3701-44-04 Payment for services.

(A) The director may contract with a third-party administrator to make payments for core medical services.

(B) The director or third-party administrator shall pay only for services authorized by the director or HIV medical case manager in accordance with rule 3701-44-03 of the Administrative Code and only upon submission of a detailed invoice. A detailed invoice must include the identification of the individual or family for whom the service was provided, a list of itemized services and the date of each service.

(1) Payment for core medical services shall not exceed the usual, customary, and reasonable charges in the community for the authorized service.

(2) Payment for health insurance premiums, co-payments for core medical services, and support services shall not exceed the actual cost of the premium, co-payment or support service.

(3) Payment for home health services shall be made in accordance with the annual fee schedule established by the director and posted on the department’s website at www.odh.ohio.gov/odhPrograms/chss/aids/aids1.aspx.

(D) The third-party administrator shall not make payment for a service if the amount to be paid causes the total payments for the geographical area where the individual receiving the service lives to exceed the amount that the director has allocated for that area, unless the director authorizes such payment.

Replaces: 3701-44-04, 3701-44-09, 3701-44-10

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, 7/20/2001