply with all program requirements.

(2) An employer may have a maximum of three minor claims at any time in addition to the one significant claim.

(a) As a minor claim exits the employer's experience period, the employer may include a new minor claim.

(b) The total combined costs of these minor claims must be below the employer's TLL.

(3) An employer may participate in the CIRP on no more than one significant claim within the program eligibility period from the date of the employer's initial participation in the program.

(4) Once a claim has been designated as the significant claim in initial enrollment for a program eligibility period, an employer is not permitted to change the claim designated as the significant claim.

(5) Settled and subrogated claims will be included in the employer's total claim count.

(6) In the first year of the program eligibility period, the employer shall participate in an industry-specific half-day safety program prescribed by the division of safety and hygiene. In subsequent years of the program eligibility period in which the employer elects to participate in the CIRP, the employer shall complete an online training class prescribed by the division of safety and hygiene.

(7) Once admitted into the CIRP, the employer must report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year no later than the date set forth in rule 4123-17-14 of the Administrative Code. An employer will be deemed to have met this requirement if the bureau receives the payroll report and the employer pays any premium owed associated with that payroll report before the expiration of any grace period established by the administrator of workers' compensation pursuant to paragraph (B) of rule 4123-17-16 of the Administrative Code.

(E) Program benefits.

The bureau will credit an employer that meets all the criteria with a discount from the employer's base rate as follows:

(1) In the first year of the program eligibility period, twenty per cent;

(2) In the second year of the program eligibility period, fifteen per cent;

(3) In the third year of the program eligibility period, ten per cent; and

(4) In the fourth year of the program eligibility period, five per cent.

(F) Removal from program.

(1) If the employer fails to meet the requirements of paragraph (C) or paragraph (D) of this rule, the bureau will remove an employer from participation in the CIRP at the beginning of the next policy year and, upon removal, will return the employer to its individual EM.

(2) An employer removed from the OCP for failure to comply with paragraph (D)(7) of this rule will be rerated for the full policy year at the employer's base rate or experience-modified rate as determined by the employer's expected losses for the policy year.

(G) An employer may appeal the bureau's application rejection or the bureau's participation removal in the CIRP to the bureau's adjudicating committee pursuant to section 4123.291 of the Revised Code and rule 4123-14-06 of the Administrative Code.

Last updated July 2, 2024 at 11:40 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-72 Deductible rule.

(A) Definitions.

As used in this rule:

(1) "Coverage period" means the twelve month period beginning July first through June thirtieth for private employers, and January first through December thirty-first for public employers. The deductible selected by the employer will apply only to claims with a date of injury within the coverage period defined in the deductible agreement.

(2) "Deductible" means the maximum amount an employer participating in the deductible program must reimburse the bureau for each claim that occurs during the policy year.

(a) "Small deductible" means a deductible less than or equal to ten thousand dollars.

(b) "Large deductible" means a deductible greater than ten thousand dollars.

(3) "Experience rated premium" means the premium obligations of an employer for the policy year excluding the disabled workers' relief fund ("DWRF") assessment. Experience rated premium may include any experience rated premium related to policy combinations. The premium is subject to the premium sized adjustment described in rule 4123-17-03.3 of the Administrative Code.

(4) "Modified rate" means the rate that employers who are experience rated pay as a percentage of their payroll. This rate is calculated by taking the base rate and multiplying it by the employer's experience modification ("EM") factor.

(5) "Base rate" means the rate that employers who are not experience rated pay as a percentage of their payroll.

(6) "Policy in good standing" means the employer is current on all payments due to the bureau and is in compliance with bureau laws, rules, and regulations at the time of enrollment or reenrollment.

(7) "Premium" means money paid and due from an employer for workers' compensation insurance. Premium does not include money paid as fees, fines, penalties or deposits.

(8) "Qualified employer" means an employer that has a state insurance fund policy that is in good standing at the time of enrollment or reenrollment. Although the employer may be a qualified employer, the bureau may not accept the employer into the deductible program for other reasons set forth in this rule.

(B) Eligibility requirements.

(1) An employer shall be eligible to participate in the deductible program only if the employer meets all of the following requirements:

(a) As of each continuing eligibility evaluation date, the employer holds active workers' compensation coverage as of the original application deadline or anniversary date of participation as follows:

(i) The employer must be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code.

(ii) The employer must be current on the payment schedule of any part-pay agreement into which it has entered for payment of premiums or assessment obligations.

(iii) If the employer selects a small deductible, the employer may not have cumulative lapses in workers' compensation coverage in excess of forty days within the preceding twelve months.

(iv) If the employer selects large deductible, the employer may not have cumulative lapses in workers' compensation coverage in excess of fifteen days within the preceding five years.

(v) The employer must report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year no later than the application deadline date set forth in rule 4123-17-74 of the Administrative Code.

(b) The employer shall demonstrate the ability to make payments under the deductible program based upon a credit score established by the bureau on an annual basis which will be applicable to all applicants for the program year. The bureau shall obtain the credit reports from an established vendor of such information. An employer that is a subsidiary of another corporate entity may use the parent corporate entity's credit score in meeting this requirement if the parent corporate entity meets financial criteria for the deductible program and executes a contract of guaranty with respect to the subsidiary's participation in the program.

(c) The bureau may require an employer to adopt additional risk mitigation measures as a prerequisite for participation in the program. These measures may include, but are not limited to, either individually or in combination, the following:

(i) Adoption of an alternative payment plan;

(ii) Providing securitization in the form of a letter of credit or surety bond; or

(iii) For employers electing a large deductible, selection of an aggregate stop-loss limit.

(2) The following employers shall not be eligible to participate in the deductible program:

(a) State agencies; and

(b) Self-insuring employers providing compensation and benefits pursuant to section 4123.35 of the Revised Code.

(C) In selecting an employer deductible program under this rule, the employer must select, on an application provided by the bureau, a per claim deductible amount, which shall be applicable for all claims with dates of injury within a one-year coverage period. The employer shall choose one deductible level from the following:

(1) Five hundred dollars;

(2) One thousand dollars;

(3) Two thousand five hundred dollars;

(4) Five thousand dollars;

(5) Ten thousand dollars;

(6) Twenty-five thousand dollars;

(7) Fifty thousand dollars;

(8) One hundred thousand dollars; or

(9) Two hundred thousand dollars.

(D) In choosing a small deductible, the employer may not choose a deductible amount that exceeds twenty-five per cent of their experience rated premium obligation during the most recent full policy year. For a new employer policy, the deductible amount shall not exceed twenty-five per cent of the employer's expected premium. In choosing a large deductible, the employer may not choose a deductible amount that exceeds forty per cent of their experience rated premium obligation for the most recent full policy year. For self-insuring employers re-entering the state insurance fund, the bureau will use the paid workers' compensation benefits from the last full policy year in place of experience rated premium. The bureau may estimate a full year's premium should only a partial year be available or if no premium is available in the most recent full policy year.

(E) An employer selecting a large deductible will undergo additional credit analysis and must submit financial information to the bureau during the enrollment period preceding each policy year they elect to participate in the program.

(1) An employer choosing a deductible level of twenty-five thousand dollars or fifty thousand dollars must submit reviewed or audited financials for at least the three most recent fiscal years. The financials must be prepared in accordance with generally accepted accounting principles (GAAP).

(2) An employer choosing a deductible level of one hundred thousand dollars or two hundred thousand dollars must submit audited financials for at least the three most recent fiscal years. The financials must be prepared in accordance with GAAP.

(F) An employer may request an annual aggregate stop-loss limit option in combination with large deductible levels. If the employer requests the aggregate stop-loss limit option, the bureau shall limit the employer's deductible billings for injuries which occur during the associated policy year to three times the deductible level chosen. The bureau may reject the employer's request to participate in the aggregate stop-loss limit option if the bureau determines that, because of the employer's premium or estimated premium size, the employer would receive a credit under this rule that would exceed the employer's maximum aggregate stop-loss liability.

(G) The employer shall file the application provided by the bureau and any other documentation required for enrollment in the deductible program by the applicable application deadline set forth in appendix A or appendix B to rule 4123-17-74 of the Administrative Code.

The bureau shall not permit an employer to enroll in a deductible program outside of the application deadline, except that the bureau will consider an employer establishing a policy in Ohio for the first time for participation where the employer submits its deductible program application to the bureau within thirty days of obtaining coverage.

(H) Renewal in the deductible program at the same level for each subsequent year shall be automatic, subject to review by the bureau of the employer's continued eligibility under paragraph (B) of this rule, unless the employer notifies the bureau in writing that the employer does not wish to participate in the program or that the employer wants to change the deductible amount for the next coverage period. The employer shall provide such notice to the bureau within the time and in the manner provided in paragraph (G) of this rule.

(I) Except as provided in paragraph (M) of this rule, an employer shall not be permitted to withdraw from the deductible program during the policy year, and no changes shall be made with respect to any deductible amount selected by the employer within the policy year.

(J) The bureau shall pay the claims costs under a deductible program and the employer shall reimburse to the bureau the costs under the deductible program as follows:

(1) The bureau shall pay all claims costs in accordance with the laws and rules governing payment of workers' compensation benefits. For small deductible levels, the amount to be included in the employer's experience for a policy year shall be any claims costs for injuries incurred in that policy year less any deductible billed to the employer under this rule. For large deductible levels, the bureau shall include the entire claims cost for injuries incurred in a policy year in the employer's experience for that policy year. Any qualifying claims in accordance with paragraphs (G)(4) and (G)(5) of rule 4123-17-03 of the Administrative Code shall be excluded from the employer's experience.

(2) The bureau shall bill the employer on a monthly basis for any claims costs paid by the bureau for amounts subject to the deductible as elected by the employer for the policy year. In addition to amounts paid by the bureau for which the bureau is seeking reimbursement from the employer, such monthly billings shall also reflect the payments to date for any claims to which a deductible is applicable.

(3) The employer shall pay all deductible amounts billed by the bureau by the invoice due date. The employer will be subject to any interest or penalty provisions to which other monies owed the bureau are subject, including certification to the attorney general's office for collection.

(4) The employer shall continue to be liable beyond any deductible program period for billings covered under a deductible program for injuries that arose during any period for which a deductible is applicable, regardless of when payment was made by the bureau.

(K) The bureau will apply the premium reduction calculation under the deductible program directly to the base rate established for the policy year for base-rated employers, or after the modified premium rate is established for experience-rated employers, but prior to any other premium adjustments, as well as the DWRF assessment. The bureau will calculate the premium reduction in accordance with the appendices of this rule, which takes into account both the deductible amount chosen by the employer and the applicable hazard group based upon the most current version of the national council on compensation insurance's hazard groupings as established by the hazard group with the largest percentage of premium, as determined at the end of the enrollment period for that year.

(1) In determining the primary classification code and appropriate hazard group, the bureau shall utilize payroll and the associated experience premium for the rating year beginning two years prior to the period in which the employer is seeking to enroll in the deductible program.

(2) For new employers, the bureau shall base the appropriate primary classification code and hazard group upon estimated payroll.

(L) Where there is a combination or experience transfer of an employer within a deductible program policy period, following the application of any other rules applicable to a combination or experience transfer, the employer may be eligible to remain in a deductible program as follows:

(1) Successor: entity not having coverage.

Predecessor: enrolled in deductible program currently or in prior policy years.

Where there is a combination or experience transfer, where the predecessor was a participant in the deductible program and the successor is assigned a new policy with the bureau, the successor shall make application for the deductible program within thirty days of obtaining a bureau policy, as set forth in paragraph (L)(3) of this rule. Notwithstanding this election, the successor shall be responsible for any and all existing or future liabilities stemming from the predecessor's participation in the deductible program prior to the date that the bureau was notified of the transfer as provided under paragraph (C) of rule 4123-17-02 of the Administrative Code.

(2) Successor: enrolled in the deductible program.

Predecessor: not enrolled in the deductible program.

(3) Successor: not enrolled in deductible program.

Predecessor: enrolled in deductible program.

Where there is a combination or experience transfer involving two or more entities, each having Ohio coverage at the time of the combination or experience transfer, and the successor policy is not enrolled in the deductible program, the predecessor shall not be automatically entitled to continue in the deductible program. The successor may make a formal application should it desire to participate in the deductible program for the next policy year. Whether or not the successor chooses or is otherwise eligible to participate in a deductible program, under paragraph (C) of rule 4123-17-02 of the Administrative Code, the successor remains liable for any existing and future liabilities resulting from a predecessor's participation in the deductible program.

(M) The bureau may remove an employer participating in the deductible program from the program with thirty days written notice to the employer for any of the following reasons:

(1) The employer participates in any plan or program that is not compatible with the deductible program under rule 4123-17-74 of the Administrative Code

(2) The bureau certifies a balance due from the employer to the attorney general;

(3) The employer makes direct payments to any medical provider for services rendered, to any medical provider for supplies or to any injured worker for compensation associated with a workers' compensation claim;

(4) The employer engages in misrepresentation or fraud in conjunction with the deductible program application process; or

(5) The employer fails to report actual payroll for the preceding policy year or fails to pay any premium due upon reconciliation of estimated premium and actual premium for that policy year, no later than the due date set forth in rule 4123-17-14 of the Administrative Code. An employer will be deemed to have complied with this requirement if the bureau receives the payroll report, and the employer pays any premium associated with the payroll report, prior to the expiration of any grace period established by the administrator pursuant to paragraph (B) of rule 4123-17-16 of the Administrative Code.

(N) An employer removed from the deductible program for failure to comply with paragraph (M) of this rule will be required to pay:

(1) Claims costs up to the deductible selected under paragraph (C) of this rule for all injuries incurred from the beginning of policy year in which the employer participated in the deductible program through the date of removal from the program; and

(2) Full experience-rated premium, without the deductible credit, from the date of removal from the deductible program through the remainder of the policy year.

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Last updated July 2, 2024 at 11:41 AM

History

Effective: July 1, 2024
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-73 Group retrospective rating program.

(A) Definitions.

As used in this rule:

(1) "Group retrospective rating" is a voluntary workers' compensation insurance program offered by the bureau. Group retrospective rating is designed to provide financial incentive to employer groups participating in the program that, through improvements in workplace safety and injured worker outcomes, are able to keep their claim costs below a predefined level.

(2) "Basic premium factor" is a component of the retrospective rating premium formula used to account for insurance charges and costs that are distributed across all employers. The basic premium factor (BPF) is based upon charges for the cost of having retrospective premium limited by the selected maximum premium ratio, the cost of claims when they exceed the per claim maximum value and the cost of excluding surplus costs from incurred losses.

(3) "Developed losses" or "total incurred losses (developed)" are a component of the retrospective rating premium formula intended to account for the fact that total incurred losses in claims are likely to increase over time. This claim cost development results from a number of factors, including, but not limited to, reactivation of claims, additional claim awards, and claims that may be incurred but not reported for a substantial period, and result in costs that would otherwise not be covered by premium collected.

(4) "Evaluation period" means the three-year period beginning immediately after the end of the retro policy year. Annual evaluations will occur three times during the evaluation period at twelve, twenty-four, and thirty-six months after the end of the retro policy year.

(5) "Incurred losses" means compensation payments and medical payments paid to date as well as open case reserves. The total incurred losses will not include surplus costs or costs as defined in paragraph (G)(4) or (G)(5) of rule 4123-17-03 of the Administrative Code and will be limited on a per claim basis.

(6) "Loss development factor" means actuarially determined factors that are multiplied by incurred losses of non-PTD/death retro claims to produce developed losses. Loss development factors (LDF) are unique to each retro policy year.

(7) "Maximum premium ratio" means a factor pre-selected by the retro group that is multiplied by the standard premium after application of the premium size factors to determine the maximum retrospective premium for the group.

(8) "Member of a retro group" means the individual employers that participate in a group retrospective rating plan of a sponsoring organization.

(9) "Reserve" means the bureau's estimate of the future cost of a claim at a specific point in time.

(10) "Retro policy year" means the policy year in which an employer is enrolled in group retrospective rating. Claim losses which occur during this year will be tracked for all retro group members and refunds or assessments will be distributed based on those losses in the subsequent evaluation period. The retro policy year start and end date will match that of the rating policy year. For public employer taxing districts, the retro policy year shall be January first through December thirty-first of a year. For private employers, the retro policy year shall be July first through June thirtieth of the following year.

(11) "Standard premium" means the total premium paid by or on behalf of an employer for a given policy year including any premium size factor adjustment, excluding the assessment for the disabled workers' relief fund. In determining standard premium, total premium paid will not be reduced by any rebates or dividends issued pursuant to rule 4123-17-10 of the Administrative Code.

(12) "Application deadline" means the application deadline for group retrospective rating as set forth in appendix A and in appendix B to rule 4123-17-74 of the Administrative Code.

(B) Sponsor eligibility requirements.

Each sponsoring organization seeking to sponsor a retro group must be certified under the bureau's sponsor certification process as specified in rule 4123-17-61.1 of the Administrative Code.

Each retro group seeking to participate in the bureau group retrospective rating program shall meet the following standards:

(1) A retro group must be sponsored by a bureau certified sponsoring organization.

(2) The employers' business in the organization must be substantially similar such that the risks which are grouped are substantially homogeneous. A group shall be considered substantially homogeneous if the main operating classification codes of the risks as determined by the premium obligations for the rating year beginning two years prior to the retro policy year are assigned to the same or similar industry groups. Industry groups are determined by appendix A to rule 4123-17-05 of the Administrative Code. Industry groups seven and nine as well as eight and nine, and industry groups two and four as well as four and six are considered similar. The bureau may allow an employer to move to a more homogeneous group when, after December thirty-first for private employer groups and June thirtieth for public employer taxing district groups, but before the application deadline, the employer:

(a) Is an employer without a full year of recorded premium;

(b) Is reclassified as a result of an audit; or

(3) A retro group of employers must have aggregate standard premium in excess of one million dollars, as determined by the administrator based upon the last full policy year for which premium information is available.

(a) For employers without a full year of recorded premium, the bureau may use the employer's expected premium.

(b) The bureau shall calculate the premium based upon the experience modified premium of the individual employers excluding group rating discounts.

(4) The retro group must include at least two employers.

(5) The formation and operation of the retro group program by the organization must substantially improve accident prevention and claims handling for the employers in the retro group. The bureau shall require the retro group to document its safety plan or program for these purposes, and, for retro groups reapplying annually for group retrospective rating coverage, the results of prior programs. The safety plan must follow the guidelines and criteria set forth under rule 4123-17-68 of the Administrative Code.

(D) Employer eligibility requirements.

Each employer seeking to participate in the bureau group retrospective rating program must meet the following standards:

(1) The employer must be a private employer or public employer taxing district that participates in the state insurance fund. A self-insuring employer or a state agency public employer shall not be eligible for participation in the group retrospective rating program.

(2) Each employer seeking to enroll in a retro group for workers' compensation coverage must have active workers' compensation coverage according to the following standards:

(a) As of the application deadline, the employer must be current with respect to all payments due the bureau, as defined in paragraph (A)(1)(b) of rule 4123-17-14 of the Administrative Code.

(b) As of the application deadline for group retrospective rating, the employer must be current on the payment schedule of any part-pay agreement into which it has entered for payment of premiums or assessment obligations.

(c) The employer cannot have cumulative lapses in workers' compensation coverage in excess of forty days within the twelve months preceding the application deadline date for group retrospective rating.

(3) No employer may be a member of more than one retro group or a retro and non-retro group for the purpose of obtaining workers' compensation coverage. An employer who has been included on a group experience rating roster for the upcoming policy year may not elect to participate in group retrospective rating after the deadline for group experience rating set forth in rule 4123-17-74 of the Administrative Code.

(4) An employer must be homogeneous with the industry group of the retro group as defined in paragraph (C)(2) of this rule.

A member of a continuing retro group who initially satisfied the homogeneous requirement shall not be disqualified from participation in the continuing retro group for failure to continue to satisfy such requirement.

(E) A sponsoring organization shall make application for group retrospective rating on a form provided by the bureau and shall complete the application in its entirety with all documentation attached as required by the bureau. If the sponsoring organization fails to include all pertinent information, the bureau will reject the application.

(1) The group retrospective rating application (U-151) shall be signed each year by an officer of the sponsoring organization.

(2) The sponsoring organization shall identify each individual employer in the retro group on an employer roster for group retrospective rating plan (U-152).

(F) A retro group's application for group retrospective rating is applicable to only one policy year. The retro group must reapply each year for group retrospective rating coverage. Continuation of a plan for subsequent years is subject to timely filing of an application on a yearly basis and the meeting of eligibility requirements each year.

(G) Upon receipt of an application for retro group, the bureau shall do the following:

(1) Determine the industry classification of the retro group based upon the makeup of retro group employers submitted.

(2) Screen prospective retro group members to ensure that their business operations fit appropriately in the retro group's industry classification.

(3) In reviewing the retro group's application, if the bureau determines that individual employers in the retro group do not meet the eligibility requirements for group retrospective rating, the bureau will notify the individual employers and the retro group of this fact, and the retro group may continue in its application for group retrospective rating coverage without the disqualified employers.

(H) The group retrospective rating sponsor shall submit to the bureau an employer statement (U-153) each year for each employer that wishes to participate in group retrospective rating with the sponsor. Where an employer files a new employer statement form in the sixty days prior to the application deadline, the bureau will presume that the latest filed employer statement form of the employer indicates the employer's intentions for group retrospective rating. An employer statement form shall remain effective until the end of the policy year as defined on the employer statement form.

(I) The bureau may request of individual employers or the retro group sponsor, additional information necessary for the bureau to rule upon the application for group retrospective rating participation. Failure or refusal of the retro group sponsor to provide the requested information on the forms or computer formats provided by the bureau shall be sufficient grounds for the bureau to reject the application and refuse the retro group's participation in group retrospective rating program.

(J) Individual employers who are not included on the final retro group roster or do not have an individual employer application (U-153) for the same retro group or another retro group sponsored by the same sponsoring organization on file by the application deadline, will not be considered for the group retrospective rating plan for that policy year; however, the bureau may waive this requirement for good cause shown due to clerical or administrative error, so long as no employer is added to a retro group after the application deadline. The group retrospective rating sponsor shall submit all information to the bureau by the application deadline.

(K) Once a retro group has applied for group retrospective rating, the organization may not voluntarily terminate the application. All changes to the original application must be filed on a bureau form provided for the application for the group retrospective rating plan and must be filed prior to the filing deadline. Any rescissions made must be completed in writing, signed by an officer of the sponsoring organization and filed prior to the filing deadline. The retro group may make no changes to the application after the last day for filing the application. Any changes received by the bureau after the filing deadline will not be honored. The latest application form or rescission received by the bureau prior to the filing deadline will be used in determining the premium obligation.

(L) After the group retrospective rating application deadline but before the end of the policy year for the retro group, the sponsoring organization may notify the bureau that it wishes to remove a member of a retro group from participation in the retro group. The sponsoring organization may request that the member of a retro group be removed from the retro group after the application deadline only for the gross misrepresentation of the member of a retro group on its application to the retro group.

(1) "Gross misrepresentation" is an act by an employer applicant for group retrospective rating or a member of a retro group that would cause financial harm to the other members of the retro group and is limited to any of the following:

(a) The sponsoring organization discovers that the employer applicant for group retrospective rating or a member of a retro group has recently merged with one or more entities without disclosing such merger on the employer's application for membership in the retro group, and such merger adversely affects the employer's risk of future losses.

(b) The sponsoring organization discovers that the employer applicant for group retrospective rating or a member of a retro group has failed to disclose the true nature of the employer's business pursuit on its application for membership in the retro group, and this failure adversely affects the loss potential of the retro group.

(2) The sponsoring organization must provide sufficient documentation, as determined by the bureau, to support its request to remove an employer from a retro group.

(3) The employer shall be removed from the group only with the bureau's approval.

(M) An employer will be removed from the group retrospective rating program for the current policy year for failure to report actual payroll for the preceding policy year and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year no later than the date set forth in rule 4123-17-14 of the Administrative Code. An employer will be deemed to have met this requirement if the bureau receives the payroll report and the employer pays premium associated with that payroll report before the expiration of any grace period established by the administrator pursuant to paragraph (B) of rule 4123-17-16 of the Administrative Code. Should an employer not comply with the provisions of this paragraph, the following will apply:

(1) Claims costs according to this rule for all injuries incurred from the beginning of the policy year in which the employer participated in group retrospective rating through the date of removal from the program shall be included in the group retrospective rating calculation; and

(2) Only premium from the beginning of the policy year through the date of removal will be included in the group retrospective rating calculation for the participation policy year.

(N) A retro group formed for the purpose of group retrospective rating may not voluntarily terminate a plan during the policy year. A change in the name of the retro group will not constitute a new retro group. A change of the organization sponsoring a retro group or moving a retro group to a new sponsoring organization shall constitute a new retro group and the members of the new retro group must meet the homogeneity requirement of paragraph (C)(2) of this rule. A retro group shall be considered a continuing retro group if more than fifty per cent of the members of the retro group in the previous rating year are members of the retro group in the current rating year.

(O) Selection of an authorized representative for the retro group shall meet the following requirements:

(1) A retro group that has been established and has been accepted by the bureau for the purpose of group retrospective rating shall have no more than one permanent authorized representative for representation of the retro group and the individual employers of the retro group before the bureau and the industrial commission in any and all policy-related matters pertaining to participation in the state insurance fund.

(2) The selection of an authorized representative must be made by submission of a completed form U-151, and any change or termination of the authorized representative can be made only by a subsequent submission of form U-151. Only an officer of the sponsoring organization may sign a U-151.

(P) The bureau shall consider an employer individually when assessing the premium payments for the retro policy year. The retro group will be considered a single entity for purposes of calculating group retrospective rating premium adjustments.

(Q) The group retrospective rating premium calculation will occur at twelve, twenty-four, and thirty-six months following the end of the group retrospective rating policy year.

(1) On the evaluation date, the bureau will evaluate all claims with injury dates that fall within the retro policy year. The incurred losses and reserves that have been established for these claims are "captured" or "frozen." The group's retrospective premium will be calculated based on the developed incurred losses of the group. The group retrospective rating premium will be compared to the group standard premium, which is the combined standard premiums of retro group members for the retro policy year as defined in paragraph (A)(11) of this rule and all subsequent group retrospective rating refunds and assessments. The difference will be distributed or billed to employers as a refund or assessment.

(a) These assessments will be limited per a maximum premium ratio selected during the group retrospective rating application process.

(b) Effective with policy years beginning on or after January 1, 2022, premium refunds or premium rebates provided to group retrospective rating employers for a policy year may not exceed, in their cumulative total, one hundred per cent of the actual premium following reporting of actual payroll and reconciliation of estimated premium and actual premium in accordance with paragraph (M) of this rule.

(c) Any reserving method that suppresses some portion of an employer's costs for the purpose of calculating an experience modification will not apply in the calculation of incurred losses for group retrospective rating.

(d) The bureau may hold a portion of refunds or defer assessments owed in the first and second evaluation periods to minimize the volatility of refunds and assessments. Any net refund or assessment will be fully distributed or billed by the bureau in the third evaluation period.

(2) Incurred losses used in the group retrospective rating premium calculation will be limited to five hundred thousand dollars per claim.

(3) Incurred losses will not include surplus or violation of a specific safety requirement (VSSR) costs.

(R) The retrospective premium calculation that will occur at various evaluation points after the retro policy year end is calculated by the following formula, with standard premium and developed incurred losses are for the total of the entire retro group:

Group retrospective rating premium =

(Basic premium factor x standard premium as defined in paragraph (A)(11) of this rule)

plus

developed incurred losses

(1) A group will elect a maximum premium ratio for the group each year as part of the group retrospective rating application process. This ratio will determine the maximum amount of total premium a retro group may pay after refunds and assessments.

(2) Options for the maximum premium ratio and the corresponding basic premium factor will be as set forth in appendix A and in appendix B to this rule.

(3) A basic premium factor is applied in the retro premium calculation to account for insurance costs, surplus costs, and a per claim cap. The basic premium factor is determined using the following factors: group size by standard premium as defined in paragraph (A)(11) of this rule as set forth in appendix D to this rule and maximum premium ratio.

(4) Developed incurred losses are created by totaling incurred losses and reserves for the entire retro group and applying an actuarially determined loss development factor as defined in appendix C to this rule.

(5) Refunds and assessments will be distributed directly to group retrospective rating employers. The amount refunded or assessed to an individual employer will be based upon the percentage of the total group standard premium paid by the employer at the time of evaluation. The refund or assessment will be multiplied by this percentage and the resulting amount will be distributed or billed to the employer.

(6) Within four months of the evaluation date, if entitled, the bureau will send premium refunds.

(7) If additional premium is owed, the additional premium is included in the employer's next invoice and must be paid by the due date stated on the invoice. The bureau will charge penalties on any additional premium not paid when it is due. If the member of a retro group is entitled to a refund for one retro policy year and owes any additional monies to the bureau, the bureau will deduct the monies due the bureau from the refund. The bureau will refund the difference to the member of a retro group. In the event that this adjustment still leaves a premium balance due, the bureau will send a bill for the balance.

(S) Terminations, transfers, and change of ownership are addressed with regard to group retrospective rating as follows:

(1) Predecessor: enrolled in group retrospective rating program.

Successor: new entity.

Where there is a combination or experience transfer during the current policy year or the sixty days preceding the application deadline for the upcoming policy year, wherein the predecessor was a participant in or applicant for the group retrospective rating program, and the successor is assigned a new policy with the bureau, the successor may be considered a member of the group retrospective rating program if agreed to by both the succeeding employer and the group retrospective rating sponsor. Written agreement signed by both the succeeding employer and the group retrospective rating sponsor must be received by the bureau within thirty days of the date of succession. If the succeeding employer and the group sponsor agree to successor joining the retro group, the successor's group retrospective rating evaluation shall be based on the group's reported payroll and claims incurred. Notwithstanding this election, the successor shall be responsible for any and all existing or future rights and obligations stemming from the predecessor's participation in the group retrospective rating program prior to the date that the bureau was notified of the transfer as prescribed under paragraph (C) of rule 4123-17-02 of the Administrative Code.

(2) Predecessor: not enrolled in group retrospective rating program.

Successor: enrolled in group retrospective program.

Where one legal entity that has established coverage and is enrolled in the group retrospective rating program, wholly succeeds one or more legal entities having established coverage and the predecessor entities are not enrolled in the group retrospective rating program at the date of succession, the payroll reported and claims incurred by the predecessor from the date of succession to the end of the policy year, shall be included in successor's retrospective rating plan. If the predecessor had at any time participated in a group retrospective rating program, the successor shall be responsible for any and all existing or future rights and obligations stemming from the predecessor's participation in the group restrospective rating program prior to the date that the bureau was notified of the transfer as prescribed under paragraph (C) of rule 4123-17-02 of the Administrative Code.

(3) Predecessor: enrolled in group retrospective rating program.

Successor: not enrolled in group retrospective rating program.

Where one legal entity that has established coverage and is not currently enrolled in a group retro plan wholly succeeds one or more entities that are enrolled in a group retro plan, predecessor's plan(s) shall terminate as of the ending date of the evaluation period. Payroll reported and claims incurred on or after the date of succession will be the responsibility of the successor under its current rating plan. The successor shall be responsible for any and all existing or future rights and obligations stemming from the predecessor's participation in the group retro program prior to the date that the bureau was notified of the transfer as prescribed under paragraph (C) of rule 4123-17-02 of the Administrative Code.

(4) Predecessor: enrolled in group retro program.

Successor: enrolled in different group retro program.

Where one legal entity that has established coverage and is enrolled in a group retrospective rating plan wholly succeeds one or more entities that are enrolled in a group retrospective rating plan, predecessor's plan(s) shall terminate as of the ending date of the evaluation period. Payroll reported and claims incurred on or after the date of succession will be the responsibility of the successor under its group retrospective rating plan. The successor shall be responsible for any and all existing or future rights and obligations stemming from the predecessor's participation in the group retrospective rating program prior to the date that the bureau was notified of the transfer as prescribed under paragraph (C) of rule 4123-17-02 of the Administrative Code.

(5) Predecessor: enrolled in group retrospective rating program.

Successor: enrolled in same group retrospective rating program.

Where one legal entity that has established coverage and is enrolled in a group retrospective rating plan wholly succeeds one or more entities that are enrolled in the same group retrospective rating plan, the successor shall be responsible for any and all existing or future liabilities stemming from the predecessor's participation in the group retrospective rating program prior to the date that the bureau was notified of the transfer as prescribed under paragraph (C) of rule 4123-17-02 of the Administrative Code. If the predecessor had at any time participated in a different group retrospective rating program, the successor shall be responsible for any and all existing or future rights and obligations stemming from the predecessor's participation in the group retrospective rating program prior to the date that the bureau was notified of the transfer as prescribed under paragraph (C) of rule 4123-17-02 of the Administrative Code.

(6) Successor: cancels coverage and was enrolled in group retrospective rating program.

Predecessor: no predecessor.

If the successor cancels coverage and there is no predecessor, the premium and losses of the canceling employer will remain with the retro group for future retrospective premium calculations. The resulting refund or assessment will be collected from the remaining members of the retro group.

Group retrospective rating sponsors and authorized representatives have the right to represent the interest of the canceled employer on behalf of the group with regard to claims which occurred during the year or years the employer was active in a retro group sponsored by the organization.

(7) Successor and/or predecessor: open group retrospective rating policy years in the evaluation period.

If the successor and predecessor are not currently enrolled in the group retrospective rating program, but either or both have open group retrospective rating policy years in the evaluation period, the successor shall be responsible for any and all existing or future rights and obligations stemming from the predecessor's participation in the group retrospective rating program prior to the date that the bureau was notified of the transfer as prescribed under paragraph (C) of rule 4123-17-02 of the Administrative Code.

(8) Partial transfer.

If an entity partially succeeds another entity and the predecessor entity has any group retrospective rating policy years in the evaluation period, the predecessor entity will retain any rights to assessments or refunds. If the successor is enrolled in the group retrospective rating program, payroll reported and claims incurred on or after the date of the partial transfer will be the responsibility of the successor under its group retrospective rating plan.

(9) Successor: files a petition for bankruptcy.

Predecessor: no predecessor.

If a current or previously group retrospective rating program employer with open retro policy years files a petition for bankruptcy under chapter seven or chapter eleven of the federal bankruptcy law, that employer shall notify the bureau legal division by certified mail within five working days from the date of the bankruptcy filing. The bureau will petition the bankruptcy court to take appropriate action to protect the state insurance fund and other related funds.

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Last updated July 1, 2025 at 9:18 AM

History

Effective: July 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-74 Deadline dates and compatibility information for employer programs.

This rule defines employer program deadlines, miscellaneous dates, and compatibility between programs. Specifics may be found in the following appendices:

Appendix A: Private employer program deadlines and miscellaneous dates.

Appendix B: Public employer taxing district program deadlines and miscellaneous dates.

Appendix C: Employer program compatibility.

This rule supersedes other rules referencing program deadlines and compatibility.

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Last updated July 1, 2025 at 9:19 AM

History

Effective: July 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-75 Bonus and rebate incentive programs.

(A) The following bonus and rebate incentives are offered:

(1) The transitional work bonus established in rule 4123-17-55 of the Administrative Code;

(2) The safety council rebate established in rule 4123-17-56.2 of the Administrative Code; and

(3) The substance use prevention and recovery program bonus established in rule 4123-17-58 of the Administrative Code.

(B) The bonus and rebate incentive levels are set forth in the appendix to this rule. The administrator may review the bonus and rebate incentive levels on an annual basis and make recommendation to the board of directors regarding the appropriate levels for each policy year.

(1) Bonus and rebate incentives earned through participation cannot reduce an employer's premium due below the amount of the minimum administrative charge for the applicable policy year period as set forth in rule 4123-17-26 of the Administrative Code.

(2) bonus and rebate incentives earned through participation shall not be issued to employers paying only the minimum administrative charge in the applicable policy year as set forth in rule 4123-17-26 of the Administrative Code.

(3) Rate adjustments made to an employer's account subsequent to the issuance of bonus or rebate incentives through an employer's participation may result in recalculation of such incentives.

(4) To qualify for any incentive under this rule, an employer must:

(a) Have coverage that is in an active policy status at the time of calculation; and

(b) Report actual payroll for the preceding policy year, and pay any premium due upon reconciliation of estimated premium and actual premium for that policy year, no later than the date set forth in rule 4123-17-14 of the Administrative Code. An employer will be deemed to have met this requirement if the bureau receives the payroll report and the employer pays premium associated with such report before the expiration of any grace period established by the administrator pursuant to paragraph (B) of rule 4123-17-16 of the Administrative Code.

(D) An employer may voluntarily withdraw from a bonus or rebate incentive program by providing notice to the employer services division of the bureau of workers' compensation. Any bonus or rebate incentive earned during the policy year in which an employer withdraws from a bonus or rebate incentive program must be repaid to the bureau.

View Appendix

Last updated July 1, 2025 at 9:19 AM

History

Effective: July 1, 2025
Promulgated Under: 111.15

Ohio Adm.Code 4123-17-76 Cancellation of workers' compensation coverage.

(A) The administrator of the bureau of workers' compensation may cancel an employer's workers' compensation coverage if any of the following apply:

(1) The employer fails to pay the required premium by the annual renewal date in accordance with rule 4123-17-14 of the Administrative Code, and the employer's estimated annual premium is equal to the minimum administrative charge as set forth in rule 4123-17-26 of the Administrative Code;

(2) The employer's policy is in lapsed status, and the employer's policy has no allowed claims filed against it within two years; or

(3) The employer is a new employer who failed to pay estimated premium and assessments when due.

(B) The effective date of cancellation shall be:

(1) For situations described in paragraph (A)(1) of this rule, the last date of the most recently completed policy year;

(2) For situations described in paragraph (A)(2) of this rule, the bureau may select a date within the current policy year; or

(3) For situations described in paragraph (A)(3) of this rule, the original effective date of the policy.

(C) The administrator, for good cause shown, may retroactively cancel an employer's workers' compensation coverage. For purposes of this rule, "good cause" shall have the same meaning as in paragraph (B) of rule 4123-14-03 of the Administrative Code.

(D) An employer may cancel its workers' compensation coverage if all of the following criteria are met:

(1) The employer must notify the bureau in writing or by phone;

(2) One of the two following circumstances apply:

(a) The employer ceases operations in Ohio, or

(b) The employer no longer has employees as defined in division (A)(1)(b) of section 4123.01 of the Revised Code, and the employer agrees to cancel any supplemental or elective coverage as permitted under Chapter 4123. of the Revised Code.

(3) The employer must submit the number of employees employed within each of the employer's assigned manual classifications and the aggregate amount of wages paid to such employees to the bureau and reconcile any premium that is due for the policy year, and any other missing policy years, as set forth in rule 4123-17-14 of the Administrative Code.

Last updated September 4, 2025 at 7:26 AM

History

Effective: September 4, 2025
Promulgated Under: 111.15

Chapter 4123-18 Rehabilitation of Injured and Disabled Workers

Ohio Adm.Code 4123-18-01 Provision of vocational rehabilitation services.

Managed care organizations (MCOs) provide vocational rehabilitation management to injured workers under the health partnership program (HPP).

(A) The rules of this chapter are applicable to the vocational rehabilitation of injured workers, whether the vocational rehabilitation services are administered by the bureau and managed by an MCO, or administered by a self-insuring employer . Self-insuring employers shall adhere to these rules to ensure that vocational rehabilitation services provided to their injured workers are equal to or greater than the services defined in this chapter.

(B) The bureau will:

(1) Develop policies to implement vocational rehabilitation services.

(2) Assure that injured workers receive appropriate remain at work or return to work vocational rehabilitation services.

(3) Audit the MCOs' vocational rehabilitation management practices and provision of services.

Last updated October 1, 2024 at 9:14 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-02 Goals of vocational rehabilitation.

(A) The bureau will take measures and make expenditures as it deems necessary to aid injured workers who have sustained compensable injuries or contracted compensable occupational diseases to remain at work or to return to work.

(B) The objectives of the surplus funded vocational rehabilitation program are to be addressed and considered in the following order:

(1) To return the injured worker to the former employer in the original job, or, if this is not possible;

(2) To encourage the employer to modify the original job or to provide employment in a different job, or, if this is not possible;

(3) To assist the injured worker in finding employment in a related industry, and if this is not possible;

(4) To assist the injured worker in finding employment in any industry.

The hierarchy of return to work objectives outlined in this paragraph may necessitate the provision of appropriate skill enhancement and/or remedial or short term training to aid an injured worker in successfully returning to work at any of the steps.

(C) The bureau will ensure that an injured worker who wishes to become self-employed is informed of the opportunities available through the opportunities for Ohioans with disabilities agency, the federal small business administration office, the local Ohio small business development center, the Ohio department of development, or other resources.

Last updated July 31, 2024 at 1:53 PM

History

Effective: May 15, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-03 Guidelines for referral to and acceptance into vocational rehabilitation.

(A) Scope of vocational rehabilitation.

(1) Vocational rehabilitation is the process of restoring the vocational functioning of a worker who experiences a work related injury and who voluntarily agrees to participate in vocational rehabilitation. Vocational rehabilitation services are focused on return to work and are not reimbursable from the surplus fund if solely directed toward the medical management of a claim.

(2) The vocational rehabilitation rules of Chapter 4123-18 of the Administrative Code aid in the development of procedures for providing reimbursable vocational rehabilitation services.

(B) Participation in vocational rehabilitation services.

(1) Anyone can refer an injured worker for vocational rehabilitation services.

(2) The bureau will determine the injured worker's eligibility under paragraph (C) of this rule for vocational rehabilitation services.

(3) The MCO will make a recommendation to the bureau regarding the injured worker's feasibility under paragraph (G) of this rule for vocational rehabilitation services.

(4) An injured worker cannot participate in a vocational rehabilitation plan or receive vocational rehabilitation services until the injured worker has been determined to be both eligible and feasible for vocational rehabilitation services. The bureau will issue an order approving or denying the injured worker's participation in vocational rehabilitation services.

(5) Referrals for vocational rehabilitation in inactive claims will be processed in accordance with rule 4123-3-15 of the Administrative Code.

The following criteria apply to requests for vocational rehabilitation services:

(1) The injured worker has a claim that is:

(a) Allowed by an order of the bureau of workers' compensation or the industrial commission or of a hearing officer, with eight or more days of lost time due to a work related injury; or

(b) Certified by a self-insuring employer.

(2) The injured worker has a significant impediment to employment or the maintenance of employment as a result of the allowed conditions in the referred claim.

(3) The injured worker has at least one of the following present in the referred claim:

(a) The injured worker is receiving or has been awarded temporary total, non-working wage loss, or permanent total compensation for a period of time that includes the date of referral. For purposes of this rule, payments made in lieu of temporary total compensation (e.g. salary continuation) will be treated the same as temporary total compensation;

(b) The injured worker was granted a scheduled loss award under division (B) of section 4123.57 of the Revised Code;

(c) The injured worker is not currently receiving compensation but has job restrictions in the claim documented by the physician of record and dated not more than one hundred eighty days prior to the date of referral; or

(d) The injured worker is receiving job retention services to maintain employment or satisfies the criteria set forth in paragraph (E) of this rule on the date of referral.

(4) The injured worker was not working on the date of referral, with the exception of referral for job retention services.

(D) Eligibility for rehabilitation services for an employee of a state agency or state university employer.

Notwithstanding the eligibility criteria of paragraph (C)(3) of this rule, an employee of a state agency or state university is eligible for rehabilitation services where the state agency or state university and the employee and employer agree upon a program of rehabilitation services.

(E) Job retention services.

(1) Job retention may be furnished when an injured worker is working and experiences a significant work related problem as a result of the allowed conditions in the claim.

(2) Job retention services may be provided if:

(a) The injured worker has received temporary total compensation or salary continuation from an allowed claim with eight or more days of lost time due to a work related injury;

(b) The physician of record provides a written statement in office notes or correspondence indicating that the injured worker has work limitations related to the allowed conditions in the claim that negatively impact the injured workers' ability to maintain the injured worker's employment; and

(c) The injured worker's employer describes the specific job task problems the injured worker is experiencing to the MCO and the MCO documents these problems in the claim. The MCO will include a statement describing why the injured worker needs job retention services to maintain employment.

(F) Non-eligibility for vocational rehabilitation services.

An injured worker becomes ineligible for vocational rehabilitation services and such services will be terminated:

(1) After the effective date of a lump sum settlement (medical, indemnity, or both);

(2) When the claim is subsequently disallowed by an order of the industrial commission, a district or staff hearing officer, or by an order of the court; or

(3) When the injured worker, after successfully completing a comprehensive vocational rehabilitation plan, subsequently resigns from employment or is terminated for cause and the resignation or termination is not due to the allowed conditions in the claim.

(G) Determination of feasibility for vocational rehabilitation services.

(1) Feasibility for vocational rehabilitation services means, based upon all available information:

(a) The injured worker is willing to participate in vocational rehabilitation services;

(b) The injured worker is able to participate in vocational rehabilitation services; and

(c) There is a reasonable probability that the injured worker will benefit from vocational rehabilitation services and return to work as a result of the services.

(2) "All available information" means records, documents, written and oral statements, and any and all medical, psychological, vocational, social, and historical data, of any kind whatsoever, developed in the claim through which vocational rehabilitation is sought or otherwise, that is relevant to the determination of an injured worker's feasibility for vocational rehabilitation services.

(H) Appeal process.

Facts supporting a decision concerning either the acceptance or denial of an injured worker into vocational rehabilitation will be documented in the bureau's order approving or denying the injured worker's participation in vocational rehabilitation services. The bureau's order approving or denying participation in vocational rehabilitation services may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code.

(I) Injured worker's right to compensation or benefits.

(1) Approval of an injured worker to participate in vocational rehabilitation services makes the injured worker eligible to receive living maintenance payments in accordance with section 4121.63 of the Revised Code and rule 4123-18-04 of the Administrative Code.

(2) Denial of an injured worker to participate in vocational rehabilitation services does not affect an injured worker's right to compensation or benefits under Chapters 4123., 4127., and 4131. of the Revised Code for which the injured worker otherwise qualifies.

Last updated October 1, 2024 at 9:15 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-04 Living maintenance.

The bureau will make living maintenance payments from the surplus fund to an injured worker approved to participate in vocational rehabilitation pursuant to rule 4123-18-03 of the Administrative Code, in accordance with the criteria set forth in this rule. Living maintenance payments are compensation under Chapters 4121. and 4123. of the Revised Code.

(A) Living maintenance payments begin on the date that the injured worker actually begins to participate in an approved vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan as defined in rule 4123-18-05 of the Administrative Code. Living maintenance is not payable on the date of referral for vocational rehabilitation services, nor the date the injured worker signed the rehabilitation agreement. Activities performed prior to the injured worker's active participation in the approved vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan are considered pre-plan activities for which living maintenance is not paid.

If salary continuation is offered and continues to be offered by the employer of record during participation in an approved vocational rehabilitation plan assessment or comprehensive vocational rehabilitation plan, an injured worker may choose to receive either salary continuation or living maintenance unless temporary total or living maintenance has been paid in the claim. In those cases, the injured worker will be paid living maintenance. Whenever salary continuation is paid by the employer, it must be paid at the injured worker's regular (full) salary level.

(B) The bureau will order suspension of living maintenance payments at such time as it becomes evident that the injured worker will not be able to participate actively in their vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan for a period of thirty days or more due to the medical instability of the injured worker. The suspension of living maintenance does not affect an injured worker's right to compensation or benefits under the Revised Code for which the injured worker otherwise qualifies.

(1) The bureau will assist the injured worker in obtaining the payment of other workers' compensation benefits to which the injured worker would otherwise be entitled, absent involvement in a vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan.

(2) Medical hold and eligibility.

The injured worker, the employer, or their representatives may make a request to the MCO for a medical hold. The MCO will forward the request, along with any necessary information, to the bureau. The bureau will determine whether, based on adequate medical documentation, the injured worker's vocational rehabilitation plan should be closed with a medical hold.

(a) A medical hold will retain the injured worker's approval to participate in vocational rehabilitation services for up to a maximum of six months from the date of vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan file closure.

(b) Upon request of the injured worker and with medical documentation indicating the stabilization of the injured worker's medical condition, the injured worker's vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan will be reactivated and, absent any extenuating circumstances, appropriate rehabilitation services will begin as soon as possible.

(C) The bureau will not pay living maintenance for any period during which an injured worker has returned to work while the injured worker's vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan remains open, other than as part of a gradual return to work plan.

However, the bureau may resume living maintenance payments if the injured worker subsequently stops working while the vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan is still open and the injured worker resumes services in said plan.

(D) The bureau will terminate living maintenance payments upon the closure of the injured worker's vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan pursuant to paragraph (F) of rule 4123-18-05 of the Administrative Code.

The termination of living maintenance does not affect an injured worker's right to compensation or benefits under the Revised Code for which the injured worker otherwise qualifies.

(E) The bureau may order deduction from any living maintenance payment an amount equal to:

(1) One-seventh of the weekly payment to which an injured worker is entitled for each full day during which the injured worker fails, without good cause, to participate in their approved vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan.

(2) Any wages or other remuneration received by the injured worker while participating in an approved vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan and receiving living maintenance. In the alternative, the injured worker may endorse the wages or other remuneration over to the bureau, or the bureau may deduct the amount from future awards of compensation.

(F) Living maintenance payments will not be paid by the bureau for a period or periods exceeding six months in the aggregate, unless the bureau determines that the injured worker will benefit from an extension of vocational rehabilitation services.

(G) Bureau orders regarding suspension of, or deduction from an injured worker's living maintenance payments or future awards of compensation may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code.

Last updated October 1, 2025 at 8:10 AM

History

Effective: October 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-05 Individualized written vocational rehabilitation plan.

(A) When vocational rehabilitation services are managed by a managed care organization (MCO), the MCO will ensure that a vocational rehabilitation case management provider contacts the injured worker and prepares a written vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan for the injured worker's acknowledgment and approval. The vocational rehabilitation case management provider will, where practical, consult with the injured worker's employer, the physician of record, and others considered appropriate. A vocational rehabilitation assessment plan may be prepared prior to the individualized written comprehensive vocational rehabilitation plan. The assessment plan may be up to four weeks in length, during which time the injured worker will be actively engaged in career exploration and assessment activities.

(B) Each written vocational rehabilitation assessment plan will include, at a minimum, the following information:

(1) The evaluation questions to be answered by the assessment;

(2) The types of services needed to complete the assessment, including:

(a) The estimated costs for the services;

(b) The estimated length of time needed to complete the services;

(3) The estimated length of time needed to complete the assessment.

(1) Identification of the injured worker's return to work goals and barriers to employment;

(2) The types of services needed;

(3) The estimated costs;

(4) The estimated length of time needed to attain the goals of the plan;

(5) An explanation of the specific strategies that will be employed to assist the injured worker in returning to work. The MCO will document that the return to work goal is addressed following the hierarchy of return to work objectives set forth in rule 4123-18-02 of the Administrative Code.

(6) The method of evaluating services.

(D) Each written job retention plan will include the following information:

(1) The problems to be addressed by the plan;

(2) The specific services necessary for the injured worker to maintain current employment;

(3) The estimated costs for the services;

(4) The estimated length of time needed to complete the services;

(5) The provider for the services.

(E) The MCO will oversee the development and implementation of the vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan by the assigned vocational rehabilitation case management provider. Once a comprehensive vocational rehabilitation plan is initiated, the MCO will approve a change in the assigned vocational rehabilitation case management provider only for extraordinary circumstances.

(F) The MCO, in conjunction with the bureau, will close an injured worker's vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan for the following reasons:

(1) The injured worker has completed a vocational rehabilitation assessment plan and it is determined further vocational rehabilitation services are not needed;

(2) The injured worker has failed to fulfill the responsibilities outlined in the vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan;

(3) The injured worker is unable to attain the goals of the vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan;

(4) The injured worker has refused, without good cause, to accept an offer of employment within the vocational goal of the comprehensive vocational rehabilitation plan;

(5) The injured worker is no longer living;

(6) The injured worker does not agree with the MCO's or bureau's decision to approve or deny specific vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan services; or

(7) The claim is subsequently disallowed by an order of the industrial commission, a district or staff hearing officer, or by an order of the court;

(8) The claim is settled (medical, indemnity, or both);

(9) The injured worker has completed a comprehensive vocational rehabilitation plan;

(10) The injured worker has completed a job retention plan;

(11) The injured worker is determined to be no longer feasible for vocational rehabilitation services as defined in rule 4123-18-03 of the Administrative Code.

(G) Appeals regarding vocational rehabilitation plan closure are governed by the alternative dispute resolution process provided for in rule 4123-6-16 of the Administrative Code.

Last updated October 1, 2024 at 9:15 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-08 Payment for rehabilitation services and related expenses from the surplus fund.

(A) General principles.

(1) Vocational rehabilitation services and related expenses, as set forth in this rule, are paid from the surplus fund established by section 4123.34 of the Revised Code, so long as such costs are incurred in a lost time claim pursuant to an approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan.

(2) Vocational rehabilitation services can include but cannot be solely directed toward medical management and allied medical treatment of the injured worker in an approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan.

(3) Any period of treatment relating to the allowed condition(s) of the claim which has been prescribed and provided prior to the approval of the vocational rehabilitation plan by the physician of record in the claim, by a specialist to whom the injured worker has been referred by the physician of record, the injured worker's employer, the managed care organization (MCO), or the bureau of workers' compensation, and which extends into the calendar period of the injured worker's approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan will be charged to the risk of the employer.

(4) Vocational rehabilitation case management costs incurred in the development and preparation of an approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan, including costs for necessary medical, psychological, and vocational evaluations, are vocational rehabilitation services and are paid from the surplus fund. On-going vocational rehabilitation case management professional services and travel are also paid from the surplus fund as part of the approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan.

(B) Nonallowed conditions.

(1) The MCO may authorize payment for treatment of a condition which is unrelated to the work related injury or occupational disease as long as it is clearly evident that the unrelated condition is impeding vocational rehabilitation or is a barrier to returning to work. The payment for treatment of these conditions will not exceed three thousand dollars for each claim.

(2) The MCO will fully document the rationale for these expenditures in both the approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan and the MCO's rehabilitation case file.

(3) Payment for such treatment does not constitute a recognition of the unrelated condition as a part of the claim.

(4) As soon as the unrelated condition is no longer affecting the work related injury or occupational disease, or payment for treatment of the condition has reached the three thousand dollar maximum, payment for any subsequent treatment is the responsibility of the injured worker.

The following expenses may be paid when authorized as part of an approved vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan.

(1) Travel expenses may be reimbursed consistent with the provisions of paragraph (B) of rule 4123-6-40 of the Administrative Code.

(2) Reasonable and necessary relocation expenses may be authorized up to a maximum of four thousand dollars per injured worker.

(a) Relocation expenses may be approved when, as determined by the MCO, the following criteria are met:

(i) Job opportunities for which the injured worker is qualified do not exist within a reasonable commute on a daily basis, and

(ii) The injured worker has secured a job at the new location.

(b) Relocation expenses may include temporary lodging.

Last updated October 1, 2024 at 9:15 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-09 Vocational rehabilitation provider fee schedule.

(A) Pursuant to sections 4121.441 and 4121.61 of the Revised Code, the administrator hereby adopts the vocational rehabilitation provider fee schedule indicated in the appendix to this rule, developed with stakeholder input.

(B) Notwithstanding paragraph (A) of this rule, consistent with division (F)(1) of section 4121.44 of the Revised Code, managed care organizations may enter into other arrangements and reimbursement agreements with medical, professional, and pharmacy providers.

View Appendix

Last updated October 1, 2026 at 9:09 AM

History

Effective: October 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-11 Incentive payments to employers who hire or retain injured workers who have completed a rehabilitation program.

The bureau, as a means of encouraging employers to retain, rehire, or hire injured workers who have successfully completed a prescribed rehabilitation program, may make payments to such employers from the surplus fund established by section 4123.34 of the Revised Code.

(A) The payments will be negotiated with the employer based upon a written agreement signed by the employer and the injured worker and approved by the bureau.

(B) The period(s) of such payment will not exceed six months in the aggregate, unless the bureau determines that the injured worker would benefit from an extension of payments.

(C) Payments under this rule are made directly to the employer on a monthly basis, provided the employer is a complying employer in the state in which it is subject to workers' compensation coverage . However, a self-insuring employer is not eligible for payments under this rule in any claim in which a self-insuring employer is the employer of record.

Last updated October 1, 2024 at 9:16 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-14 Injured workers suffering compensable injuries, occupational diseases or death while in an approved vocational rehabilitation plan.

(A) Claims for injury, occupational disease or death incurred in the course of and arising out of participation in an approved vocational rehabilitation plan and not in the course of and arising out of any employment, may be filed for compensation and benefits.

(B) The full or average weekly wage for the rehabilitation injury, occupational disease, or death claim will be calculated using the full or average weekly wage information in the original claim pursuant to which the injured worker undertook participation in the prescribed rehabilitation program; provided, that if the statewide average weekly wage in the year of the rehabilitation injury, occupational disease or death is different from that applicable to the original claim, the injured worker's full or average weekly wage will be calculated using the original wage information but subject to the maximum compensation rate in such subsequent year.

(C) All compensation and benefit awards arising out of such a claim are charged to the surplus fund account established by section 4123.34 of the Revised Code, and not charged through the state insurance fund to the employer of record in the claim through which the injured worker was receiving vocational rehabilitation services so long as the employer pays assessments into the surplus fund account for the payment of such compensation and benefits. If the employer is a self-insuring employer, these compensation and benefits are paid by the self-insuring employer directly as a part of a claim.

Last updated October 1, 2024 at 9:16 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-16 Self-insuring employer's obligation to provide vocational rehabilitation services.

(A) Employers who provide compensation and benefits pursuant to section 4123.35 of the Revised Code shall furnish all eligible and feasible injured workers with vocational rehabilitation services equal to or greater in quality and content than the services administered by the bureau and managed by the managed care organizations (MCOs).

(B) Upon referral, a self-insuring employer will determine whether the injured worker is eligible and feasible for vocational rehabilitation services using the criteria set forth in rule 4123-18-03 of the Administrative Code. If it is determined that the injured worker is eligible and feasible for vocational rehabilitation services, the self-insuring employer shall provide vocational rehabilitation case management services equal to or greater in quality and content than the services administered by the bureau and managed by the MCOs, utilizing the services of a provider who meets the minimum credentialing criteria set forth in rule 4123-6-02.2 of the Administrative Code. The self-insuring employer will submit a copy of the approved vocational rehabilitation plan to the injured worker and the injured worker's representative.

(C) The bureau will inspect and review the quality and content of authorized self-insuring employers' vocational rehabilitation services in order to determine whether or not such services are equal to or greater in quality and content than the services administered by the bureau and managed by the MCOs. Such inspections and reviews will be conducted upon receipt of evidence indicating that a self-insuring employer's vocational rehabilitation services are of a lesser quality than the services administered by the bureau and managed by the MCOs.

(D) The bureau may direct complaints of sub-standard vocational rehabilitation programs to the bureau's self-insured department for review.

(E) The self-insuring employer will promptly pay living maintenance, wages in lieu of compensation, or salary continuation directly to the injured worker, in accordance with rule 4123-18-04 of the Administrative Code.

Last updated October 1, 2024 at 9:16 AM

History

Effective: October 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-18-21 Wage loss payments to injured workers who complete rehabilitation plans.

(A) For purposes of this rule:

(1) "Successful return to work" as a result of an approved vocational rehabilitation plan means that the injured worker has obtained employment no later than sixty days from the date of closure of the injured worker's approved comprehensive vocational rehabilitation plan or has retained employment following the closure of the injured worker's job retention plan, and the employment:

(a) Is within the physical or psychiatric limitations caused by the impairments resulting from the allowed conditions in the claim in which the injured worker completed the comprehensive vocational rehabilitation plan or job retention plan; and

(b) Is reasonable in comparison with the return to work goals of the comprehensive vocational rehabilitation plan or job retention plan completed by the injured worker.

(2) "Suitable employment," "comparably paying work," and "present earnings" have the same meaning as in rule 4125-1-01 of the Administrative Code.

(B) In claims with a date of injury on or after August 22, 1986, the bureau will make living maintenance wage loss payments to injured workers who complete an approved comprehensive vocational rehabilitation plan or job retention plan, successfully return to work as defined in paragraph (A)(1) of this rule, and experience a wage loss while employed as a consequence of the physical and/or psychiatric limitation caused by the impairments resulting from the allowed conditions in the claim.

(1) An injured worker may request living maintenance wage loss payments by submitting an application for living maintenance wage loss (on form RH-18 or equivalent) and medical documentation of their physical or psychiatric limitations, or both.

(2) Subsequent applications for living maintenance wage loss payments must be submitted by the injured worker before the specified end date of the documented restrictions or every six months, whichever occurs first.

(a) If the physical or psychiatric limitations are temporary, medical documentation regarding the ongoing status of the restrictions must be submitted with any subsequent application for living maintenance wage loss payments.

(b) If the physical or psychiatric limitations are permanent, the bureau may request supplemental medical documentation be submitted with subsequent applications.

(3) If an injured worker voluntarily limits their income by choosing to work fewer hours or by accepting a job which does not constitute suitable employment which is comparably paying work, the injured worker's living maintenance wage loss benefits will be calculated as sixty-six and two-thirds per cent of the difference between the greater of the injured worker's full weekly wage or average weekly wage on the claim for which the injured worker underwent a rehabilitation plan and the weekly wage the injured worker would have earned had the injured worker not voluntarily limited their income.

(a) In determining whether an injured worker has voluntarily limited their income, the bureau may review all relevant factors set forth in rule 4125-1-01 of the Administrative Code in determining whether the injured worker has returned to suitable employment which is comparably paying work.

(b) An injured worker who wishes to change jobs after the initial receipt of living maintenance wage loss payments must notify the bureau. The bureau will review the criteria set forth in paragraph (B)(3)(a) of this rule to ensure that the job the injured worker wishes to change to constitutes suitable employment which is comparably paying work.

(4) If the injured worker accepts employment below the reasonable expectations of the return to work goals of the vocational rehabilitation plan, or if the injured worker can reasonably be expected to obtain different employment for which earnings are more comparable to those prior to the injury, the injured worker may be required to make a good faith effort to search for suitable employment which is comparably paying work. The bureau will consider factors such as the goals of the vocational rehabilitation plan, the labor market, the skills and work history of the injured worker, and any other factors that would assist in making such determination.

(5) To receive living maintenance wage loss payments under this rule after approval of these benefits by the bureau, an injured worker must provide proof of present earnings at least every four weeks, or on a quarterly basis if the injured worker has a substantial variation in income, in the form of pay stubs, payroll reports from the injured worker's current employer, or a wage statement on form RH-94(A) or equivalent.

(6) Living maintenance wage loss payments are charged to the surplus fund established by section 4123.34 of the Revised Code.

(C) The bureau will calculate living maintenance wage loss payment amounts based upon the information submitted by the injured worker pursuant to paragraph (B)(4) of this rule. Payments will be sixty-six and two-thirds per cent of the difference between the greater of the injured worker's full weekly wage or average weekly wage on the claim for which the injured worker underwent a rehabilitation plan and the weekly wage received while employed up to a maximum per week equal to the statewide average weekly wage.

(D) Payments may continue for up to a maximum of two hundred weeks but will be reduced by the corresponding number of weeks in which an injured worker receives payments pursuant to division (B) of section 4123.56 of the Revised Code.

(E) Facts supporting a decision concerning the eligibility or non-eligibility of an injured worker for living maintenance wage loss will be documented in the bureau's order approving or denying the living maintenance wage loss. The bureau's order approving or denying living maintenance wage loss may be appealed to the industrial commission pursuant to section 4123.511 of the Revised Code.

Last updated October 1, 2025 at 8:10 AM

History

Effective: October 1, 2025
Promulgated Under: 119.03

Chapter 4123-19 General Procedures for State Insurance Fund; Self-Insuring Employers

Ohio Adm.Code 4123-19-01 Definitions.

(A) "Benefits" means medical, surgical, nursing, and hospital attention and services and medicines, and funeral expenses as provided in sections 4123.52, 4123.55 to 4123.62, and 4123.64 to 4123.67 of the Revised Code.

(B) "State insurance fund employer" are hereby defined as those employers who pay their full premium into the state insurance fund.

(C) "Self-insuring employers" are hereby defined as those employers who demonstrate sufficient financial ability to carry their own insurance; who do not desire to insure the payment thereof, except as provided in division (B) of section 4123.82 of the Revised Code; who secure authority from the administrator to pay compensation and benefits directly; who pay into the state insurance fund an assessment as established by a rule of the bureau adopted in accordance with section 111.15 of the Revised Code; who pay to the bureau a contribution to the self-insuring employers' guaranty fund pursuant to section 4123.351 of the Revised Code; and who provide an additional security, where required by the bureau, in the amount or form that may be specified by the bureau.

(D) "Self-insurance" is a privilege granted or denied by the administrator. Once granted the privilege of self-insurance, the employer determines the first level of a claim and must have employees with a working knowledge of current Ohio workers' compensation law and all rules and regulations of the bureau and the industrial commission. A self-insuring employer may, without any prior order from the industrial commission or the bureau, grant or refuse to grant any claim made under the Ohio Workers' Compensation Act. In granting a claim or awarding payment of compensation or benefits, the employer may provide to its employees compensation or benefits that are greater than those required by law. The employer may not pay compensation or benefits less than that which is required by law.

Last updated February 5, 2026 at 1:41 PM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-03 Where an employer desires to secure the privilege to pay compensation and benefits directly.

(A) All employers granted the privilege to pay compensation and benefits directly shall demonstrate sufficient financial strength and administrative ability to assure that all obligations under section 4123.35 of the Revised Code will be met promptly. The administrator of workers' compensation shall deny the privilege to pay compensation and benefits directly, where the employer is unable to demonstrate its ability to promptly meet all the obligations under the rules of the industrial commission and the bureau and section 4123.35 of the Revised Code. The administrator of workers' compensation shall consider, but shall not be limited to the factors in divisions (B)(1) and (B)(2) of section 4123.35 of the Revised Code where they are applicable in determining the employer's ability to meet all obligations under section 4123.35 of the Revised Code.

The administrator of workers' compensation shall review all financial records, documents, and data necessary to provide a full financial disclosure of the employer, including but not limited to, the balance sheets and a profit and loss history for the current year and the previous four years. The administrator of workers' compensation shall consider whether the employer has demonstrated the financial ability to pay any and all claims obligations. Unless an applicant obtains waiver under paragraph (D) of rule 4123-19-03.1 of the Administrative Code, financial records submitted to the bureau must be audited by a certified public accountant, in accordance with generally accepted accounting principles, and shall include the certified public accountant's audit opinion.

(1) The administrator of workers' compensation may waive certain requirements of divisions (B)(1) and (B)(2) of section 4123.35 of the Revised Code pursuant to rule 4123-19-03.1 of the Administrative Code.

(2) The administrator of workers' compensation shall not grant the status of self-insuring employer to the state, except that the administrator may grant the status of self-insuring employer to a state institution of higher education, including its hospitals.

(B) The employer shall secure from the bureau proper application form(s) for completion. The completed application shall be filed with the bureau at least ninety days prior to the effective date of the employer's requested status as a self-insuring employer. The administrator of workers' compensation may require that the application be accompanied by an application fee as established by bureau resolution to cover the cost of processing the application in accordance with section 4123.35 of the Revised Code. The application shall not be deemed complete until all required information is attached thereto. Prior to presentation to the administrator of workers' compensation, applicable items listed in divisions (B)(1) and (B)(2) of section 4123.35 of the Revised Code shall be made available to the bureau and shall be reviewed by the bureau.

(C) The bureau shall accept only application forms which provide answers to all questions asked and furnish all required information.

(D) Return of the completed forms required by this rule and any additional information required by the bureau to process the employer's application should be submitted at least ninety days prior to the effective date of the employer's requested status as a self-insuring employer.

(1) If the administrator determines to grant the privilege of self-insurance, the bureau shall issue a finding of fact, which has been prepared by the bureau and signed by the administrator of workers' compensation, subject to all conditions outlined in paragraph (M) of this rule.

(2) If the administrator of workers' compensation determines not to grant the privilege of self-insurance, the bureau shall so notify the employer, whereupon the employer shall be required to continue to pay its full premium into the state insurance fund.

(E) All employers that have secured the privilege to pay compensation and benefits directly, will be required to make contributions as determined by the administrator of workers' compensation to the self-insuring employers' guaranty fund established under section 4123.351 of the Revised Code, and if an additional security is required by the bureau, the amount form of the additional security may be specified by the bureau. If the additional security is in the form of a surety bond, the bond shall be from a company approved by the bureau and authorized to do business in the state of Ohio by the Ohio department of insurance. The surety bond shall be in the form prescribed by the bureau. If the additional security is in the form of a letter of credit, the letter of credit must be provided by a federally insured financial institution. The penalized amount of such additional security is to be fixed by the administrator of workers' compensation.

(F) The surety bond or additional security furnished by the employer shall be for an amount and period as established by the bureau and may be periodically reviewed and reevaluated by the bureau. The surety bond or additional security shall provide on its face that the surety shall be responsible for the payment of all claims where the cause of action, as determined by the date of injury or date of occupational disease, arose during the liability of the surety bond or additional security. The liability under the surety bond or additional security and the rights and obligations of the surety shall be limited to reimbursement for the amounts paid from the surplus accounts of the state insurance fund by reason of the default of the self-insuring employer in accordance with division (B) of section 4123.82 of the Revised Code; however, in the event of such self-insuring employer's default, the bureau shall first seek reimbursement from the surety bond or additional security, which shall be first liable and exhausted, before payment is made from the self-insuring employers' guaranty fund established under section 4123.351 of the Revised Code. Upon default of the self-insuring employer, it shall be the responsibility of the administrator of workers' compensation to represent the interests of the state insurance fund and the self-insuring employers' guaranty fund. The administrator of workers' compensation, on behalf of the self-insuring employers' guaranty fund, has the rights of reimbursement and subrogation and shall collect from a defaulting self-insuring employer, or other liable persons, all amounts the bureau has paid or reasonably expects to pay from the self-insuring employers' guaranty fund on account of the defaulting self-insuring employer.

(G) The security herein required to be given by the employer shall be given to the state of Ohio, for the benefit of the disabled employees or the dependents of deceased employees of the employer filing the same, and shall be conditioned for the payment by the employer of such compensation to disabled employees or the dependents of deceased employees of such employer, and the furnishing to them of benefits equal to or greater than is provided by the Ohio workers' compensation law and for the full compliance with the rules, regulations, and procedures of the industrial commission and the bureau.

(H) If another or parent corporation or entity owns fifty per cent or more of the stock of an employer, the bureau may, in its discretion, require the employer to furnish a contract of guaranty executed by the ultimate domestic parent corporation or entity. The bureau shall require an alternative form of security if it does not require a contract of guaranty executed by the ultimate domestic parent corporation or entity.

(I) Employees having one or more years of experience as a workers' compensation administrator for a self-insuring employer in Ohio shall be deemed sufficiently competent and knowledgeable to administer a program of self-insurance. A self-insuring employer that employs a workers' compensation administrator who have less than one year of experience as a workers' compensation administrator in Ohio shall not have its status as a self-insuring employer affected pending notification by the bureau as to whether mandatory attendance of the employer's workers' compensation administrator at a bureau training program is required. If the bureau determines that the employer's workers' compensation administrator is not able to administer a self-insuring program, the bureau may direct mandatory attendance of the employer's workers' compensation administrator at a bureau training program until such time as the bureau determines that the employer's workers' compensation administrator is sufficiently competent and knowledgeable to run such a workers' compensation program. The cost of the bureau's training of the workers' compensation administrator(s) under this rule will be borne by the self-insuring employer or self-insuring employer applicant. By accepting the privilege of self-insurance, an employer acknowledges that the ultimate responsibility for the administration of workers' compensation claims, in accordance with the law and rules of the bureau and the industrial commission, rests with that employer. The self-insuring employer's records and compliance with the bureau and the industrial commission rules shall be subject to periodic audit by the bureau.

A self-insuring employer or applicant shall designate one of its Ohio employees who is knowledgeable and experienced with the requirements of the Ohio Workers' Compensation Act and rules and regulations therein, as Ohio administrator of its self-insuring program. This rule is not intended to prevent the hiring of an attorney or representative to assist the employer in the handling and processing of workers' compensation claims. The requirement for an Ohio administrator may be waived at the discretion of the bureau. The name and telephone number of the Ohio administrator, or non-Ohio administrator where the Ohio requisite has been waived, shall be posted by the employer in a prominent place at all the employer's locations. The Ohio administrator's duties shall include, but not be limited to:

(1) Acting as liaison between the employer, the bureau, and the industrial commission, and providing information to the agency upon request;

(2) Providing assistance to claimants in the filing of claims and applications for benefits;

(3) Providing information to claimants regarding the processing of claims and the compensation and benefits to which claimants may be entitled, including eligibility and filing requirements;

(4) Providing the various forms to be used in seeking compensation or benefits;

(5) Accepting or rejecting claims for benefits; and

(6) Approving the payment of compensation and benefits to, or on behalf of, claimants, pursuant to paragraph (L) of this rule.

(J) Employers that are granted the privilege of paying compensation and benefits directly, in accordance with these rules and regulations, shall:

(1) File with the bureau via the bureau's website a report of paid compensation annually on or before the last day of February each year;

(2) Maintain a record of all injuries and occupational diseases resulting in more than seven days of temporary total disability or death occurring to its employees and report the same to the bureau upon forms to be furnished by the bureau; and

(3) Observe all the rules, regulations, and procedures of the industrial commission and the bureau with reference to determining the amount of compensation and benefits due to the disabled employee or the dependents of deceased employees, and payment of the same.

(K) If a self-insuring employer fails to timely file its annual report of paid compensation, the bureau may estimate the amount of paid compensation and assess the employer based on this estimate pursuant to rule 4123-17-32 of the Administrative Code. If the employer subsequently provides the bureau with actual paid compensation figures, the bureau shall adjust the paid compensation and any assessment accordingly. A self-insuring employer that is no longer a self-insuring employer in Ohio and has failed to timely file a report of paid compensation shall be subject to this rule.

(L) Minimal level of performance as a criterion for granting and maintaining the privilege to pay compensation and benefits directly.

(1) The employer must be able to furnish or make arrangements for reasonable medical services during all working hours. A written explanation of what arrangements have been made or will be made to provide medical treatment shall be supplied with the application for self-insurance.

For an employer desiring to be first granted the privilege of self-insured status, the employer shall provide to the bureau for the bureau's approval the employer's plan for the following:

(a) Criteria for the selective contracting of health care providers;

(b) Plan structure and financial stability for the medical management of claims;

(c) Procedures for the resolution of medical disputes between an employee and the employer, an employee and a provider, or the employer and a provider, prior to an appeal under section 4123.511 of the Revised Code;

(d) Upon the request of the bureau, provide a timely and accurate method of reporting to the administrator of workers' compensation necessary information regarding medical and health care service and supply costs, quality, and utilization; and,

(e) Provide an employee the right to change health care providers.

(2) The employer shall promptly pay the fees of outside medical specialists to whom the industrial commission or the bureau shall refer claimants for examination or where the industrial commission or the bureau refers the claim file for review and opinion by such specialist except as provided by law in cases where the claim was subsequently disallowed. Such fees shall be paid within the time limits provided for payment of medical bills under paragraph (L)(5) of this rule.

(3) Every employer shall keep a record of all injuries and occupational diseases, including contested or denied claims, and shall report all claims with more than seven days of total disability or death, including contested or denied claims, to the bureau and to the employee or the claimant's surviving dependents in accordance with rule 4123-3-03 of the Administrative Code. For all claims reported to the bureau, the employer shall electronically update and report the allowed conditions on the bureau's website within fourteen days of the employer's acceptance of a condition or following the appeal period of the final administrative order if the condition was contested. Claims resulting in seven days or less of total disability shall be reported to the employee.

(4) The employer shall provide to the claimant and upon request, shall file with the bureau or the industrial commission, medical reports relating thereto and received by it from the treating physician and physicians who have seen the claimant in consultation for the allowed injury or occupational disease, or any injury or occupational disease for which a claim has been filed. The claimant shall provide to the employer and, upon request, shall file with the bureau or the industrial commission, medical reports relating thereto and received from the treating physician and physicians who have seen the claimant in consultation for the allowed injury or occupational disease or any injury or occupational disease for which a claim has been filed. The claimant shall honor the employer's request for appropriate written authorization to obtain medical reports to the extent that such reports pertain to the claim.

(5) Within thirty days after receipt of a hospital, medical, nursing, or medication bill duly incurred by the claimant, the employer shall either pay such bill, or if the employer contests any of such matters, shall notify the provider, the employee, and, only upon request, the bureau or industrial commission in writing. Such written notice shall specifically state the reason for nonpayment. The employer's notification to the employee shall indicate that the employee has the right to request a hearing before the industrial commission. If the matter is heard by the industrial commission, the employer shall pay compensation and benefits due and payable under an order as provided by section 4123.511 of the Revised Code. Payments issued more than fourteen days from receipt of an order allowing compensation will be considered non-compliant with this requirement. If the employer allows a claim for benefits and compensation without a hearing, the employer shall pay such benefits and compensation no later than twenty-one days from acquiring knowledge of the claim or the claimant's filing of the C-84 form, whichever is later.

(6) The employer shall acknowledge a written request for a change of physicians within seven days of receipt of the request that includes the name of the physician and proposed treatment. The employer may advise the injured worker of an impractical situation concerning the injured worker's choice of physician, such as the provider is retired, is deceased, is no longer licensed, is under license suspension, is incarcerated, has affirmatively refused to treat the claimant or serve as the physician of record, is not a physician as defined in paragraph (P) of rule 4123-6-01 of the Administrative Code, or is otherwise unavailable to treat the claimant. The employer cannot impede the claimant's freedom to choose a treating physician for the allowed conditions in the claim.

(7) The employer shall approve or deny a written request for treatment within ten days of the receipt of the request. The employer cannot deny a treatment request, or contest payment of any bill for the treatment, if the employer did not respond within ten days of receipt of the treatment request. The employer cannot deny a treatment request, or contest payment of any bill for the treatment, if the employer did not respond within ten days of receipt of the treatment request.

(8) The employer shall make its records and facilities available to the employees of the bureau at all reasonable times during regular business hours. A public employer shall make the reports required by section 4123.353 of the Revised Code available for inspection by the administrator of workers' compensation and any other person at all reasonable times during regular business hours.

(9) The employer shall pay all compensation as required by the workers' compensation laws of the state of Ohio. By becoming self-insured, the employer agrees to abide by the rules and regulations of the bureau and the industrial commission and further agrees to pay compensation and benefits subject to the provisions of these rules. The employer shall proceed to make payment of compensation or benefits without any previous order from the bureau or the industrial commission and shall start such payments as required under the Workers' Compensation Act unless the employer contests the claim. The employer may allow for compensation payments to be available through debit card, electronic funds transfer, or direct deposit with the claimant's authorization.

(10) The employer may notify the bureau's medical section and the claimant at least sixty days prior to the completion of the payment of two hundred weeks of compensation for temporary total disability with the request that the claimant be scheduled for examination by the medical section. Payment of temporary total disability compensation after two hundred weeks shall continue uninterrupted until further order of the industrial commission up to the maximum required by law, unless the claimant has returned to work, or the treating physician has made a written statement that the claimant is capable of returning to his former position of employment or has reached maximum medical improvement or that the disability has become permanent, or, after hearing, an order is issued approving the termination of temporary total disability compensation.

(11) Upon written request by the claimant or claimant's representative, the employer shall make available for review all the employer's records pertaining to the claim. Such review is to be made at a reasonable time, not to exceed three business days, and place. The claimant, upon written request, shall provide the employer or its representative with an appropriate written authorization to obtain records pertaining to the claim.

(12) Upon written request by the claimant or claimant's representative, the employer shall provide copies of the employer's records pertaining to the claim within three business days. Extensions may be granted to the employer, but not to exceed fourteen days from the date of the request, with agreement of the claimant or claimant's representative. An employer may provide copies in electronic form, or through electronic access to the records, with agreement of the requesting party. Except as provided for in this rule, an employer may not assess a fee or charge the claimant or the claimant's representative for the cost of providing a copy of the employer's records pertaining to the claim. Where the employer has previously provided a copy of the record or records pertaining to the claim to the claimant or the claimant's representative, the employer may charge a fee for the copies. The employer's fee shall be based upon the actual cost of furnishing such copies, not to exceed twenty-five cents per page.

(13) The employer shall inform a claimant, and the bureau, in writing, within thirty days from the filing of the claim with the employer, as to what conditions the employer has recognized as related to the injury or occupational disease and what conditions, if any, the employer has denied. The same timeframe applies to medical only claims.

(14) The employer shall post notices of its self-insuring status indicating the location for the filing of a claim and the job title and department of the employees designated by the employer to be the person or persons responsible for the processing of workers' compensation claims.

(15) A public employer, except for a board of county commissioners described in division (G) of section 4123.01 of the Revised Code, a board of a county hospital, or a publicly owned utility, who is granted the status of self-insuring employer pursuant to section 4123.35 of the Revised Code shall comply with the section 4123.353 of the Revised Code.

(16) A self-insuring employer is prohibited from entering into a professional employer organization agreement as defined in section 4125.01 of the Revised Code, or an alternate employer organization agreement as defined in section 4133.01 of the Revised Code, as a client employer.

(M) If a state insurance fund employer or a succeeding employer, as described in rule 4123-17-02 of the Administrative Code, applies for the privilege of paying compensation and benefits directly, by transferring from the state insurance fund to self-insurance, the actuary of the bureau shall determine the amount of the liability of such employer to the bureau for its proportionate share of any deficit in the fund. To determine an employer's liability under this rule, the actuary of the bureau shall develop a set of factors to be applied to the pure premium paid by an employer on payroll for a seven-year period, as described in this paragraph. The factors shall be based on the full past experience of the industrial commission and the bureau as reflected in the most recent calendar year end audited combined financial statement of the industrial commission and the bureau, and shall also accommodate any projected change in the financial condition of the fund for the current calendar year, or any additional period for which an audited combined financial statement is unavailable. The factors shall be revised annually effective July first based on the most recent calendar year audited combined financial statement and the projected change in the financial condition of the fund in the current calendar year or any additional period for which an audited combined financial statement is unavailable. The annually revised factors shall be adopted by rule 4123-17-40 of the Administrative Code. Factors effective July first of each year shall apply to all applications for self-insurance filed on or after July first of that year through June thirtieth of the following year. The revised factors shall be applied to the pure premium paid by the employer on payroll for the seven calendar accident years ending December thirty-first of the year preceding the year in which the factors are adopted under rule 4123-17-40 of the Administrative Code. In the event the audited combined financial statement of the industrial commission and the bureau reveals that no deficit exists, or in the event the application of the factors adopted by rule 4123-17-40 of the Administrative Code yields a negative number, the employer will incur no liability under this paragraph, but will not receive any refund for prior premiums paid except for those matters specifically addressed in paragraph (M)(2) of this rule. As used in this rule, "pure premium paid" means premiums actually paid under a base rating plan or an experience rating plan and minimum premium paid under a retrospective rating plan. It does not include premiums billed for actual claims costs, including reserves at the end of ten years, under a retrospective rating plan. Obligations under a retrospective rating plan remain the responsibility of the employer regardless of the employer's status. The same principles shall apply to cases of a merger by a self-insuring employer and a state insurance fund employer under the self-insuring employer's status. In addition, the following provisions shall apply:

(1) Within thirty days of the receipt from the employer of the necessary forms and of a separate statement of assets and liabilities, the bureau will forward to the employer a letter stating the amount of liability (if any) due the state insurance fund as outlined in this rule and a copy of the computation of such liability (if any).

(2) Within thirty days of the date of mailing of the letter by the bureau as outlined in paragraph (M)(1) of this rule, the employer shall reply by a letter, acknowledging that the employer agrees with the amount of liability specified in the letter and that there are no protests or claims hearings pending which could affect the amount of the liability. If any such matters are pending and would affect the liability, they must be detailed and set forth in the letter from the employer. This letter must also acknowledge that any protest letters, applications for disability relief as provided in section 4123.343 of the Revised Code, or other requests affecting the employer's state fund insurance experience filed subsequent to the date of this letter shall be considered invalid for both rebate of premium on state insurance fund experience and the calculation of liability cited in this rule. This letter must also specify the suggested effective date of the transfer to self-insurance which the employer requests, subject to paragraph (B) of this rule which requires that the effective date must be at least ninety days after the date the application forms are received by the bureau. Failure to comply with the requirements set forth herein shall terminate further consideration of the application.

(3) Subsequent to the approval of the employer's self-insured status and the effective date thereof by the administrator of workers' compensation, the bureau shall issue a settlement sheet statement containing the adjustment required above and billing for an advance deposit as required by other rules of the bureau. The employer shall pay the amounts required by this paragraph, pay the contribution to the self-insuring employers' guaranty fund under section 4123.351 of the Revised Code, submit a performance surety bond or additional security, if required by the bureau, and estimated final payroll report as a state insurance fund employer, all within thirty days of the date of the mailing of the self-insured certificate.

(4) The final adjustments of all premiums due the state insurance fund for the final payroll reports and final bureau audit, if any, as well as the pending protests letters, applications for disability relief as provided in section 4123.343 of the Revised Code, or other requests affecting the risk's state insurance fund experience as specified in paragraph (M)(2) of this rule, shall all be settled and paid within six months from the date of transfer from the state insurance fund to self-insured status. Employer's records must be made available promptly for final audit which must also be completed within six months from the date of the transfer from the state insurance fund to self-insurance.

(N) If there is any change involving additions, mergers, deletions of entities, or ownership changes of a self-insuring employer, which would materially affect the administration of the employer's self-insuring employer program or the number of employees included in such program, the employer shall notify the bureau's self-insured department within thirty days after the change occurs. Based upon the information provided or additional information requested by the bureau, the bureau will determine the effect of the change on the employer's self-insuring employer status, the adequacy of the employer's contribution to the self-insuring employers' guaranty fund, and the need for additional security.

(O) If a public employer granted the privilege of self-insurance elects to provide coverage for volunteers and probationers performing services for the political subdivision, the employer shall include such volunteers and probationers as employees to be covered under the self-insurance policy. A public employer's coverage of a work-relief employee under Chapter 4127. of the Revised Code shall be included in the public employer's self-insurance policy.

(P) If a self-insuring employer or applicant elects to secure excess loss coverage which undertakes to indemnify a self-insuring employer against all or part of such employer's loss as provided for in division (B) of section 4123.82 of the Revised Code, that self-insuring employer or applicant shall:

(1) Name the bureau as a beneficiary to the excess loss coverage contract in the event the bureau takes over administration and payment of the claims of the self-insuring employer or applicant;

(2) Provide a complete copy of the excess loss coverage contract, including the declaration page, to the bureau's self-insured department; and

(3) In the event of default by the self-insuring employer or applicant, the excess loss coverage must indemnify the bureau for all compensation, benefits, and disabled workers' relief fund costs incurred on claims covered by the excess loss coverage contract.

(Q) If a self-insuring employer or applicant elects to secure excess loss coverage which undertakes to indemnify a self-insuring employer against all or part of such employer's loss as provided for in division (B) of section 4123.82 of the Revised Code, this election cannot be used to satisfy any security requirements of self-insurance as provided in sections 4123.35 and 4123.351 of the Revised Code.

Last updated April 3, 2024 at 1:28 PM

History

Effective: April 1, 2024
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-03.1 Waiver of certain requirements.

(A) Definitions.

As used in this rule:

(1) "Applicant" means an employer who is applying for the privilege to pay compensation directly pursuant to section 4123.35 of the Revised Code.

(2) "Certified financial statements" means financial statements that have been audited by a certified public accountant, in accordance with generally accepted accounting principles, and include the certified public accountant's audit opinion.

(3) "Reviewed financial statements" means financial statements that have been subject to procedures performed by a certified public accountant in accordance with the statements on standards for accounting and review services as contained in the professional standards promulgated by the American institute of certified public accountants and in effect on the date of the applicant's application for the privilege to pay compensation directly. Such statements must include full footnote disclosure, prepared and submitted in accordance with generally accepted accounting principles.

(B) When the bureau grants a waiver of requirements under this rule, the bureau may require the applicant to furnish security in addition to the security required under rule 4123-19-03 of the Administrative Code. The amount of such additional security shall be in the form and amount as determined by the administrator and paid prior to the granting of self-insurance. In the event of the default of the self-insuring employer, the bureau shall first seek reimbursement from the additional security, which shall be first liable and exhausted, before payment is made from the self-insuring employers' guaranty fund under section 4123.351 of the Revised Code.

(C) The bureau may waive the requirement set forth in division (B)(1)(a) of section 4123.35 of the Revised Code that an applicant operate for at least two years in Ohio if, upon review of the applicant's request for waiver and application, the bureau determines such waiver is appropriate.

(D) The bureau may waive the requirement of division (B)(1)(d) of section 4123.35 of the Revised Code that an applicant submit certified financial statements if the applicant submits reviewed financial statements and the bureau determines such waiver is appropriate. The bureau may use the services of a commercial credit reporting bureau to assist in the evaluation of an applicant's ability to meet its workers' compensation obligations.

(E) The bureau may waive the requirement of division (B)(2)(b) of section 4123.35 of the Revised Code that an applicant that is a public employer submit financial statements reflecting the unreserved and undesignated year-end fund balance in the applicant's general fund if the bureau determines such waiver is appropriate. The administrator may require a supplemental schedule reflecting the public employer's unreserved and undesignated year-end fund balance in the public employer's general fund.

(F) The bureau may waive the requirement of division (B)(2)(f) of section 4123.35 of the Revised Code that an applicant that is a public employer submit an annual financial audit released by the auditor of state within seven months after the end of the public employer's fiscal year if the employer submits an annual financial audit released by the auditor of state within nine months after the end of the public employer's fiscal year.

Last updated February 3, 2025 at 7:12 AM

History

Effective: August 18, 2017
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-05 Where a self-insuring employer becomes a state insurance fund employer.

(A) This rule applies to a self-insuring employer that transfers to the state insurance fund.

(B) Where a self-insuring employer becomes a state insurance fund employer, the employer shall be rated at the appropriate experience modifier to the employer's basic premium rate. A self-insuring employer, or a subsidiary, or a part thereof, that returns to the state insurance fund as a state insurance fund employer shall provide the administrator with compensation and benefits costs for itself and for any subsidiaries by claim, and payroll by manual classification and year, and any other information as the administrator may require. The self-insuring employer shall submit this information by the date set by the administrator, and in a format determined by the administrator. This information must be submitted each year following the employer's return to the state insurance fund, for as many years as required by the administrator to develop the employer's state fund experience modification factor. The employer may be required to submit additional information to the administrator if the administrator determines that additional information is needed to develop the employer's state fund experience modification factor. The administrator shall use this information to develop a state fund experience modification factor based in whole or in part on the employer's self-insured experience.

(C) Failure to provide the required information will result in assignment of an experience modification factor of two and ineligibility for employer programs for the self-insuring employer that returns to the state insurance fund, until such time as the required information is provided or a state insurance fund experience modification factor is developed based fully on the employer's state insurance fund experience. This provision does not apply to a client employer of a self-insured alternate employer organization or self-insured professional employer organization.

(D) The adjustment of the self-insurance premium of such employer shall be computed on an earned premium basis as of the date of transfer from self-insurance to the state insurance fund, which adjustment shall be controlled by the rules controlling the ordinary premium adjustment.

(E) A self-insuring employer that transfers to the state insurance fund shall continue to administer self-insured claims for dates of injury, disease, or death during the period of self-insurance, and the employer shall be responsible to continue to pay compensation and benefits directly. Further, the employer shall remain obligated to pay to the bureau the self-insuring employer assessment calculated on the basis of the paid compensation for such claims attributable to the individual self-insuring employer according to the provisions of division (J) of section 4123.35 of the Revised Code and the provisions of rule 4123-17-32 of the Administrative Code. An employer that has had its self-insurance status revoked, not renewed, or cancelled, and the employer is not required to enter the state insurance fund, must comply with the provisions of rule 4123-17-32 of the Administrative Code.

Last updated January 3, 2023 at 9:51 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-06 Procedures for revocation of self-insuring status.

(A) The bureau may direct that a public hearing be held on the question of revocation of a self-insuring employer's privilege of self-insurance if the employer that has elected with the approval of the bureau to pay compensation and benefits, directly thereafter fails in any one of the following:

(1) Continued failure to file medical reports requested by the bureau or industrial commission or to submit reports to the injured worker required under law or rule;

(2) Continued failure to pay compensation or benefits in accordance with any law or bureau or industrial commission rules in a timely manner;

(3) Failure to provide reasonable medical facilities;

(4) Continued failure to pay all costs of administration including fees of medical specialists to whom the industrial commission or the bureau refers claimants for physical examinations or refers claim files for review and opinion, or failure to pay claimant's travel expenses within thirty days as required by law or rule;

(5) Continued failure to keep a record of all injuries and occupational diseases resulting in more than seven days of temporary total disability or death or involving seven days or less of lost time where it appears that there will be permanent partial disability compensable under division (A) of section 4123.57 of the Revised Code, or where the employer denies the claim, and to report the same to the bureau, and to furnish a copy of such report to the employee it concerns or to his surviving dependents;

(6) Continued failure to pay compensation within two weeks or benefits including failure to respond to a written request for authorization to change physicians within seven days, failure to approve or deny a written request for treatment within ten days, failure to pay hospital, medical, nursing, or medication bills duly incurred by the claimant within the period of thirty days after receipt of a fee bill, unless the employer contests any of such matters, in which event the employer shall promptly notify the employee in writing, as well as the provider, for requests to change physicians or for treatment requests of for fee bill, and, only upon request, the bureau or the industrial commission of such contest, specifically stating the reason for contesting such matter, and notifying the employee of the right to request a hearing before the industrial commission;

(7) Failure to make its records and facilities available to employees of the bureau;

(8) Repeated failure to permit a claimant, dependents of a deceased worker, or their representatives, to review all of the employer's medical records pertaining to the claim at all reasonable times and places within three business days of receiving a request;

(9) Repeated failure to timely provide a claimant, dependents of a deceased worker, or their representatives, copies of claim file records in accordance with paragraph (L)(12) of rule 4123-19-03 of the Administrative Code;

(10) Repeated failure to inform a claimant or dependents of a deceased worker and the bureau, in writing, as to what conditions it has recognized as related to his injury or occupational disease and what, if any, conditions it denies;

(11) Harassing, dismissing, or disciplining employees who have made complaints to the bureau;

(12) Failure to pay contributions to the self-insuring employers' guaranty fund as set forth in section 4123.351 of the Revised Code; or,

(13) Repeated failure to comply strictly with any rule, regulation or order prescribed by the industrial commission or the bureau.

(B) Should the bureau have reason to believe that the self-insuring employer has failed to comply with any of the matters listed in paragraph (A) of this rule involving the employer's financial strength or administrative ability to meet its obligations as a self-insuring employer, the bureau shall refer the matter for a public hearing on the question of revocation of the employer's privilege of self-insurance. Such public hearing shall be conducted before the self-insured review panel in accordance with the provisions of rule 4123-19-14 of the Administrative Code for issues involving the financial strength or the administrative ability of the employer to operate a self-insured workers' compensation program. The public hearing shall be conducted before the self-insuring employers evaluation board in accordance with the provisions of rule 4123-19-13 of the Administrative Code for issues involving unresolved complaints by injured workers or allegations of misconduct by the self-insuring employer.

(C) The employer and its representative shall be notified in writing that such a public hearing will be held and shall be furnished with copies of any complaint or report from the employees of the bureau. For matters to be heard before the self-insured review panel, the bureau shall mail a notice of hearing to the employer and its representatives, setting forth the date, time, and place of the hearing not less than twenty one days before such hearing. For matters to be heard before the self-insuring employers evaluation board, the bureau shall mail a notice of the hearing to the claimant and the claimant's representative if the issue is a complaint. The notice shall be mailed not less than fourteen days before such hearing.

(D) At the hearing the testimony given shall be taken by a court reporter and copies of the transcript of such testimony shall be furnished to the self-insuring employer, the claimant, their representatives, the administrator, and the members of the self-insured review panel or the self-insuring employers evaluation board.

(1) Should the self-insured review panel find that the self-insuring employer has materially violated any part of this rule or is incapable of operating a self-insuring program, or refuses to conform to the rules and regulations of the industrial commission and the bureau, then the administrator will forthwith issue a revocation of authority to pay compensation and benefits directly.

(2) Should the self-insuring employers evaluation board recommend to the administrator that an employer's privilege of self-insurance be revoked, the administrator shall promptly and fully implement such recommendation without further hearing.

(3) An employer that has been revoked pursuant to paragraph (D)(1) or (D)(2) of this rule shall be required to pay forthwith its eight months' advance estimated premium into the state insurance fund.

(E) The bureau may, at its discretion and after proper hearing, revoke the self-insuring status of a unit of a parent company when the evidence presented at the hearing clearly shows that the unit is operating at a different location from the parent company, and its actions causing the revocation were not directed nor authorized by the parent company.

Last updated January 3, 2023 at 9:51 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-08 Renewal of self-insuring risks.

(A) The privilege of an employer to pay compensation and benefits directly, must be renewed annually. Beginning with the effective date of this rule, prior to renewal of the employer's privilege of self-insurance, the bureau shall re-evaluate the employer's financial strength and administrative ability as described in rule 4123-19-03 of the Administrative Code. The bureau will consider past performance of the self-insuring employer as an additional factor in determining whether to renew the privilege of self-insurance. Waivers granted for good cause by the administrator pursuant to paragraph (H) of rule 4123-19-03 of the Administrative Code will continue in effect indefinitely unless there is a significant change, in the opinion of the bureau.

(B) Self-insuring employers desiring to continue paying compensation and benefits directly shall secure from the bureau a copy of the appropriate form of application which shall be completed and returned in the manner prescribed to the bureau. The employer may also be required to include a reporting of the amount of payments made and the amount of reserves established for the aforementioned claims as sufficient to cover future liabilities. The properly completed renewal forms shall be signed by the Ohio self-insuring program administrator who has been designated by the employer to the bureau or an officer of the company and filed ninety days prior to the renewal date.

(C) The application forms and the employer's financial statement shall be reviewed by the bureau. In order to renew its status as a self-insuring employer, the employer shall establish the following to the bureau's satisfaction that:

(1) The employer has fulfilled the minimal level of performance standards that an employer is required to meet before being granted permission to pay compensation and benefits directly as provided in paragraph (L) of rule 4123-19-03 of the Administrative Code; .

(2) The employer has substantially resolved all outstanding complaints filed with the bureau;

(3) The employer has achieved a satisfactory rating in its most recent audit report; and

(4) If the employer elects to secure excess loss coverage which undertakes to indemnify a self-insuring employer against all or part of such employer's loss as provided for in division (B) of section 4123.82 of the Revised Code, the employer is required to comply with paragraph (P) of rule 4123-19-03 of the Administrative Code. If the employer has previously submitted a complete copy of the excess loss coverage contract, and there have been no material changes to the excess loss coverage, the employer may submit the declaration page of the excess loss coverage with the renewal application. The bureau may require additional information concerning excess loss coverage upon review of the declaration page.

(D) Upon compliance with these requirements, the administrator may approve the renewal application. If the application is granted, the bureau will notify the applicant within thirty days prior to the renewal date. In this notification, the bureau shall specify the contribution to the self-insuring employers' guaranty fund and the amount and form of the additional security, if required.

(E) If the employer, upon receipt of notification of additional security as provided in paragraph (D) of this rule, promptly provides the bureau with the security in the amount and form specified by the bureau, the bureau thereafter will issue the employer a revised findings of fact and certificate which will be sent to the employer by the bureau.

(F) In the event the bureau finds that the minimum criteria set forth in the rules have not been met, the bureau shall give written notice to the applicant that the privilege to pay compensation and benefits directly, will not be renewed. The notice shall give the employer two weeks to exercise the right to a public hearing before the self-insured review panel, in accordance with the provisions of rule 4123-19-14 of the Administrative Code. If no hearing is requested or if the self-insured review panel or, on appeal, the administrator upholds the non-renewal, the applicant shall forthwith be required to:

(1) Pay its full premium into the state insurance fund for the intervening period from the date of the expiration of the last renewal date to the date of the final order of non-renewal; and

(2) Obtain a binder for state fund coverage as of the expiration date of its last renewal.

(G) If an employer's privilege to pay compensation and benefits directly is not renewed, the employer must secure coverage through the state insurance fund for any ongoing operations. If such employer does not secure state fund coverage, that employer shall be deemed an amenable but noncomplying employer pursuant to sections 4123.01 to 4123.99 of the Revised Code.

(H) If, for any reason, the administrator cannot approve the employer's application for renewal prior to the expiration of its present authorization, an extension may be granted until such time as the final disposition of the application for renewal can be made.

Last updated January 3, 2023 at 9:52 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-09 In regard to complaints filed by employees against self-insuring employers under the provisions of section 4123.35 of the Revised Code.

(A) The bureau shall receive all complaints, regardless of the source, concerning any employer engaged in paying compensation and benefits directly to its employees. The bureau shall transfer to the self-insuring employers evaluation board only those complaints which are not resolved. An employer shall respond in writing to a complaint within fourteen days of receipt thereof, and the employer's response shall be made a part of the complaint file. Failure of an employer to timely respond in writing to the complaint within fourteen days may result in a valid complaint determination.

(B) The administrator shall investigate and process all complaints against a self-insuring employer through the bureau's self-insured department. The self-insured department may address any violations by a self-insuring employer that are discovered during the course of the investigation of a complaint, regardless if the violation is initially reported. However, the bureau may dismiss a complaint based upon the employer's action or lack of action with respect to events that occurred more than two years prior to the filing of the complaint, unless the facts could not have been reasonably known to the claimant.

(C) The bureau shall maintain a file of all complaints that relate to the employer, together with any information filed by the employer as to such complaints. A copy of all complaints shall become a part of the self-insuring employer's file and shall be available at the time of renewal consideration. The bureau shall evaluate each complaint and take appropriate action as follows:

(1) If the bureau records for such employee does not contain full information as to the matter which is the subject of the complaint, the bureau may attempt to obtain such information by correspondence with the self-insuring employer, the claimant, and their authorized representatives, if any.

(2) The bureau may also audit the program of the employer in the manner provided in section 4123.35 of the Revised Code.

(D) Following receipt of all necessary information, including but not limited to bureau records, correspondence from the employee and the employer, or an audit by the bureau, the bureau may dismiss the complaint as invalid or find that the complaint has been resolved. Any unresolved complaint against a self-insuring employer shall be referred to the board for further action in accordance with the provisions of rule 4123-19-13 of the Administrative Code. If the bureau determines that a complaint is invalid or resolved and decides not to present the complaint to the board, the claimant may request that the complaint be presented to the administrator or the board for further consideration. If the bureau determines that a complaint is valid, a self-insuring employer may request that the complaint be presented to the administrator or the board for further consideration.

(E) All requests by claimants or self-insuring employers in accordance with paragraph (D) of this rule shall be filed within fourteen days of receipt of the bureau's decision. Failure to timely file the request shall be grounds for dismissal of the request, and the bureau's decision shall be final.

(F) Complaints referred to the bureau as provided in this rule shall be retained in the employer's file for a period of four years from the date of resolution.

(G) No employer that elects to pay compensation and benefits directly shall harass, dismiss, or otherwise discipline an employee for making a complaint. Upon receipt of information that such harassment, dismissal or other disciplinary action has been taken, the bureau shall assign the matter for hearing pursuant to the provisions of rule 4123-19-13 of the Administrative Code before the members of the board. If the board finds that such employer is guilty of harassing, dismissing or otherwise disciplining the claimant for making the complaint, the board shall levy a reasonable financial penalty under the circumstances as the board deems appropriate, payable by the employer to the surplus fund.

(H) Repeated violations of this rule shall be grounds for revocation of the employer's privilege to pay compensation and benefits, directly.

Last updated January 3, 2023 at 9:52 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-10 In regard to audits by the bureauof workers' compensation.

(A) The bureau shall audit the programs of employers who elect to pay compensation directly in the following situations:

(1) On a random basis;

(2) Whenever the bureau has grounds for believing that an employer is not in full compliance with the rules of the industrial commission or the bureau or the provisions of Chapter 4123. of the Revised Code;

(3) Upon request from the self-insured review panel or the self-insuring employers evaluation board.

(B) Such audits shall include the employer's methods of furnishing benefits; the employer's payment of compensation or benefits to claimants and dependents and whether this is being done in a proper and timely manner; whether the employer has promptly filed all reports required under the rules of the industrial commission and the bureau and the provisions of Chapter 4123. of the Revised Code. Such audits may also be used to evaluate whether the employer is providing medical examinations and evaluations in a timely manner; and whether the employer has harassed, dismissed, or otherwise disciplined employees who have filed complaints against such employer with the bureau.

(C) The bureau shall report its findings on such audits to the employer, the self-insured review panel, or the self-insuring employers evaluation board, where the panel or board had requested the audit, and shall evaluate such findings and take such action as is indicated.

Last updated January 3, 2023 at 9:52 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-11 Fixing time limits beyond which the failure of a self-insuring employer to provide for the necessary medical examinations and evaluations may not delay a decision on a claim.

(A) When a self-insuring employer has provided or arranged for a necessary medical examination or evaluation, in accordance with paragraph (A) of rule 4121-03-09 of the Administrative Code, the self-insuring employer shall promptly notify the industrial commission of such action.

(B) Failure of a self-insuring employer to provide for or arrange for the scheduling of such necessary medical examinations and evaluations within the period of fifteen days from the notification shall not delay a decision in the claim.

Last updated January 3, 2023 at 9:52 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-12 Grounds for holding public hearings to evaluate the program for self-insuring employers.

The administrator shall hold a public hearing to evaluate the program for self-insuring employers in the following situations:

(A) If there has been a substantial amendment of the statutes relating to self-insuring employers;

(B) If decisions are rendered by the supreme court of Ohio which materially change the interpretation of such statutes or invalidate material portions of the rules of the industrial commission or the bureau; or

(C) If there is substantial evidence that the self-insuring employers are not complying with the laws of the state of Ohio or the rules and procedures of the bureau or the industrial commission.

Last updated January 3, 2023 at 9:53 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-13 Self-insuring employers evaluation board.

(A) Section 4123.352 of the Revised Code establishes a self-insuring employers evaluation board. The board shall consist of three members:

(1) The member of the industrial commission representing the public, serving ex officio, as chairman.

(2) A member of the Ohio self-insurers association appointed by the governor with the advice and consent of the senate.

(3) A member of labor appointed by the governor with the advice and consent of the senate.

(4) Not more than two of the members shall be of the same political party.

(5) For purposes of administration, the board shall be part of the bureau. The bureau shall furnish the necessary office space, staff, and supplies. The board shall meet as the board determines or as requested by the bureau.

(B) All unresolved complaints or allegations of misconduct against a self-insuring employer shall be referred to the board by the bureau.

(1) The board shall investigate and may order the employer to take corrective action in accordance with such schedule as the board fixes.

(2) A board determination need not be made by formal hearing but must be issued in written form and contain the signatures of at least two members.

(3) If after a hearing pursuant to Chapter 119. of the Revised Code and the rules of the industrial commission and the bureau, the board determines an employer has failed to correct deficiencies within the time fixed by the board, or is otherwise violating Chapter 4123. of the Revised Code or the rules of the industrial commission or the bureau, the board shall recommend to the administrator:

(a) Revocation of the employer's privilege of self-insurance;

(b) Probation;

(c) A civil penalty not to exceed ten thousand dollars for each violation of the law or rules, payable into the self-insuring employers' guaranty fund; or

(d) Any other appropriate penalty.

(4) A board recommendation to revoke an employer's privilege of self-insurance must be by unanimous vote.

(5) A penalty other than revocation shall be by majority vote of the board and will be the responsibility of the bureau to monitor for compliance.

(6) The bureau shall promptly and fully implement recommendations from the board for disciplining a self-insuring employer.

Last updated January 3, 2023 at 9:53 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-14 Self-insured review panel.

(A) The administrator may delegate the authority granted to the administrator under Chapters 4121. and 4123. of the Revised Code for determining self-insuring employer matters as may be authorized. For this purpose, the administrator may appoint a self-insured review panel to provide advice to the administrator and the self-insured department of the bureau and provide employers with hearings on matters referred to the panel, or as requested by the employer. The bureau shall refer all unresolved issues involving the financial strength or the administrative ability of the employer to operate a self-insured workers' compensation program to the panel for a hearing.

(B) The panel shall consist of three members appointed by the administrator who have expertise or experience in matters relating to self-insuring employers.

(C) The panel shall hold meetings and hearings to determine matters referred to it by the administrator or the self-insured department for a review. The panel may issue decisions without formal hearing, and may advise the administrator or the self-insured department on issues referred to it. The panel shall afford an employer the opportunity for a formal hearing before the panel upon request.

(D) If an employer requests a hearing before the panel, or the panel determines that a hearing is in the best interests of the employer or the state insurance fund, the panel shall mail a notice of hearing to the employer and its representatives, setting forth the date, time, and place of the hearing. The notice shall be mailed not less than twenty-one days before the date of such hearing. In justifiable cases, an emergency hearing may be arranged with the panel.

(E) The panel shall keep a record of its dockets and proceedings. The panel's decisions shall be reduced to writing and mailed to all interested parties and shall state the evidence upon which the decision was based and the reasons for the panel's actions. The decision of the panel shall be the decision of the administrator. If the employer files a written appeal within fourteen days of the employer's receipt of the panel's decision, at the administrator's discretion, the administrator may reconsider the decision of the panel, and may conduct a formal hearing for such purpose.

(F) The administrator may authorize the panel to consider the following matters:

(1) Granting or denying an application for the privilege to pay compensation and benefits directly;

(2) Non-renewals of self-insured status;

(3) Revocation of self-insuring employer status;

(4) Issues of a self-insuring employer's adequacy of contribution to the self-insuring employers' guaranty fund or need for additional security under section 4123.351 of the Revised Code; and

(5) Any other self-insuring employer matter as authorized and delegated by the administrator under Chapters 4121. and 4123. of the Revised Code.

Last updated January 3, 2023 at 9:53 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-15 Assessment for self-insuring employers' guaranty fund.

(A) The bureau shall require self-insuring employers to pay a contribution to the self-insuring employers' guaranty fund as provided in this rule. The contributions due from self-insuring employers shall be established at rates as low as possible but such as will ensure sufficient monies to guarantee the payment of any claims against the fund. All self-insuring employers who are paying compensation as defined by division (L) of section 4123.35 of the Revised Code, whether active or inactive as a self-insuring employer, are required to pay a contribution to the fund as provided in this rule.

(B) The bureau shall maintain a minimum balance of funds in the fund of one and one-quarter times the prior year's payments from the fund as determined at the end of each calendar year to ensure sufficient monies to guarantee the payment of any claims against the fund. When the bureau determines that there are insufficient funds in the fund and an assessment is necessary to ensure the minimum balance in the fund, the bureau shall assess all self-insuring employers an annual contribution as determined by the administrator to maintain the minimum balance. Annual contributions will not be assessed to all self-insuring employers when the bureau determines that the fund exceeds the minimum amount necessary to guarantee the payment of any claims against the fund, except as provided in paragraph (C) of this rule. The administrator may offer a rebate to self-insuring employers who use the bureau's electronic payment and e-notification offerings.

(C) In addition to any contribution required of all self-insuring employers as provided in paragraph (B) of this rule, the contribution to the self-insuring employers' guaranty fund shall be as follows:

(1) New self-insuring employers, for each of the first three years of self-insurance, shall be assessed six per cent of base rated premium as reported on the most recent full policy year's payroll submitted as a subscriber to the state insurance fund. This assessment shall not apply to entities added to the coverage of an existing self-insuring risk after the first three years of self-insurance of the existing risk. If the applicant has not been a subscriber to the state insurance fund for a full policy year, the applicant shall submit to the administrator payroll amounts, manual classifications, and such other information as the administrator may require to calculate the applicant's base rated premium for the previous policy year, had the applicant been operating in Ohio as a subscriber to the state insurance fund.

(2) A self-insuring employer identified as a high-risk employer by the bureau shall be assessed six per cent of the previous year's paid compensation as reported to the bureau or shall be required to provide appropriate security as defined in rule 4123-19-03 of the Administrative Code.

(3) The assessment shall not be less than five thousand dollars for any twelve-month period of coverage. All annual premiums to the self-insuring employers' guaranty fund are due and shall be collected within forty-five days from the receipt of the bureau's invoice. Self-insuring employers not making timely payments shall be subject to revocation of self-insuring employer status.

(D) As used in this rule, the bureau shall determine whether a self-insuring employer is a high-risk employer based upon a review of the self-insuring employer's certified financial records submitted with the application for self-insuring employer renewal. The bureau's analysis and determination may include, but is not limited to, a review of the self-insuring employer's equity to debt ratio, return on equity, Z-score, Moody's rating, or other nationally recognized financial rating of the long-term stability of a company.

Last updated January 3, 2023 at 9:53 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-19-16 Self-insured construction projects.

(A) As used in this rule:

(1) "Responsible self-insuring employer" or "responsible employer" means the self-insuring employer or the public school employer that enters into a construction contract and applies for permission to self-insure the construction contract. The responsible employer is the entity responsible for the cost of the construction project and generally will be the owner of the project. The responsible employer is the payor under the contract. "Responsible self-insuring employer" or "responsible employer" may include a self-insuring general contractor or construction manager whose principal source of business is the execution of construction projects.

(2) "Public school employer" means an employer defined in division (R) of section 4123.35 of the Revised Code that enters into a construction contract exceeding twenty five million dollars and applies for permission to self-insure the construction contract, whether or not the employer is a self-insuring employer.

(3) "General contractor" means a self-insuring employer that has entered into a contract with an owner to perform more than fifty per cent, by value, of the work on a construction project.

(4) "Construction manager" means a self-insuring employer that has entered into a contract with an owner to provide substantially the same services described in division (A) of section 9.33 of the Revised Code in connection with a construction project. Regardless of any contrary terms of section 9.33 of the Revised Code, for purposes of this rule, the term "construction manager" is not limited to public projects and may apply even if the construction manager also performs construction work on the project.

(5) "Contracting employer" or "subcontracting employer" means any employer, whether state fund or self-insured, that has contracted either directly with a responsible self-insuring employer or with a contracting or subcontracting employer to perform construction services on the construction project. The contracting employer is the payee under the contract, except for where the contracting employer has subcontracted with another contracting employer.

(B) The purpose of this rule is to establish standards by which the administrator of workers' compensation may permit a responsible self-insuring employer to self-insure a construction project entered into by the responsible self-insuring employer pursuant to division (O) of section 4123.35 of the Revised Code.

(C) The administrator of workers' compensation's authority to grant self-insured status for a construction project is permissive. The bureau may establish criteria for granting self-insured status to ensure the financial stability and claims continuity of the workers' compensation program. The burden of proof is on the responsible self-insuring employer to satisfy the requirements of divisions (O), (P), and (Q) of section 4123.35 of the Revised Code, including designation of a safety professional and employment of an ombudsperson for the construction project, and such other requirements as the administrator of workers' compensation may establish by this rule or other policy for granting permission to self-insure a construction project.

(D) A responsible employer filing an application to self-insure a construction project shall be a self-insuring employer under the Ohio workers' compensation statutes, except that a public school employer may be a state fund employer. A public school employer shall be self-insured for the construction project only and shall maintain state fund coverage for its employees.

(E) In order for a responsible employer to be considered for self-insurance under division (O) of section 4123.35 of the Revised Code, the responsible employer must submit an application within ninety days prior to the desired effective date including, but not limited to, the following information:

(1) Dates the construction project is scheduled to begin and end, including the site(s) of the construction project;

(2) The estimated cost of the project;

(3) The contracting and subcontracting employers whose employees are to be self-insured by the responsible employer, including estimated payroll and any changes to the list of contracting and subcontracting employers during the duration of the project that shall be sent to the bureau within two business days;

(4) The provisions of a safety program specifically designed for the project;

(5) A statement as to whether a collective bargaining agreement governing the rights, duties, and obligations of each of the parties to the agreement with respect to the project exists between the responsible self-insuring employer and a labor organization.

(6) The administrator of workers' compensation may require other information as needed to aid in the decision-making process.

(F) If the administrator of workers' compensation approves the application, the administrator of workers' compensation shall mail to the responsible self-insuring employer a certificate granting the privilege to self-insure the construction project. Upon approval, the responsible employer is responsible for the administration and payment for the life of the claim of all claims under Chapters 4121. and 4123. of the Revised Code for the employees of any contracting employers and subcontracting employers covered under the certificate who receive injuries or are killed in the course of and arising out of employment on the project, or who contract an occupational disease in the course of employment on the project.

(G) The responsible employer is entitled to all of the protections provided under Chapters 4121. and 4123. of the Revised Code with respect to the employees of the contracting and subcontracting employers covered under the certificate as if the employees were employees of the responsible employer.

(H) The contracting and subcontracting employers included under the certificate are entitled to the protections provided under Chapters 4121. and 4123. of the Revised Code with respect to the contracting and subcontracting employer's employees who are employed on the construction project which is the subject of the certificate.

(I) The contracting and subcontracting employers included under the certificate shall identify in their payroll records for audit and compliance purposes the employees who are considered the employees of the responsible employer listed in that certificate for purposes of Chapters 4121. and 4123. of the Revised Code, and the amount that those employees earned from employment on the project that is subject to the certificate. The contracting or subcontracting employer shall exclude the payroll for its employees under the construction project from its payroll report, and the administrator of workers' compensation shall not consider the payroll when determining those contracting or subcontracting employers' premiums or assessments required under Chapters 4121. and 4123. of the Revised Code.

(J) The responsible employer shall include in the amount of paid compensation it reports pursuant to division (L) of section 4123.35 of the Revised Code, the amount of paid compensation that the responsible employer paid pursuant to division (O) of section 4123.35 of the Revised Code.

(K) For a public school employer, the bureau may grant the privilege of participating as a self-insuring employer for a construction project under this rule on a one year basis, and shall consider the project for renewal annually pursuant to rule 4123-19-08 of the Administrative Code.

(1) Additional security.

(a) A public school employer shall be required to make contributions as determined by the administrator of workers' compensation to the self-insuring employers' guaranty fund established under section 4123.351 of the Revised Code. In addition, the employer shall provide additional security as required by the bureau in the amount or form that may be specified by the bureau. At a minimum, the additional security shall be one hundred twenty-five per cent of the expected workers' compensation losses of the construction project as determined by the bureau. The security shall be in force on or before the administrator of workers' compensation grants the privilege to self-insure the construction project. In the event the initial calculation of expected losses is shown to be less than the actual losses, additional security shall be provided as required by the bureau.

(b) The public school employer shall assign the additional security required by this rule to the bureau for the benefit of the disabled employees or the dependents of deceased employees of the public school employer for the construction project. In addition, the security shall be applied to disabled workers' relief fund payments to employees of the construction project and administrative expenses of the bureau in the management of such claims of employees of the construction project.

(c) Notwithstanding the authority of the bureau to seek reimbursement from the self insuring employers' guaranty fund, or from surety, excess loss insurance, and any other sources provided by the employer, the legal obligation to pay the costs of injuries, occupational diseases, and deaths incurred under the construction project remains with the public school employer.

(2) Disabled workers relief fund.

A public school employer shall be required to pay the ultimate costs of disabled workers relief fund payments to employees of the construction project, no matter the status of the construction project at the time the disabled workers' relief fund payments are made to the employees of the construction project.

(3) Excess loss insurance.

A public school employer may purchase excess loss insurance subject to the provisions concerning excess loss insurance in rules 4123-19-03 and 4123-19-08 of the Administrative Code. In the event the excess loss insurance is purchased, all rights to recovery from that insurance must be assignable to the bureau in the event of bankruptcy of the public employer school facility employer.

(4) Reducing the costs of the construction project.

As a condition precedent to the bureau granting the privilege to self-insure the construction project, the highest elected official(s) of the public school employer shall certify to the bureau the costs savings of self-insuring the construction project. The certification shall include data as required by the bureau, including but not limited to a cost analysis showing the costs of insuring the project with the Ohio state insurance fund and the costs of self insuring the project.

(5) Safety plan.

A safety professional shall be assigned to each construction project. The safety professional shall be responsible for ensuring that activities are performed in accordance with the site-specific health and safety plan ("HASP") and training of site personnel.

A site-specific HASP shall be created prior to the start of the project and shall, at a minimum, contain the following elements:

(a) Identify all recognized site hazards associated with each phase of the project. Particular attention should be given to fall hazards, trenching operations, and electrical hazards.

(b) Identify key personnel and alternates responsible for site safety and health and the appointment of a site safety and health officer. Roles and responsibilities of the key personnel and alternates must be defined.

(c) Evaluate the risks associated with each operation and identify the appropriate control measures to be taken to minimize or eliminate those risks.

(d) Address training requirements for both routine and non-routine activities.

(e) Include contingencies in the HASP, which may include: communications, both internal and external, first aid provisions and providers; identification of nearest medical facility; post emergency phone numbers; and site control to prevent access by unauthorized personnel.

(f) Include employee involvement, such as involvement in inspections, incident investigations, and hazard analyses.

(g) Collect documentation of information, such as hazard inspections, audits of the HASP, injury/illness data, incident investigations, industrial hygiene surveys, maintenance records, and job hazard analyses.

(6) Organizational plan criteria.

The public school employer shall:

(a) Identify a self-insured program administrator to be knowledgeable in the rules and laws of Ohio self-insurance for workers' compensation;

(b) Identify its plan to obtain timely payroll information for all contractors and subcontractors covered, to ensure timely calculation and distribution of injured worker compensation and benefits; its methodology for payment of compensation and benefits; and its method of educating each contractor and its employers as to proper claim reporting and access to medical care procedures;

(d) Provide to the bureau for approval the employer's plan for medical management of claims as required by paragraph (L)(1) of rule 4123-19-03 of the Administrative Code;

(e) Plan to ensure accurate accounting of workers covered under the construction project; and

(f) Identify the bank used for the workers' compensation account.

(7) Ombudsperson duties.

The public school employer shall employ an ombudsperson for the construction project. The ombudsperson shall:

(a) Have experience in workers' compensation or the construction industry, or both;

(b) Communicate with and provide information to employees who are injured in the course of, and arising out of, employment on the construction project;

(d) Provide information to claimants, third party administrators, employers, and other persons in protecting their rights under the workers' compensation laws and rules.

Last updated January 3, 2023 at 9:54 AM

History

Effective: January 1, 2023
Promulgated Under: 119.03

Chapter 4123-20 Marine Industry Fund

Ohio Adm.Code 4123-20-01 Application for subscription to the marine industry fund.

(A) Any employer doing business in the state of Ohio and having, by reason of operations within the territorial boundaries of this state, exposure to liability under the "United States Longshoremen's and Harbor Workers' Compensation Act," 33 U.S.C. section 901 et seq., may make application to the marine industry fund created by section 4131.13 of the Revised Code.

(B) An employer wishing to subscribe to the marine industry fund shall complete an application for subscription provided by the bureau of workers' compensation. No disposition will be made of any such application until the same is complete, and no such application will be deemed complete until all information requested by the bureau in connection therewith is supplied. The bureau has the right to make reasonable inspections of an applicant's place of business, and of any records which may be pertinent to such applicant's application for subscription at any time prior to reaching a decision regarding an application for subscription.

(C) In determining whether to accept or reject an application for subscription to the marine industry fund, the administrator of workers' compensation shall consider the following criteria, which are set out by way of illustration and not by way of limitation:

(1) The applicant's history with respect to Ohio workers' compensation, including compliance with applicable laws and rules, payment of premiums and assessments, safety record, and experience ratings; and

(2) The applicant's history with respect to Longshoremen's Act insurance, including the names of prior carriers, record of payment of premiums, record of cooperation with carriers in the processing of claims, safety record, and experience rating.

(D) The administrator has the authority, in the administrator's discretion, to accept or reject an application for subscription to the marine industry fund. The decision of the administrator is final.

Last updated July 1, 2025 at 9:27 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-20-02 Subscription to the marine industry fund.

(A) An employer whose application for subscription to the marine industry fund has been approved by the administrator of workers' compensation as provided in rule 4123-20-01 of the Administrative Code will be issued a marine industry fund insurance policy upon payment of the initial premium required for such policy.

(B) Coverage under a marine industry fund insurance policy is not effective until the initial premium is received by the bureau of workers' compensation.

(C) Any policy of insurance issued by the marine industry fund expires at midnight on the expiration date stated on the face of such policy. Any such policy may be renewed by payment of the renewal premium. Payment of a renewal premium prior to the stated expiration date is effective to continue the coverage of the insured without lapse.

(D) Payment of a renewal premium after the expiration date is ineffective to continue the coverage of the insured employer without lapse. If an insured employer tenders payment of a renewal premium after the stated expiration date, the administrator may, in the administrator's discretion, reinstate the coverage of such employer as of the date of receipt of payment or require the employer to submit a new application for subscription to the marine industry fund. In no event will retroactive coverage be granted with respect to any period when the coverage of an insured employer has lapsed.

(E) An employer may cancel its marine industry fund policy by notifying the bureau in writing, including by email or fax. The cancellation request must provide the cancellation effective date. BWC will send correspondence instructing the employer to report actual payroll through the last date it had employees perform maritime work and pay any premium that is owed within forty-five days of the cancellation.

(1) If the employer fails to report the actual payroll within forty-five days of cancellation, BWC will increase the employer's estimated annual premium (EAP) by ten per cent and bill the employer. Failure to pay any premium owed will result in certification to the attorney general.

(2) If the employer's prepaid premium is greater than the premium owed through the cancellation effective date based on actual payroll, the balance will be refunded to the employer.

Last updated July 1, 2025 at 9:27 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-20-03 Premium payment.

(A) Except as otherwise provided in this rule, premiums for marine industry fund insurance coverage are payable in advance, in annual installments, at a rate determined by the administrator of workers' compensation, subject to the approval of the bureau of workers' compensation board of directors. An employer whose premiums are above the minimum administrative charge may change to semi-annual installments upon request. An employer must make the request no later than May fifteenth preceding the policy year. The amount of premium is determined by applying the rates and classification codes in use by the marine industry fund for such period to the estimated payroll of the insured for a period of twelve months. If an employer elects semi-annual installments, the premium will be equal to one-half of the premium for the twelve-month period.

(B) The initial premium required for the issuance of a new marine industry fund insurance policy will be estimated premium sufficient to cover premium for the twelve-month period, unless semi-annual installments were selected. If an employer elects semi-annual installments, the premium required for issuance will be estimated premium equal to one-half of the premium for the twelve-month period.

(C) Renewal premiums are due no later than the date indicated on each invoice. The premium required to renew a marine industry fund insurance policy will be the prepaid premium for the next renewal period, determined in accordance with the provisions of paragraph (A) of this rule.

(D) All prepaid premiums are subject to adjustment at or after the close of the period with respect to which such prepaid premium was submitted. Adjustments are based on the employer's report of actual payroll for the period, or upon audit findings reported by the authorized agents of the marine industry fund.

(E) For all payroll periods beginning July 1, 2025, if the employer estimates no payroll or calculates estimated premium of less than the minimum administrative charge for the reporting period, the employer will pay a minimum annual non-refundable administrative charge of one hundred twenty dollars annually.

Last updated July 1, 2025 at 9:27 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-20-04 Notice of estimated premium, payroll reporting and reconciliation of premium due.

(A) The bureau will provide employers a notice of estimated annual premium no later than the first day of May preceding the policy year for which such premium is due.

The notice includes:

(1) The estimated payroll used by the marine industry fund to calculate the employer's estimated premium due:

(2) The classification code(s) used by the marine industry fund in which the employer's payroll is allocated and the base rate for each of the classification codes identified:

(3) The employer's estimated premium due for the applicable policy year.

The employer may revise the estimated payroll amount used to calculate estimated premium due for the policy year for good cause shown, as determined by bureau policy. Requests will not be accepted to revise payroll after the last business day in November of that policy year.

(B) Payroll report and reconciliation of premium due.

(1) At the conclusion of each policy year, every employer will submit a payroll report to the bureau containing the number of employees employed within each of the employer's assigned classification codes and the aggregate amount of wages paid to such employees over the relevant time period.

(2) The bureau will establish a reconciliation process to address the difference between the estimated gross payroll and actual gross payroll.

(3) The payroll report must be filed by and any balance due the marine industry fund paid by the thirty-first day of August following the conclusion of the policy year. Any balance due the employer will be credited to the employer's account.

(4) If the employer fails to submit the final payroll report, the bureau will not lapse the employer's coverage. The bureau will increase by ten percent the estimated premium and bill the employer. The bureau will certify the premium balance to the attorney general seventy-five days after the due date if not paid. The bureau may cancel coverage for the subsequent renewal period for failure to submit the final payroll report.

(C) No provision of this rule may be construed to limit in any way the right of the bureau to audit the payroll records of the insured or to make adjustments based on the findings of such audits.

Last updated July 1, 2025 at 9:28 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-20-05 Payroll to be reported.

(A) When completing payroll reports pursuant to rule 4123-20-04 of the Administrative Code, an insured shall report to the marine industry fund all remuneration earned by such employees of the insured as engaged in activities constituting "maritime employment" within the meaning of the "Longshoremen's and Harbor Workers' Compensation Act," but limited to employees whose maritime employment is within the territorial boundaries of the state of Ohio, and employees employed to work in Ohio who, in the course of and incidental to their employment within the state of Ohio, temporarily leave the state. As used in this rule the term "remuneration" means all compensation for personal services paid under a contract of hire, oral or written, express or implied. "Remuneration" includes, but is not be limited to salaries or hourly wages paid by cash or check.

(B) In the case of an employee who spends some time performing duties in "maritime employment" and some time performing duties of a non-maritime nature, only the remuneration of such employee's maritime employment shall be reported to the marine industry fund for premium purposes.

(C) The entire remuneration of officers of a corporation shall be reported to the marine industry fund. In the case of a corporate officer who is a shareholder of the insured, the payment of a bona fide dividend on the shares owned by such officer will not be deemed to constitute remuneration for purposes of this rule, nor will any other payment made to such officer solely on account of his ownership of shares of the insured.

(D) A sole proprietor will not be considered to be an employee of the enterprise, and the remuneration of a sole proprietor shall not be reported to the marine industry fund. This provision does not relieve a sole proprietor from the obligation to report the remuneration earned by his employees.

(E) The remuneration of partners shall be reported to the marine industry fund. This provision does not relieve a partnership from the obligation to report the remuneration earned by employees of the partnership.

(F) The remuneration of employees whose duties are exclusively of a non-maritime character, or whose maritime activities occur entirely on waterways outside the territorial boundaries of Ohio, shall not be reported to the marine industry fund.

Last updated July 1, 2025 at 9:28 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-20-06 Audits and inspections.

(A) At any time during the term of any marine industry fund insurance policy, and for a period of two years after the termination of any such policy, the bureau of workers' compensation has the right to make reasonable inspections of the insured's place of business, and any records, payrolls, books of account, ledgers, or contracts which reflect upon the payroll expenditures of the insured, or the allocation of such payroll expenditures to the appropriate classification codes.

(B) Refusal on the part of the insured to permit reasonable audits and inspections, or willful interference by the insured with the bureau carrying out any audit or inspection, is sufficient reason for cancellation of the marine industry fund coverage of the insured.

(C) If the findings of any audit or inspection reveal a discrepancy in the amount of premium paid by the insured for any period, the bureau has the right to adjust the account of the insured in accordance with the audit findings.

Last updated July 1, 2025 at 9:28 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Ohio Adm.Code 4123-20-07 Controversion of claims.

(A) The marine industry fund is authorized under regulations promulgated by the United States department of labor to act as an insurance carrier with respect to liabilities created by the provisions of the "Longshoremen's and Harbor Workers' Compensation Act." The marine industry fund, in such capacity, is recognized under applicable provisions of the governing federal law and regulations, as a party in interest to all proceedings regarding claims filed against employers insured by the fund.

(B) All notices of injury received from employers insured by the marine industry fund, and all notices of claims received from the department of labor will be promptly reviewed by the bureau of workers' compensation. The administrator of workers' compensation or the administrator's designee is authorized to file notices of controversion in the name of the marine industry fund in all cases wherein such action is warranted by the facts of the case or the law applicable to such facts. In the event that a notice of controversion is filed, the administrator or designee is authorized to represent, or cause to be represented, the interest of the marine industry fund in all proceedings pertinent to a controverted claim.

Last updated July 1, 2025 at 9:28 AM

History

Effective: July 1, 2025
Promulgated Under: 119.03

Chapter 4123-21 Coal-Workers' Pneumoconiosis Fund

Ohio Adm.Code 4123-21-01 Procedures for subscription to the coal-workers' pneumoconiosis fund.

(A) As used in sections 4131.01 to 4131.06 of the Revised Code, "operator" and "operator of a coal mine" have the same meaning as "operator" as defined in the "Federal Coal Mine Health and Safety Act of 1969," 83 Stat. 742, 30 U.S.C. 801 et seq., as now or hereafter amended, and as implemented by the regulations of the secretary of labor under Title IV of the act, who, by reason of operations within the territorial boundaries of Ohio is amenable to Title IV of the act, including claims reviewed and allowed under 30 U.S.C. 945. Any operator as herein defined may elect to become a subscriber as defined in division (D) of section 4131.01 of the Revised Code by applying for coverage and paying the premiums specified in this chapter.

(B) An employer wishing to subscribe to the coal-workers' pneumoconiosis fund shall complete an application for subscription, which shall be provided by the bureau of workers' compensation. No disposition will be made of any such application until the same is complete, and no such application will be deemed complete until all information requested by the bureau in connection therewith is supplied. On reasonable advance notice, the applicant shall provide the bureau with access to all records pertinent to the application for subscription. The administrator of workers' compensation has the authority to accept or reject an application for subscription to the coal-workers' pneumoconiosis fund.

(C) Employers who are active subscribers to the coal-workers' pneumoconiosis fund on the date of adoption of these rules will not have to reapply for coverage. However, renewal of the subscription to the fund thereafter shall be deemed acceptance of the terms, conditions and duties contained in Chapter 4123-21 of the Administrative Code.

Last updated August 1, 2023 at 8:38 AM

History

Effective: August 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-21-02 Determination of coverage.

(A) An employer whose application for subscription to the coal-workers' pneumoconiosis fund has been approved by the administrator of workers' compensation will be issued a coal-workers' pneumoconiosis fund insurance policy upon payment of the initial premium required for such policy.

(B) Coverage under a coal-workers' pneumoconiosis fund insurance policy is not effective until the initial premium is received by the bureau of workers' compensation or its designee.

(C) Any policy of insurance issued by the coal-workers' pneumoconiosis fund expires at midnight on the expiration date stated on the face of the policy. Any such policy may be renewed by payment of the renewal premium. Payment of renewal premium in accordance with rule 4123-21-03 of the Administrative Code will be effective to continue the coverage of the insured.

(D) Coverage with respect to claims filed on or after the effective date of this rule will be afforded in claims where the claimant's last exposure to the conditions causing the disease occurs both while in the employment of the subscriber and during a period of active subscription to the coal-workers' pneumoconiosis fund.

Last updated August 1, 2023 at 8:38 AM

History

Effective: August 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-21-03 Premium payment.

(A) When the initial application for coverage is received and accepted, the applicant will be billed initial premium based upon its estimated gross annual payroll provided by the employer on its application for subscription. Premiums for coal workers' pneumoconiosis insurance coverage are payable in annual installments. An employer whose premiums are above the minimum administrative charge may change to semi-annual installments upon request. An employer must make the request no later than April first preceding the policy year.

(B) The initial premium required for issuance of a new coal-workers' pneumoconiosis fund insurance policy will be an advance deposit sufficient to cover premiums for a twelve-month period, unless semi-annual installments were selected. If an employer elects semi-annual installments, the premium required for issuance will be an advance deposit equal to one-half of the premium for a twelve-month period.

(C) Annual renewal premiums are due and payable no later than April thirtieth of each year. Semi-annual installment renewal premiums are due and payable by April thirtieth and October thirty-first of each year. Where applicable, the coal workers' pneumoconiosis fund will provide the notice of impending cancellation required by paragraph (B) of rule 4123-21-07 of the Administrative Code on or before May twenty-sixth of each year, for annual installments and on or before November twenty-sixth where an employer fails to make its semi-annual installment payment. The premium required for renewal for the next annual period will be determined in accordance with the provisions of paragraphs (A) and (B) of this rule. However, the administrator of workers' compensation, subject to the approval of the bureau of workers' compensation board of directors, may by rule establish a minimum annual premium, payment of which is a condition to continuation of coverage.

(D) Upon cancellation of coverage other than by default, any premiums due through the date of cancellation will be deducted from the advance premium deposit and the balance will be refunded to the former subscriber.

Last updated August 1, 2023 at 8:39 AM

History

Effective: August 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-21-04 Notice of estimated premium, payroll reporting and reconciliation of premium due.

(A) The bureau will provide employers a notice of estimated premium due no later than March first preceding the policy year. BWC will estimate annual premium based on payroll from the most recently completed policy year.

The notice includes all the following:

(1) The estimated payroll used by the coal workers' pneumoconiosis fund to calculate the employer's estimated premium due;

(2) The manual classification(s) in use by the coal workers' pneumoconiosis fund in which the employer's payroll is segregated and the base rates for each of the manual classifications identified;

(3) The employer's estimated premium due for the applicable policy year.

The employer may revise the estimated payroll amount used to calculate estimated premium due for the policy year for good cause shown, as determined by bureau policy specific to the coal workers pneumoconiosis fund. Requests will not be accepted to revise payroll after April first preceding the policy year.

(B) At the conclusion of each policy year, the bureau or its designee will mail the insured a payroll report. The insured shall return the payroll report, and include a statement of the insured's actual payroll and the number of employees employed within each of the insured's assigned manual classifications for the prior policy period.

(1) The report shall contain the premium payment total based on the estimated gross payroll;

(2) The payroll report shall reconcile the premium difference between the estimated payroll and the actual payroll;

(3) The payroll report must be filed by and any balance due the coal workers' pneumoconiosis fund paid by August fifteenth, and effective the policy year beginning July 1, 2024, by the thirty-first day of August, following the conclusion of the policy year. Any balance due the employer shall be credited to the insured.

(C) Officers of a corporation, partners, or sole proprietors who engage in work activity directly related to the extraction, processing or transportation of coal shall report their remuneration to the coal-workers' pneumoconiosis fund. Reporting of officers', partners' or proprietors' remuneration is a condition precedent to the extension of coal-workers' pneumoconiosis fund coverage to such individuals as claimants.

(D) No provision of this rule may be construed to limit in any way the right of the bureau or its designee to audit the payroll records of the insured or to make adjustments based upon the findings of such audits.

Last updated August 1, 2023 at 8:39 AM

History

Effective: August 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-21-05 Audit and inspections.

(A) At any time during the term of any coal-workers' pneumoconiosis fund insurance policy, and for a period of two years after the termination of any such policy, the bureau of workers' compensation has the right to make reasonable inspections of any records, payrolls, books of account, ledgers or contracts which reflect upon the payroll expenditures of the insured, or the allocation of such payroll expenditures to the appropriate manual classifications.

(B) Refusal on the part of the insured to permit reasonable audits, or willful interference by the insured with the bureau carrying out any audit or inspection, is sufficient reason for cancellation of the coal-workers' pneumoconiosis fund coverage of the insured.

(C) If any audit or inspection reveals a discrepancy in the amount of premium paid by the insured for any period, the bureau will adjust the account of the insured in accordance with the audit findings.

Last updated August 1, 2023 at 8:39 AM

History

Effective: August 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-21-06 Default, retroactive coverage.

(A) Payment of a renewal premium received after the expiration date is ineffective to continue the coverage of the insured employer.

(B) The administrator of workers' compensation may, upon request, and for good cause shown:

(1) Approve the original black lung coverage to take effect retroactively, upon payment of past due premiums, interest thereon, and such other terms, conditions or exclusions as the administrator may find appropriate; or

(2) Approve retroactive coverage for cancelled periods, upon payment of past due premiums, interest thereon, and with such other terms, conditions, or exclusions as the administrator may find appropriate.

(C) Such request shall be submitted to the bureau by the employer concerned or by its duly authorized representative. The reason for the relief sought shall be fully explained. The bureau may hold a request in abeyance until the request is properly completed, and the applicant will be notified accordingly.

(D) The administrator may refer all such requests to the adjudicating committee, appointed by the administrator of workers' compensation, for a determination pursuant to rule 4123-14-06 of the Administrative Code.

Last updated August 1, 2023 at 8:39 AM

History

Effective: August 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-21-07 Effect of cancelled subscription.

(A) No coverage will be extended to an operator whose subscription has been cancelled, except:

(1) In the case of a successor operator who immediately applies for coverage effective the day following cancellation of the prior operator's coverage pursuant to rule 4123-21-01 of the Administrative Code, and

(2) In the case described in paragraph (D) of rule 4123-21-02 of the Administrative Code.

(B) Thirty days prior to cancellation of an operator's subscription, the bureau will notify the defaulting operator and the United States department of labor of the impending cancellation.

(C) An operator whose subscription has been cancelled may apply for reinstatement at any time, provided that such application shall be governed by rules 4123-21-01 and 4123-21-02 of the Administrative Code.

Last updated August 1, 2023 at 8:39 AM

History

Effective: August 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-21-08 Controversion of claims.

(A) The bureau of workers' compensation is authorized under regulations promulgated by the United States department of labor to act as an insurance carrier with respect to liabilities created by Title IV of the "Federal Coal Mine Health and Safety Act of 1969," as amended. In this capacity, it is recognized under applicable provisions of federal law and regulations as a party in interest to all proceedings regarding claims filed against employers insured by said fund.

(B) All notices of claims received from employers insured by the coal-workers' pneumoconiosis fund, and all notices of claims received from the department of labor will be promptly reviewed by the bureau. The administrator or the administrator's designee is authorized to file notices of controversion in the name of the coal-workers' pneumoconiosis fund, in all cases wherein such action is warranted by the facts of the case or the law applicable to such facts.

(C) In any controverted claim the administrator or designee is authorized to represent the interest of the coal-workers' pneumoconiosis fund in all proceedings pertinent to the controverted claim. This rule will not be construed to limit or preclude a subscriber from obtaining private counsel to represent it in such claims and expenses thereby incurred are the responsibility of the subscriber.

(D) Expenses in connection with the controversion of claims by the coal-workers' pneumoconiosis fund are charged to the coal-workers' pneumoconiosis fund.

Last updated August 1, 2023 at 8:40 AM

History

Effective: August 1, 2023
Promulgated Under: 119.03

Ohio Adm.Code 4123-21-09 Rule to transfer funds from coal-workers pneumoconiosis fund to mining regulation and safety fund.

(A) Pursuant to division (B) of section 4131.03 of the Revised Code, the director of natural resources annually may request the administrator of workers' compensation to transfer a portion of the funds from the net position of the coal-workers pneumoconiosis fund to the mining regulation and safety fund created in section 1513.30 of the Revised Code for the purposes specified in that section.

(B) If the administrator receives a request, the administrator may transfer an amount not to exceed one million dollars on the first day of July or as soon as possible thereafter.

(C) The administrator may transfer a portion of the funds from the net position of the coal-workers' pneumoconiosis fund to the mining regulation and safety fund only if the ratio of assets to liabilities of the coal-workers' pneumoconiosis fund at the time of the request is greater than or equal to 1.5. If such ratio is below 1.5 at the time of the request, the administrator may only the transfer funds to the mining regulation and safety fund after the ratio of assets to liabilities rises above 1.5 and a qualified actuary has determined that this ratio is not likely to fall below 1.5 over an acceptable defined period.

Last updated January 4, 2024 at 9:12 AM

History

Effective: July 16, 2020
Promulgated Under: 119.03