3701-44-03 HIV medical case management.

(A) The director shall designate community based HIV medical case managers through the department’s grant process.

(B) Selected HIV medical case managers shall comply with the Ryan White part B program, sections 3701.24 to 3701.249 of the Revised Code and Chapter 3701-44 of the Administrative Code.

(C) HIV medical case managers shall provide medical case management services to individuals with HIV as specified in their grant awards. The services shall include the following:

(1) Make authorization decisions for payment for services requested by individuals eligible for benefits under the Ryan White part B program. Authorization may be given orally or in writing. If authorization is given orally, the HIV medical case manager must make a notation of the specific services authorized and the date and manner of such authorization. The HIV medical case manager shall authorize payment for services only after making all of the following determinations:

(a) The individual requesting the service is eligible for the service pursuant to rule 3701-44-05 of the Administrative Code;

(b) The individual is not covered by a third-party source for that service, including medical assistance established by Chapter 5111. of the Revised Code for the service requested. Except for home health services, an individual shall be considered to be covered by a third-party source if the source will provide any payment for the service, even if the payment does not cover the provider’s full costs. Payment for home health services may be authorized to supplement payment by a third party payment source;

(c) The provider who will provide the service is authorized by the director pursuant to rule 3701-44-06 of the Administrative Code; and

(d) There are sufficient funds to cover payment for the service.

(2) If the HIV medical case manager denies payment for a requested service, the manager shall provide written notice of the denial to the individual requesting the service. The written notice shall include the reasons for the denial, a statement that the individual may request reconsideration of the decision in accordance with rule 3701-44-07 of the Administrative Code, and an explanation of the process for requesting the reconsideration.

Replaces: 3701-44-03, 3701-44-04

Effective: 08/02/2009

R.C. 119.032 review dates: 08/01/2014

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 9/23/91 (Emer), 12/22/91, 5/20/1999