3701-43-11 Application and eligibility for provision of diagnostic services.

(A) Application for provision of diagnostic services as defined in paragraph (D) rule 3701-43-01 of the Administrative Code requires the following:

(1) The applicant, parent, guardian or other legal representative of the child for whom services are being requested shall submit to the director a signed consent form allowing the program to release information to persons or agencies who may participate in or facilitate the delivery of authorized services to the child; and

(2) The managing physician shall sign and submit to the director a medical application on a form prescribed by the director. The form shall be completed in full and shall include an individual plan for diagnostic services describing the medical and nonmedical procedures needed for diagnosing or confirming a medical condition of the applicant. The completed medical application inclusive of signed consent forms shall be received by the director within sixty days of the initial examination.

(B) Subject to paragraph (C) of this rule, an applicant is eligible for diagnostic services if based on information submitted pursuant to paragraph (A) of this rule the director determines that the applicant is in need of diagnostic services to determine whether or not the applicant has a medically handicapping or potentially medically handicapping condition.

(C) Notwithstanding paragraph (B) of this rule, the director may determine that the applicant is not in need of diagnostic services necessary to determine whether or not he has a medically handicapping or potentially medically handicapping condition if either of the following apply:

(1) Diagnostic services for the same medically handicapping or potentially medically handicapping condition have previously been authorized for the applicant and there has been no change in managing physician or no substantial change in the suspected handicapping condition that was previously approved for diagnostic services; or

(2) Diagnostic services are being requested for school or adoptive placement.

(D) If the completed medical application is received by the director within sixty days of the date of initial examination by the managing physician, eligibility for diagnostic services shall be effective no earlier than the initial date of examination by the managing physician.

(E) Based on the type and number of services requested on the managing physician's individual plan for diagnostic services, the director shall establish for each eligible recipient a period of eligibility for payment of diagnostic services which shall not exceed one hundred eighty days from the effective date of eligibility.

(F) The director shall notify the applicant or his or her parent, guardian or other legal representative, selected providers of major services, the local health department and the managing physician of the approval or proposed denial of eligibility and the effective date of eligibility, if approved. The director shall issue this notification within sixty days of the date of receipt of the last document necessary to make the eligibility determination or of the failure to submit timely an application or requested additional information. A notice of proposed denial of eligibility shall contain a statement of the reasons for denial and a description of the reconsideration procedure established by paragraph (B) of rule 3701-43-23 of the Administrative Code.

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
Prior Effective Dates: 10/3/1992, 12/1/01, 9/1/08