3701-44-04 Payment for services under the Ryan White program.

(A) The director shall make payments for services under the Ryan White program in accordance with the requirements specified in this rule.

(B) The director shall allocate specific amounts of the money available for the consortia portion of the Ryan White program to pay for services to individuals and families residing in each of the geographic areas served by HIV care consortia. The director may revise these allocations as he or she considers appropriate. The director shall ensure that at least fifteen percent of the money available for the consortia portion of the Ryan White program is expended for services to infants, children, women, and families with HIV disease.

(C) The director may contract with a third-party administrator to make payments under this rule. The administrator shall pay the usual, customary, and reasonable charges in the area for the services at issue. If there is no usual, customary, and reasonable charge for a given service, the administrator shall pay an amount specified for the service by the HIV care consortium serving the geographic area where the services are provided. If there is no consortium serving the area, the administrator shall pay an amount specified by the director.

(D) The administrator shall make payments only for services for which payments are authorized by the appropriate community-based HIV case manager or the director. Upon request of an eligible individual, the case manager shall determine whether or not to authorize payment of the requested services in accordance with paragraph (E) of this rule. Authorization may be given orally or in writing.

(E) The community-based HIV case manager shall authorize payment for services only after making all of the following determinations:

(1) That the individual receiving services or a member of the service recipient’s family is eligible under rule 3701-44-05 of the Administrative Code;

(2) That the provider is eligible under rule 3701-44-06 of the Administrative Code;

(3) That all such services are HIV-related and enhance the health or prevent deterioration of the recipient’s health;

(4) That the HIV care consortium designated by the director to serve the area where the individual or family receiving services resides or the director, as applicable, has included the service in the list of covered services established under paragraph (B) or (D) of rule 3701-44-03 of the Administrative Code;

(5) That the service does not exceed any of the limitations established under paragraph (C) of rule 3701-44-03 of the Administrative Code. A case manager may authorize services in excess of those limitations if he or she obtains prior approval from the director, and

(6) That the recipient of services is not covered by any third-party payment source, including the medicaid program established by Chapter 5111. of the Revised Code, for the service at issue. A recipient shall be considered to be covered by a third-party payment source if such a source will provide any payment for the service, even if the payment does not cover the provider’s charges fully.

(F) If a community-based case manager denies authorization of payment for a requested service, he or she shall provide written notification of the denial to the person requesting authorization. The notice shall state the reasons for the denial and inform the person of the reconsideration process under rule 3701-44-07 of the Administrative Code.

(G) After providing authorized services, the provider shall bill the recipient of the services and send a copy of the bill to the community-based case manager within forty-five days after the services were provided. The case manager, after verifying that the services were authorized, shall forward the bill to the third-party administrator for payment.

(H) In addition to the requirements of paragraph (D) of this rule, the third-party administrator shall make payments under this rule for authorized services only if both of the following conditions are met:

(1) The amount to be paid does not cause the total payments for the geographic area where the service recipient lives to exceed the amount that the director has allocated to provide services in that area under paragraph (B) of this rule unless the director has indicated a need to do so:

(2) The bill identifies the individual or family for whom the services were provided and itemizes the charges for all services for which payment is requested.

(I) The third-party administrator shall send the director biweekly written reports that identify, by number, the recipients of services for which payments were made during the preceding period, the providers to whom the payments were made, the amounts of the payments, the types of services for which the payments were made, and the geographical areas involved. The administrator also shall provide any other information required by the director.

R.C. 119.032 review dates: 04/30/2004 and 04/30/2009

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 5/20/1999