(A) The director shall apply the criteria prescribed by this rule in determining whether or not to authorize the provision of treatment services and goods to recipients, pursuant to division (E) of section 3701.023 of the Revised Code. An applicant's managing physician shall request authorization for provision of goods or services by submitting an individualized plan of treatment as part of the medical application for program eligibility under rule 3701-43-15 of the Administrative Code.
(B) Requests for authorization for provision of services or goods to recipients that are not included in the current individualized plan of treatment may be submitted by the recipient's managing physician or other BCMH provider to the director within eleven months of the date of service on forms prescribed by the director.
(C) The managing physician and any provider must furnish any information requested by the director, including but not limited to medical or operative reports, hospital discharge summaries, evaluation reports, and other descriptions of services, that is necessary to determine whether the goods or services may be authorized. The information must be submitted so that it is received by the director within eleven months of the date of service. The managing physician and any provider also shall submit any information requested by the director to evaluate the results achieved by the provision of the goods or services.
(D) Subject to paragraph (E) of this rule, the director shall authorize treatment services or goods if:
(1) The services or goods are included in the recipient's individualized plan of treatment, submitted by the recipient's managing physician, in accordance with paragraph (B)(2) of rule 3701-43-15 of the Administrative Code;
(2) The services or goods meet the definition of treatment services or goods, as prescribed by paragraph (X) of rule 3701-43-01 of the Administrative Code, with respect to the specific medically eligible or associated condition for which they are requested;
(3) The services or goods are furnished by providers, as defined by 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 or goods requested and the goods or services are furnished after the effective date of the provider's approval;
(4) The request for authorization and any additional documentation requested by the director are submitted in compliance with paragraphs (A), (B), and (C) of this rule; and
(5) The services are rendered or the goods furnished in Ohio. The director may waive the requirement prescribed by this paragraph if comparable goods or services are not available in Ohio or if the director determines that travel to obtain comparable services or goods in Ohio would present an undue travel or financial hardship for the recipient. In making determinations under this paragraph, the director may consult with one or more members of the medical advisory council or with other individuals with expertise in the area.
(E) In determining whether provision of requested treatment services or goods may be authorized, the director shall consider whether or not the goods or services are necessary for treatment of the recipient's medically eligible condition, in accordance with the applicable standards of care and medical policies. The director shall not authorize provision of any goods or services that are not listed in the standards of care or medical policies as being necessary for treatment of the condition or that are in excess of a limitation contained in the standards or policies.
(1) If a recipient's condition is not addressed by the standards of care or medical policies, the director may use the standards of care or medical policies applicable to conditions that are similar to the recipient's condition to determine which goods or services may be authorized.
(2) The director may deny authorization for provision of goods or services for treatment of a recipient's medically eligible condition if payment for the services or goods will be made by another governmental or private entity, including the medicaid program, or if payment could have been made by such an entity and was not made because of an act or omission by the recipient, parent, guardian or other legal representative or a provider.
(3) In accordance with the applicable medical policies or standards of care, the director may authorize provision of goods or services for treatment of a recipient's physical health impairment which, as an isolated condition, would not be a medically eligible condition under rule 3701-43-17 of the Administrative Code, if the impairment is associated with a medically eligible condition for which the recipient is receiving treatment goods or services authorized under this rule.
(4) In emergency or extraordinary circumstances that present an undue risk of significant harm to a recipient, the director may waive any of the criteria or procedures established by paragraph (D) or (E) of this rule that would prevent authorization of requested goods or services.
(5) In circumstances which present an undue hardship to a recipient, the director may extend the time requirements of paragraphs (B) and (C) of this rule for a period not to exceed one hundred fifty days if sufficient justification for the extension is provided by the managing physician, the recipient, parent, guardian, or other legal representative, or another recipient advocate.
(6) The director may deny authorization for provision of goods or services that otherwise may be authorized under the applicable medical policies or standards of care upon a determination that the goods or services are not necessary for treatment of the particular recipient's condition.
(F) In authorizing provision of major services or goods such as inpatient or outpatient surgery, inpatient hospital stays, medications, or durable medical equipment, the director may limit the provision of the goods or services to a specified provider or providers, based upon complexity, necessary follow-up care, and other relevant factors.
(G) Notwithstanding paragraph (E) of rule 3701-43-01 of the Administrative Code, provision of treatment services or goods may be authorized only by a licensed registered nurse or a physician employed by the Ohio department of health.
The department shall notify in writing the applicant, parent, guardian or other legal representative of the child and the managing physician of the approval or proposed denial of authorization for provision of goods or services under this rule. A notice of proposed denial shall include a statement of the reasons for denial and a description of the reconsideration procedure under paragraph (B) of rule 3701-43-23 of the Administrative Code.
R.C. 119.032 review dates: 05/23/2008 and 09/01/2013
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701.022, 3701.023
Prior Effective Dates: 1/2/1989, 5/20/91, 12/1/2001