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Ohio Laws and Rules
(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 central based home health program within the Ryan White program to pay for services to individuals and families residing in Ohio. The director may revise these allocations as the director considers appropriate.
(C) The director may contract with a third-party administrator to make payments under this rule. The third-party 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 Ohio department of health Ryan White home health coordinator.
(D) The third-party administrator shall make payments only for services for which payments are authorized by the registered nurse coordinator or the director. Upon request of an eligible individual the registered nurse coordinator 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 Ohio department of health Ryan White home health coordinator shall authorize payment for services only after making all of the following determinations:
(1) That the individual receiving services is eligible under rule 3701-44-11 of the Administrative Code;
(2) That the provider is eligible under rule 3701-44-12 of the Administrative Code;
(3) That the service is needed as a the result of the service recipient’s HIV disease or is needed because of the HIV disease of a member of the recipient’s family and;
(4) That the recipient of services is not fully covered by any third-party payment source, including the medicaid program established by Chapter 5111. of the Revised Code, for the service at issue. The Ryan White home health program may supplement medicaid or another third party payor.
(F) If the program coordinator 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 registered nurse coordinator within sixty days after the services were provided. The coordinator shall forward the bill to the third-party administrator for payment after verifying that the services were authorized.
(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 program to exceed the amount that the director has allocated to provide services under paragraph (B) of this rule;
(2) The bill identifies the individual or family for whom the services were provided and itemizes the charges for all the services for which payment is requested.
(I) The third-party administrator shall sendto the department bi-weekly 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 designated geographical areas involved. The administrator also shall provide any other information requested by the department.
R.C. 119.032 review dates: 06/29/2006 and 06/29/2011
Promulgated Under: 119.03
Statutory Authority: 3701.241
Rule Amplifies: 3701.241
Prior Effective Dates: 7/20/2001