Alternative Dispute Resolution Process

In the event a dispute arises out of the workers' compensation process regarding quality assurance, utilization review, medical necessity and other treatment and provider issues, CHS, in compliance with Ohio BWC Rule 4123-6-16, has developed the following policy: Providers treating an Ohio injured worker represented by CompManagement Health Systems, Inc. must follow this policy when filing a dispute on a decision rendered by CHS, BWC or a Qualified Health Plan represented by CHS.

The following outlines the steps of the Alternative Dispute Resolution Policy:

Step 1:
Provider Appeals CHS Decision:
In most cases, denial of reimbursement for treatment will have been based on a peer review by one of CHS associate medical directors, of the medical submitted by the POR. In some cases, denial will have beeen based on a lack of medical documentation, requested by CHS Case Management, but not provided by the POR. This is a "technical denial", which must still be processed if appealed. The peer review at this level is not part of the ADR process. The provider may appeal a MCO medical decision. Appeals must be submitted in writing to CHS within 14 days of receipt of written notice of CHS determination.

Step 2:
Peer Review - Level 1
CHS, self-insuring employer or QHP must have a medical dispute resolution that includes one independent level of review. The independent level of review shall consist of a peer review or ADR IME conducted by an individual or individuals licensed pursuant to the same section of the Revised Code as the health care provider. This independent reviewer shall not be a CHS medical director or one of the associate medical directors.

Step 3:
Appeal to the Bureau of Workers' Compensation
If the provider chooses to appeal the decision of the Level 1 Peer Review, the provider must send a written notice of appeal to CHS within seven (7) days after receipt of the Level I Review/decision. CHS will forward the appeal for review to Ohio BWC within seven (7) days of receipt from the Provider. BWC will provide an independent review of the unresolved dispute and issue a decision within fourteen (14) days after receipt.

Step 4:
Appeal to the Industrial Commission
The decision reached by the independent review performed by the Ohio BWC may be appealed to the Industrial Commission by the Injured Worker, Employer or their representatives pursuant to section 4123.511 of the Revised Code. By law, CHS nor the Provider are parties to the claim; therefore, cannot appeal any BWC order, including those regarding medical issues.

Appeals may be sent to:
CompManagement Health Systems, Inc.
PO Box 1040
Dublin, Ohio 43017
Attn: ADR Coordinator/Supervisor
Or via fax: 1-800-334-4229

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