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All workers are entitled to reasonable health care, supplies and reasonably necessary transportation incurred for such services. Medical benefits are payable from the date the compensable injury occurred.

A. Under this Act the Administrator retains the right:

1. To require the injured employee to see a medical doctor (M.D.) or doctor of osteopathy (D.O.) for his/her initial medical examination. After the initial exam, the Administrator may authorize another type of medical provider, including but not limited to, a D.O., doctor of chiropractic (D.C.), nurse practitioner and/or physician assistant to follow up the medical care as directed by the initial M.D. The injured employee will be required to see a M.D. at least every four weeks if the employee has not been released to regular duty work; and

2. To request second opinions, independent medical evaluations, or to restrict payments to “preferred providers” of the appropriate specialty or to institute a managed care program in selected warrantable cases; and

3. To require tests of a diagnostic nature to be pre-authorized, without such pre-authorization no benefits may be claimed under this Act; and

4. To request medical records pertinent to the adjudication of a claim and for purposes of determining compensable status. The nonrelease of information supporting the nature of the injury will preclude the payment of benefits; and

5. To contract, pre-authorize and/or negotiate for medical care, equipment, pharmaceuticals and/or products; and

6. To apply usual and customary schedule of benefits from an approved source in order to determine the reimbursement rate for medical treatment according to regional variation. It will be understood that the standard guidelines are a tool only, and subject to modification as appears justified by the Administrator; and

7. To thoroughly investigate all questionable or suspicious claims. Any claim found to be false or exaggerated will result in claim denial under this Act and no benefits will be paid; and

8. To recover any payment made if benefits paid under this Act are in excess of benefits that should have been paid.

B. Final authority for closing a claim will be the Administrator’s right and responsibility based upon:

1. The termination of necessity for further medical treatment (achievement of maximum medical improvement); or

2. Claim inactivity for the length of time appropriate to the nature of the injury/disease as identified in Section 4-304(C) of this Title; or

3. The expiration of one hundred fifty-six (156) weeks from the date of injury, or in the case of an occupational disease or cumulative trauma, one hundred fifty-six (156) weeks from the earliest of the first manifestation of the symptoms or notification from the attending physician that the illness is inherent or related to the worker’s occupation regardless of disability and/or current medical status.

C. No benefits are payable for the following types of charges:

1. Confinement, treatment, or service that is not for medically necessary care of work-related injury or disease; or

2. Any part of a charge for confinement, treatment, or service that exceeds reasonable and customary (prevailing) charges or that exceeds the appropriate fee schedule, whichever is least; or

3. Travel expenses, unless prior written approval is obtained from the Administrator; or

4. Comfort or convenience services and supplies; or

5. Any over-the-counter medications unless prescribed by an attending physician.

D. Medical appeals concerning reimbursement levels or medical review must be directed to the Administrator in writing.

E. Limitation of Treatment. Payment of chiropractic care shall be limited to eighteen (18) visits, additional payments may be made at the Administrator’s discretion. ONCA 12-76, eff. Oct. 1, 2012; ONCA 15-52, eff. Nov. 6, 2015.