3701-43-12 Authorization for payment of diagnostic services.

(A) Subject to paragraphs (B) and (C) of this rule, diagnostic services shall be authorized for applicants determined to be eligible for diagnostic services pursuant to paragraph (B) of rule 3701-43-11 of the Administrative Code if all of the following apply:

(1) The services are included in the applicant's medical application submitted by the managing physician in accordance with paragraph (A)(2) of rule 3701-43-11 of the Administrative Code, or additional services have been requested by the applicant's managing physician or other BCMH provider on forms prescribed by the director;

(2) The services are furnished by providers, as defined in paragraph (P) of rule 3701-43-01 of the Administrative Code, who are approved under applicable provisions of this chapter to provide the specific services requested and the services are furnished within the period of eligibility for diagnostic services;

(3) The services are deemed necessary by the director for an assessment of the eligible applicant's condition in accordance with medical policies and the applicable standards of care as defined in paragraph (U) of rule 3701-43-01 of the Administrative Code;

(4) The managing physician and any provider shall furnish to the director upon request medical reports and progress records verifying completion of the diagnostic services and indicating whether the child has a handicapping condition;

(5) The services are rendered in Ohio. The director may waive this requirement if comparable services are not available in Ohio or if the director determines that travel to obtain comparable services in Ohio would present an undue hardship for the applicant; and

(6) Request for authorization of services must be received within eleven months from date of service to enable payment for those services to occur in accordance with this chapter.

(B) Notwithstanding paragraph (A) of this rule and pursuant to division (G) of section 3701.023 of the Revised Code, the director may deny payment of diagnostic services for an eligible recipient if payment for the services will be made by a third party payor.

(C) Notwithstanding paragraph (A) of this rule, in authorizing provision of major services such as surgery or inpatient hospital stays, the director may limit the authorization for payment of diagnostic services to a specified type and number of services or to specific providers based upon the applicant's condition.

(D) The department 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