3701-43-02 Standards and procedures for determining eligibility of providers.

(A) The director shall apply the standards and procedures prescribed by this rule and by rules 3701-43-03 to 3701-43-08 and 3701-43-13 of the Administrative Code for the purposes of reviewing the applications of provider applicants and for making determinations as to whether these applicants are eligible providers.

(1) For the purposes of this chapter "provider applicant" means a health care professional, hospital, medical equipment supplier or other individual, group or agency that makes application to become a provider, as defined in paragraph (P) of rule 3701-43-01 of the Administrative Code.

(2) Subject to the termination provisions prescribed by rule 3701-43-10 of the Administrative Code, anyone who is a provider for the program for medically handicapped children or adults with cystic fibrosis on the effective date of this rule is not required to apply for approval under this rule and shall be considered a provider for the purposes of this chapter.

(B) In addition to meeting the standards prescribed by the applicable provisions of this chapter, a provider applicant shall meet the following requirements to be eligible to be a provider:

(1) Participate as a provider in the Ohio medicaid program, if providers of the same type as the provider applicant may be medicaid providers;

(2) Be located in Ohio, except that the director may approve a provider applicant located outside Ohio who meets the standards prescribed in the applicable provisions of this chapter for the purpose of providing diagnostic or treatment services or goods:

(a) Not available in Ohio; or

(b) For recipients for whom travel to obtain comparable services within Ohio would present undue financial or transportation hardship.

The director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area in deciding whether to approve a provider applicant not located in Ohio;

(3) Submit a provider application on a form prescribed by the director, which shall be completed in full and shall include any additional information required by applicable provisions of this chapter;

(4) The provider applicant shall submit any additional information requested by the director for purposes of determining whether the applicant meets the standards for eligibility to be a provider no later than sixty days after the date of the director's request; and

(5) Sign a provider agreement on a form prescribed by the director.

(C) If the director determines that the provider applicant meets all applicable eligibility standards and the other applicable provisions of this chapter, the director shall approve the applicant as a provider. Except as provided in rule 3701-43-22 of the Administrative Code, if the director determines that a provider applicant does not meet the standards for eligibility or has not complied with any of the procedural requirements prescribed by this rule or other applicable rules of this chapter, the director shall not approve the applicant as a provider.

(D) For each provider, the director shall specify the scope of services or goods the provider is approved to provide. The director shall determine the scope of goods or services based upon:

(1) Applicable statutes and rules for licensure of the provider;

(2) The scope of goods or services normally furnished by the provider;

(3) The provider's specialty, skill and experience or other factors specified in applicable provisions of this chapter.

Upon request by a provider and based upon sufficient documentation, the director may revise the approved scope of goods or services.

(E) The director shall notify a provider applicant in writing of approval or disapproval under paragraph (C) of this rule within thirty days after completion of all application procedures. A notice of approval also shall state the scope of goods or services the provider is approved to provide, as determined under paragraph (D) of this rule, and the effective date of approval. The effective date of approval shall be the first day of the month in which the provider applicant complied with all applicable requirements for interviews and submission of additional documentation. A notice of disapproval shall state the reasons for disapproval.

(F) A provider applicant whose application has been disapproved may request reconsideration of the application by the director by submitting a written request for reconsideration and any written materials that the provider applicant wishes to be considered so that they are received by the director no later than forty-five days after the date on the notice of disapproval issued under paragraph (E) of this rule. The director may request additional information, which the provider applicant shall submit so that it is received by the director no later than forty-five days after the date on the request. The director shall issue a written decision on reconsideration within forty-five days after receipt of the request or any requested additional information.

R.C. 119.032 review dates: 10/28/2013 and 10/28/2018
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021 , 3701.022 , 3701.023 , 3701.023
Prior Effective Dates: 1/2/1989, 12/1/01, 09/01/08