Medical Care Disputes

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Medical Care Disputes

Medical Care Organization (MCO) Decision Process

Managed Care Organizations (MCO) are organizations certified by the Bureau of Workers' Compensation to manage medical care. Providers submit bills to the MCO, which will make the initial determination on whether or not to pay the bill.

When there is a denial of your doctor's C-9 Request for Authorization to Provide Medical Care, the following decision making process is supposed to be followed:

21 days	The MCO has 21 days to make a decision. MCO's medical dispute resolution process includes review by an individual or individuals licensed pursuant to the same section of the Revised Code as the health care provider. From the time the MCO recieves notice of a medical dispute, the dispute process must be completed in 21 days, according to Ohio Administrative Code Section 4123-6-16.
7 days	If the provider, injured worker, or employer is not satisfied with the MCO decision, they can appeal to the BWC. Any appeal must be filed within 7 days of the MCO decision.
7 days	The MCO must refer the dispute to the BWC within 7 days of receipt of the appeal of their decision in order to have the BWC review the disputed medical issue.
14 days	The BWC has 14 days to decide the medical dispute. The BWC will issue a 'tentative order' announcing that decision.
14 days	The BWC tentative order may be appealed to the Industrial Commission (IC). An appeal must be filed within 14 days of the tentative order. Only the injured worker or employer may appeal to the IC. Neither the Medical provider and nor the MCO can appeal to the IC. If the tentative order is not appealed, it becomes a final order.

The Injured Worker should always inform their lawyer of any medical treatment denial. A Certified Workers' Compensation Specialist knows the procedure to file the necessary appeals to protect the Injured Worker's right to receive medical care.