ADR is the process for resolving medical disputes between the managed care organization (MCO), BWC, employer, injured worker, their representatives and/or provider without litigation. ADR affords due process about conflicts in medical treatment, but does not include fee schedule grievances, dismissed C-9s (4123-6-16.2) and reactivation issues.
Providers, injured workers, employers or their representatives may initiate the ADR appeal process by completing the ADR Appeal to the MCO Medical Treatment/Service Decision (C-11) or equivalent and submitting it to the worker’s MCO within 14 calendar days of written notification of a MCO decision. The 21-calendar day dispute resolution process requires an Independent level of professional review.
The MCO's dispute resolution process must:
- Contain a peer review by an individual(s) licensed pursuant to the same section of the Ohio Revised Code as the healthcare provider requesting the disputed issue;
- If the MCO has already obtained one or more peer reviews during previous disputes involving the same or similar treatment, the MCO may obtain a different perspective review from a licensed physician who falls outside the peer review criteria;
- If an individual healthcare provider not eligible to be a physician of record would be providing the service requested in the dispute, the review may be conducted by an individual eligible to be a physician of record whose scope of practice includes the service requested.
The dispute process must be complete within 21 days of receiving written receipt of the dispute unless the MCO reverses their decision. The MCO submits its recommended decision to BWC and within two days the bureau issues a final BWC Order
Special circumstances will allow the MCO to temporarily pend an appeal:
- If the MCO receives a medical dispute which is similar to a previous treatment request and the appeal is pending before the bureau or the Ohio Industrial Commission the new dispute may be pended until the previous appeal is resolved.
- If the MCO receives a medical dispute related to services for a condition not allowed in the claim, and the issue of the allowance of the additional condition is pending before the bureau or the Industrial Commission, the MCO may pend the appeal until the bureau or the Industrial Commission make a decision on the additional condition allowance.
Once the decision is made, the MCO will resume the appeal process.
The MCO may refer its recommended ADR decision to BWC without obtaining an independent level of professional review if the services have been approved by the MCO through standard treatment guidelines, pathways, or presumptive authorization guidelines.
In lieu of a file review, the injured worker may be ordered to attend an ADR Independent Medical Examination (IME). This tolls the time frame until the MCO recieives the examining physician’s report. The MCO has seven days to submit the decision and BWC issues an order within two days.