Alternative dispute resolution (ADR) review process

Managed care organizations (MCOs) must have a medical dispute resolution process that includes one level of review. BWC provides a second level of review for disputes not resolved at the MCO level. 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 health-care provider requesting the disputed issue;
• Be complete within 21 days of receiving written receipt of the dispute. MCOs must notify the parties involved in the dispute and their representatives of the decision in writing.

If the injured worker, employer or provider still disagrees, he or she may request, within seven days of receiving the MCO’s decision, a second level of review. The party must submit the request in writing. The MCO will refer the dispute to BWC for an independent review. The MCO must refer the request to BWC within seven days of receiving the request.

BWC’s ADR unit handles the second level of the ADR process and keeps the customer service team informed of progress and outcomes.

If a disagreement still exists after the second level of review, the injured worker, employer or their representatives may file an appeal with the Industrial Commission of Ohio (IC). The IC hears the medical disputes only if the two levels of ADR have been exhausted.