Chapter 5101:3-1 General Provisions

(A) “Medical necessity” is a fundamental concept underlying the medicaid program. Physicians, dentists, and limited practitioners render, authorize, or prescribe medical services within the scope of their licensure and based on their professional judgment regarding medical services needed by an individual. Unless a more specific definition regarding medical necessity for a particular category of service is included within division-level 5101:3 of the Administrative Code, “medically necessary services” are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. A medically necessary service must:

(1) Meet generally accepted standards of medical practice;

(2) Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;

(3) Be appropriate to the intensity of service and level of setting;

(4) Provide unique, essential, and appropriate information when used for diagnostic purposes;

(5) Be the lowest cost alternative that effectively addresses and treats the medical problem; and

(6) Meet general principles regarding reimbursement for medicaid covered services found in rule 5101:3-1-02 of the Administrative Code.

(B) Preventive health care, though not customarily thought of as a “medically necessary” service, is available through the department’s early periodic screening, diagnosis and treatment (EPSDT, also known as healthchek) program or through managed care plans (MCPs) that have contracted with the department.

Effective: 07/01/2006

R.C. 119.032 review dates: 03/24/2006 and 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 12/30/77, 7/1/80, 2/19/82, 10/1/84, 10/1/87, 6/1/91, 5/30/02

(A) Most medical procedures are reimbursable within certain administrative limitations; some are reimbursable if approved in advance by the department through prior authorization or pre-certification; and, some are ordinarily not reimbursable.

(B) The following general principles determine whether a particular medical service is reimbursable:

(1) The service is determined to be medically necessary as defined in rule 5101:3-1-01 of the Administrative Code.

(2) The consumer or authorized representative originates all requests for medicaid services.

(3) Services are provided within the limits of the medicaid benefit package, within the scope and practice of the provider as defined by applicable federal, state, and local laws and regulations.

As required by the centers for medicare and medicaid services (CMS), habilitation services (as defined in 42 U.S.C. 1396n(c)(5) release date: December 27, 2005) are covered under medicaid only when:

(a) They are a part of services provided in an intermediate care facility for persons with mental retardation (ICF/MR), or

(b) They are included under a federally approved home and community-based services (HCBS) waiver, and are medically necessary services identified in an enrollee’s particular HCBS waiver. Special education and related services that otherwise are available to the individual through a local educational agency and vocational rehabilitation services that otherwise are available to the individual through a program funded under 29 U.S.C. 730 (release date: September 29, 2005) are not reimbursable through federally approved waivers.

(4) The consumer selects the eligible provider of his or her choice, with the exception of consumers enrolled in the primary alternative care and treatment (PACT) program as defined in Chapter 5101:3-20 of the Administrative Code.

(5) The service is rendered by an eligible provider.

(6) The consumer makes no payment for medicaid-covered services, except as noted in rule 5101:3-1-13.1 of the Administrative Code.

(7) The consumer receives medical services at the same cost as or less than non-medicaid individuals. This means that the department will not pay for services that are free to the general public, except when medicaid reimbursement for such services is prescribed by federal law as referenced in rule 5101:3-1-03 of the Administrative Code. In addition, the department will not pay for services that are charged at a rate greater than the provider’s usual and customary charge to other patients. For inpatient hospital services billed by hospitals reimbursed on a prospective payment basis, as defined in Chapter 5101:3-2 of the Administrative Code, the department will not pay, in the aggregate, more than the provider’s customary and prevailing charges for comparable services. Chapter 5101:3-3 of the Administrative Code defines these provisions as they apply to providers of long-term care services.

(C) The consumer has the right to appeal to the department, in accordance with division-level 5101:6 of the Administrative Code, any decision that adversely affects the consumer.

Effective: 07/01/2006

R.C. 119.032 review dates: 03/24/2006 and 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 12/30/77, 7/1/80, 2/19/82, 10/1/84, 10/1/87, 6/1/91, 5/30/02

(A) For persons eligible under both medicaid, administered by the Ohio department of job and family services (ODJFS), and the children with medical handicaps (CMH) program, administered by the Ohio department of health (ODH), medicaid is the first payer of health care claims (unless a consumer has third party insurance and/or is a medicare beneficiary, then rules 5101:3-1-05 and 5101:3-1-08 of the Administrative Code regarding coordination of benefits with a primary payer apply) and its payment constitutes payment in full.

(B) As long as eligibility has been established under the CMH program and services were authorized by the bureau for children with medical handicaps (BCMH), medicaid providers shall submit all claims for services to persons eligible under both medicaid and the CMH program first to ODJFS for adjudication under the medicaid program (unless there is a primary payer as described in paragraph (A) of this rule). The medicaid program covers services that are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code. If the service or services are not covered under medicaid, the claim shall be denied. The reason for the denial will be stated on the ODJFS remittance advice. When the service or services are denied by medicaid, a claim may be submitted for payment to BCMH along with documentation of the denial from ODJFS.

Replaces: 5101:3-1-03

Effective: 09/01/2007

R.C. 119.032 review dates: 09/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 3/5/82, 10/1/87, 7/7/02

Paragraphs (A)(7) to (F)(4) of this rule do not apply to pharmacy services covered under the medicare part D program. Pharmacy services covered under the medicare part D program should be billed in accordance with rule 5101:3-9-06 of the Administrative Code.

(A) Definitions.

(1) “Medicare” is a federally financed program of hospital insurance (part A) and supplemental medical insurance (also called SMI and/or part B) for aged and disabled persons.

(2) “Medicare Benefits” means the health care services available to the consumer through the medicare program where payment for the services are either completely the obligation of the medicare program or in part the obligation of the medicare program with the remaining payment (cost sharing) obligations belonging to the consumer, some other third party payer and/or medicaid.

(3) “Original Medicare (also known as traditional medicare)” is a health plan that pays for medicare benefits provided to beneficiaries on a fee-for-service basis.

(4) “Medicare Advantage Plan (also known as medicare part C plan)” is a managed care delivery system that includes coverage for both hospital insurance and SMI, but the delivery of health care services are contracted to and provided by an approved medicare managed care plan, preferred provider organization, private fee-for-service plans or medicare specialty plans.

(5) “Medicare Cost Sharing” means the portion of a medicare crossover claim paid by medicaid.

(6) “Dual Eligibles or Dually Eligible Consumers” are individuals who are entitled to medicare hospital insurance and/or SMI and are eligible for medicaid to pay some form of medicare cost sharing. The following is a list of dual eligibles that qualify to have medicaid pay all or part of the cost sharing portion of a paid medicare claim:

(a) “Qualified Medicare Beneficiaries without Other Medicaid (QMB Only)” are individuals entitled to medicare hospital insurance, have income of one hundred per cent of the federal poverty level (FPL) or less and resources that do not exceed twice the limit for supplemental security income (SSI) eligibility, and are not otherwise eligible for full medicaid benefits.

(b) “QMBs with Full Medicaid (QMB Plus)” are individuals entitled to medicare hospital insurance, have incomes of one hundred per cent FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full medicaid benefits.

(c) “Specified Low-Income Medicare Beneficiaries with Full Medicaid (SLMB Plus)” are individuals entitled to medicare hospital insurance, have income of greater than one hundred per cent FPL, but less than one hundred twenty per cent FPL and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full medicaid benefits.

(d) “Medicaid Only Dual Eligibles (for example Non QMB)” are individuals entitled to medicare hospital insurance and/or SMI and are eligible for full medicaid benefits. They are not eligible for medicaid in any of the other dual eligible categories (for example QMB). Typically, these individuals need to spend down to qualify for medicaid or fall into a medicaid eligibility poverty group that exceeds the limits of other dual eligible categories.

(7) “Medicare Crossover Claim” means any claim that has been submitted to the Ohio department of job and family services (ODJFS) for medicare cost sharing payments after the claim has been adjudicated and paid by the medicare central processor, medicare carrier/intermediary or the medicare managed care plan and the medicare central processor or medicare carrier/intermediary has determined the deductible, coinsurance and/or co-payment amounts. Claims denied by the medicare carrier/intermediary or the medicare managed care plan are not considered medicare crossover claims. See paragraphs (E) and (F) of this rule for policy on services denied or not covered by medicare.

(a) “Automatic Crossover Claim” is a medicare claim submitted to ODJFS via the automatic medicare crossover process described in paragraph (B)(1)(a) of this rule.

(b) “Provider-Submitted Crossover Claim” means a medicare crossover claim submitted to ODJFS as described in paragraph (B)(1)(b) of this rule.

(B) Medicare crossover process.

(1) The medicare program determines the portion of medicare cost sharing, if any, due to the provider based on medicare’s business rules and submits the claim for payment to ODJFS using the automatic medicare crossover process.

(a) The “Automatic Medicare Crossover Process” is the coordination of benefit (COB) process whereby the provider bills medicare for services provided to the patient who meets the criteria described in paragraphs (A)(6)(a) to (A)(6)(d) of this rule or is a dual eligible described in paragraph (A)(6) of this rule. Medicare adjudicates the claim, pays the provider and electronically submits the claim to ODJFS for the medicare cost sharing amounts. Then, the provider is paid by medicaid within ninety days from the date of payment by medicare.

(b) When the automatic medicare crossover process does not work (i.e., the provider has received payment by medicare, has not received a payment from medicaid for the medicare cost sharing portion and at least ninety days has elapsed from the date of the receipt of the medicare payment), the provider may submit a medicare crossover claim directly to ODJFS. This is considered the “Provider-Submitted Crossover Claim Process.”

(2) For a provider to receive reimbursement through the automatic medicare crossover process, all of the following criteria must be met:

(a) The provider must be recognized as both a medicare and medicaid provider;

(b) The provider must accept medicare assignment; and

(c) The consumer must be receiving health care benefits under the original medicare part A and part B program (i.e., the consumer is not enrolled in a medicare managed care plan). At this time ODJFS does not have payer-to-payer COB arrangements with medicare managed care plans.

(3) For medicare crossover claims, the total sum of the payments made by ODJFS, medicare and/or all other third party payers is considered payment in full and no additional payment may be requested from the consumer with the exception of medicare co-payments as specified in paragraph (E)(5) of this rule. This is true whether or not the provider normally accepts assignment under medicare.

(a) When the provider’s total reimbursement from medicare and all other third party payers equals or exceeds the medicare approved (allowed/covered) amount, no additional payment will be made by ODJFS.

(b) If payment (other than the cost sharing amounts) is inadvertently received from both medicare and medicaid for the same service, the ODJFS claims adjustment unit must be notified in accordance with the provisions set forth in rule 5101:3-1-19.8 of the Administrative Code.

(4) For a provider to receive reimbursement through the provider-submitted crossover claim process, crossover claims must be submitted to ODJFS either within three hundred sixty-five days from the date of service or within one hundred eighty days from the medicare payment date. When other third party payers are involved in the payment of the claim after the claim has been paid by medicare, the claim must be submitted within one hundred eighty days from the date of payment by the payer responsible immediately prior to the submission to ODJFS.

(5) Crossover claims are not subject to medicaid co-payments in accordance with rule 5101:3-1-09 of the Administrative Code.

(C) When the medicaid consumer is covered by other third party payers, in addition to medicare, medicaid is the payer of last resort. Whether or not medicare is the primary payer, providers must bill all other third party payers prior to submitting a crossover claim to ODJFS in accordance with rule 5101:3-1-08 of the Administrative Code.

(D) ODJFS will not pay for services denied by medicare for lack of medical necessity, but may pay claims denied for reasons other then medical necessity in accordance with paragraph (F) of this rule as long as the services are covered under the medicaid program. ODJFS will not pay for and service payable by, but not billed to, medicare.

(E) Reimbursement for medicare cost sharing on medicare crossover claims.

Reimbursement for medicare crossover claims is limited to the dual eligibles listed in paragraph (A)(6) of this rule.

(1) The medicaid maximum reimbursement for the medicare cost sharing of hospital inpatient, outpatient or emergency room services is set forth in rule 5101:3-2-25 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(2) The medicaid maximum reimbursement for the medicare cost sharing of nursing facility services is set forth in Chapter 5101:3-3 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(3) The medicaid maximum reimbursement for the medicare cost sharing of all other part B services not included in paragraph (E)(1) of this rule is set forth in rule 5101:3-1-05.3 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(4) The medicaid maximum reimbursement for the medicare cost sharing of all advantage plan (part C) services is set forth in rule 5101:3-1-05.1 of the Administrative Code for consumers that elected to receive medicare benefits under a medicare advantage plan.

(5) Cost sharing for medicare part D services is not reimbursable by ODJFS in accordance with rule 5101:3-9-06 of the Administrative Code. Dually eligible consumers may be required to pay medicare co-payments for prescription drugs that are covered by medicare part D.

(F) Services that are not covered by medicare must be submitted to ODJFS as a regular medicaid claim and should never be submitted as a medicare crossover claim.

When the service is denied by medicare, and is also denied by medicaid with an error message indicating that the service is covered under medicare and the provider has documentation to support the service is not covered under medicare, the provider must do all of the following when requesting payment consideration from ODJFS:

(1) Complete an appropriate “CMS 1500 Form (rev. 12/1990)” or a “CMS UB-92 Form (rev. 01/1992)”;

(2) Attach the summary notice of medicare benefits that shows the denied medicare services the provider is requesting ODJFS to consider for payment;

(3) Attach a completed “JFS 06653 Medical Claim Review Request Form (rev. 07/2003)”; and

(4) Submit all forms together to the address indicated on the JFS 06653 form.

Replaces: 5101:3-1-05

Effective: 12/18/2006

R.C. 119.032 review dates: 12/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 4/1/79, 10/1/84, 10/1/87, 1/9/89 (Emer), 4/10/89, 5/1/90 (Emer), 7/1/90, 5/30/02

(A) For qualified medicare beneficiaries and medicaid consumers enrolled in medicare part C managed health care plans (medicare advantage plans) the department will pay as cost sharing the lesser of:

(1) The providers billed charges for the service (except for hospital and nursing facility services); or

(2) The deductible, coinsurance and co-payment amount as provided by the medicare part C plan; or

(3) The difference between the medicare part C plan’s payment to a provider for a service or services identified and the medicaid maximum allowable reimbursement rate for the same identified service or services; or

(4) The medicaid liability for the cost sharing if the service had been rendered under medicare part A or part B.

(B) This payment arrangement applies to qualified medicare beneficiaries and medicaid consumers enrolled in a medicare part C plan.

(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims submitted for payment.

(1) Providers submitting medicare part C crossover claims to the medicaid program must be able to provide upon request documentation that supports that the information provided on the claim matches the information on the part C plan’s remittance advice.

(2) Providers submitting medicare part C crossover claims to the medicaid program who are paid under a capitation arrangement with the medicare part C plan, and do not submit claims to the plan for services rendered, must be able to provide upon request documentation of the capitation arrangement including specific details about the plan’s cost sharing requirements.

HISTORY: Eff. 5-14-04 (Emer.) ; 7-30-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.02

Rule amplifies: RC 5111.01, 5111.02

R.C. 119.032 review dates: 07/30/2009

(A) The reimbursement set forth in paragraph (B) of this rule is limited to medicare part B services that meet all of the following criteria:

(1) Are not hospital services as defined in Chapter 5101:3-2 of the Administrative Code;

(2) Are covered as supplemental medical insurance (SMI) benefits under medicare; and

(3) Are provided to dual eligibles listed in paragraph (A)(6) of rule 5101:3-1-05 of the Administrative Code who elected to receive their medicare benefits under original medicare.

(B) The Ohio department of job and family services (ODJFS) will pay the lesser of the sum of the medicare deductible and coinsurance amounts or the difference between the medicare approved (allowed/covered) amount and the sum of the payments made by medicare and all other third party payers. If the payment made by medicare and all other third party payers exceeds the medicare approved amount, ODJFS will not make any additional payment to the provider.

Effective: 12/18/2006

R.C. 119.032 review dates: 12/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

(A) Section 2176 of Public Law 97-35, the Omnibus Budget Reconciliation Act of 1981, established a waiver program under which states can be reimbursed for providing home and community-based services (HCBS). Under the HCBS waivers, states can designate specific target populations who can receive a wider range of HCBS than normally covered under the state plan. Waiver requests submitted by the states to the secretary of the department of health and human services may be approved for a three-year period; each waiver may be renewed for five-year periods.

(B) Eligibility for HCBS waiver programs is limited to medicaid recipients who, in the absence of home and community services, would require long-term care in a nursing facility (NF), intermediate care facility for the mentally retarded (ICF-MR) or hospital as designated by the specific waiver.

(C) HCBS waivers must be limited to one of the following target groups or any subgroup thereof that the state may define:

(1) Aged or disabled, or both; or

(2) Mentally retarded or developmentally disabled, or both; or

(3) Mentally ill.

(D) At no time during the term of a HCBS waiver may the number of individuals approved to receive waiver services exceed the specific number annually allocated in the waiver.

(E) Descriptions, approval information and reimbursement rates for each of the HCBS waivers can be found as follows:

(1) PASSPORT HCBS waiver information can be found in rule 5101:3-1-06.1 of the Administrative Code.

(2) The payment standards governing reimbursement for HCBS waiver programs administered by the Ohio department of mental retardation and developmental disabilities (ODMR/DD) can be found in rule 5101:3-41-11 of the Administrative Code.

(3) Ohio home care waiver reimbursement rates and billing procedures are set forth in rule 5101:3-46-06 of the Administrative Code.

(4) Transitions MR/DD waiver reimbursement rates and billing procedures are set forth in rule 5101:3-47-06 of the Administrative Code.

(5) Transitions carve-out waiver reimbursement rates and billing procedures are set forth in rule 5101:3-50-06 of the Administrative Code.

(6) Choices HCBS waiver information can be found in rule 5101:3-1-06.4 of the Administrative Code.

(7) Assisted living HCBS waiver information can be found in rule 5101:3-1-06.5 of the Administrative Code.

Effective: 07/01/2006

R.C. 119.032 review dates: 03/24/2006 and 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85

Prior Effective Dates: 10/1/87, 7/1/98, 1/1/04

(A) The department received approval effective July 1, 1990 to provide home and community-based (HCBS) services to persons aged sixty and over who require intermediate or skilled care in a program known as preadmission screening system providing options and resources today (PASSPORT).

(1) The PASSPORT HCBS waiver services and program eligibility criteria are set forth in Chapter 5101:3-31 of the Administrative Code.

(2) Financial eligibility for the PASSPORT HCBS waiver program is determined in accordance with Chapter 5101:1-39 of the Administrative Code.

(3) Maximum allowable reimbursement rates for the PASSPORT HCBS waiver program are listed in appendix A to this rule and are to be effective on July 1, 2007. The maximum allowable reimbursement rates for services rendered prior to July 1, 2007 are the maximum allowable reimbursement rates in appendix A of this rule less three percent. PASSPORT HCBS reimbursement must be provided in accordance with paragraphs (A) to (C) of rule 5101:3-1-60 of the Administrative Code.

Appendix

PASSPORT Waiver Rates

Service       Billing Maximum       Billing unit

Enhanced adult day service $41.20 1 day

Enhanced adult day service $20.60 1/2 day

Enhanced adult day service $1.29 15 minutes

Intensive adult day service $54.08 1 day

Intensive adult day service $27.04 1/2 day

Intensive adult day service $1.69 15 minutes

Adult day service transportation $2.18 1 mile

Adult day service transportation $16.32 1 one-way trip

Adult day service transportation $20.11 1 round trip

Meals: home delivered $6.51 1 meal

Meals: therapeutic $9.19 1 meal

Homemaker service $3.79 1/4 hour

Chore service $2,575.00 1 job

Social work counseling service $16.03 1/4 hour

Nutritional consultation service $13.14 1/4 hour

Personal care service $4.28 1/4 hour

Home medical equipment & supplies: Ambulatory $5,150.00 1 Item

Home Med. Eq. and Supplies: Ambulatory – Second One $5,150.00 1 Item

Home Med. Eq. and Supplies: Ambulatory – Third One $5,150.00 1 Item

Home Med. Eq. and Supplies: Non-Ambulatory $5,150.00 1 Item

Home Med. Eq. and Supplies: Non-Ambulatory – Second One $5,150.00 1 Item

Home Med. Eq. and Supplies: Non-Ambulatory – Third One $5,150.00 1 Item

Home Med. Eq. and Supplies: Hygiene and Disposables $5,150.00 1 Item

Home Med. Eq. and Supplies: Hygiene and Disposables-Second One $5,150.00 1 Item

Home Med. Eq. and Supplies: Hygiene and Disposables-Third One $5,150.00 1 Item

Home Med. Eq. and Supplies: Equipment Repair $5,150.00 1 Item

Home Med. Eq. and Supplies: Nutrition Supplement and Supplies $5,150.00 1 Item

Emergency response system $46.35 1 month rental

Emergency response system $46.35 installation

Emergency response system $100.00 alternative ERS device

Minor home modification $7,725.00 1 completed work order

Independent living assistance: in person activities $5.15 1/4 hour

Independent living assistance: travel attendant $5.15 1/4 hour

Independent living assistance: telephone assistance $5.15 completed call

Transportation $1,287.50 1 round trip

Transportation $643.75 1 one way trip

All services are reimbursed at the usual and customary rates or the Medicaid maximum rate whichever is lower.

Effective: 10/01/2007

R.C. 119.032 review dates: 07/16/2007 and 10/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 1/1/04, 7/1/06, 7/2/07 (Emer.)

Rescinded eff 7-1-05

Rescinded eff 7-1-06

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the choices home and community based services (HCBS) waiver. ODA will administer the waiver pursuant to an interagency agreement with the Ohio department of job and family services (ODJFS), in accordance with section 5111.91 of the Revised Code.

(B) The choices waiver provides HCBS to persons aged sixty and over who reside in the service area defined in the approved 1915(c) waiver for the choices program and who require intermediate level of care as set forth in rule 5101:3-3-06 of the Administrative Code or skilled care level of care as set forth in rule 5101:3-3-05 of the Administrative Code and are enrolled in the waiver.

(1) The choices HCBS waiver services and program eligibility criteria are set forth in Chapter 5101:3-32 of the Administrative Code.

(2) Financial eligibility for the choices HCBS waiver program is determined in accordance with Chapter 5101:1-39 of the Administrative Code.

(3) Maximum allowable reimbursement rates for the choices HCBS waiver program are listed in appendix A to this rule and are to be effective on July 1, 2007. The maximum allowable reimbursement rates for services rendered prior to July 1, 2007 are the maximum allowable reimbursement rates in appendix A of this rule less three percent. Choices HCBS reimbursement must be provided in accordance with paragraphs (A) to (C) of rule 5101:3-1-60 of the Administrative Code.

Appendix A

Choices Waiver Rates

The following services are available only to choices enrollees in the service area defined in the approved 1915 (c) waiver for the choices program.

Service       Billing Maximum       Billing unit

Enhanced adult day service $41.20 1 day

Enhanced adult day service $20.60 1/2 day

Enhanced adult day service $1.29 15 minutes

Intensive adult day service $54.08 1 day

Intensive adult day service $27.04 1/2 day

Intensive adult day service $1.69 15 minutes

Adult day service transportation $2.18 1 mile

Adult day service transportation $16.32 1 one-way trip

Adult day service transportation $20.11 1 round trip

Home care attendant service $38.63 1/4 hour

Home medical equipment & supplies: Ambulatory $5,150.00 1 Item

Home medical equipment & supplies : Non-Ambulatory $5,150.00 1 Item

Home medical equipment & supplies: Hygiene and Disposables $5,150.00 1 Item

Home medical equipment & supplies: Equipment Repair $5,150.00 1 Item

Home medical equipment & supplies: Nutrition supplement and Supplies $5,150.00 1 Item

Emergency response system $46.35 1 month rental

Emergency response system $46.35 installation

Emergency response system $100.00 alternative ERS device

Minor home modification $7,725.00 1 completed work order

Meals: home delivered $6.51 1 meal

Meals: therapeutic $9.19 1 meal

Alternative meals service $30.90 1 meal

Pest control $772.50 1 job

All services are reimbursed at the usual and customary rates or the Medicaid maximum rate whichever is lower.

Effective: 10/01/2007

R.C. 119.032 review dates: 07/16/2007 and 10/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 1/1/04, 7/1/05, 7/1/06, 7/2/07 (Emer.)

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the assisted living home and community based services (HCBS) waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of job and family services (ODJFS), in accordance with section 5111.91 of the Revised Code.

(B) The assisted living home and community based services (HCBS) waiver is an alternative to nursing facility placement for persons age twenty-one and over who require intermediate level of care as set forth in rule 5101:3-3-06 of the Administrative Code or skilled level of care as set forth in rule 5101:3-3-05 of the Administrative Code and are enrolled in the waiver.

(1) The assisted living HCBS waiver services and program eligibility criteria are set forth in Chapter 5101:3-33 of the Administrative Code.

(2) Financial eligibility for the assisted living HCBS waiver program is determined in accordance with Chapter 5101:1-39 of the Administrative Code.

(3) Maximum allowable reimbursement rates for the assisted living HCBS waiver program are listed in appendix A to this rule. Assisted living HCBS reimbursement must be provided in accordance with paragraphs (A) to (C) of rule 5101:3-1-60 of the Administrative Code.

The billing maximum for the community transition service listed in appendix A to this rule represents the cumulative maximum for the items purchased or deposits made through the community transition service during the consumer’s period of eligibility for this service as established in rule 173-39-02.17 of the Administrative Code.

APPENDIX A

Assisted Living Waiver Rates

Effective July 1, 2006

Service                         Billing Maximum     Billing Unit

Assisted Living Service-Tier 1       $49.98       1 day

Assisted Living Service-Tier 2       $60.00       1 day

Assisted Living Service-Tier 3       $69.98       1 day

Community Transition Service       $1500.00       1 completed job order or deposit made

Effective: 03/22/2008

R.C. 119.032 review dates: 11/13/2007 and 03/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.85, 5111.89

Rule Amplifies: 5111.85, 5111.89

Prior Effective Dates: 07/01/2006

Rescinded eff 7-1-06

Paragraph (A) of this rule contains common definitions regarding coordination of benefits used in this and other rules of the Administrative Code. Paragraphs (B) to (M) of this rule explain the Ohio department of job and family services’s (ODJFS) expectations of providers in regard to the collection of all third party resources for a rendered service to a medicaid consumer prior to the provider requesting reimbursement from ODJFS.

(A) Definitions.

(1) “Coordination of benefits (COB)” means the process of determining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits for a medicaid consumer.

(2) “Explanation of benefits (EOB)” or “remittance advice” means the information sent to providers and/or plan beneficiaries (consumers) by any other third party payer, medicare and/or medicaid to explain the adjudication of the claim.

(3) “COB claim” means any claim that meets either the definition of third party claim as described in paragraph (A)(9) of this rule or the definition of medicare crossover claim as described in rule 5101:3-1-05 of the Administrative Code.

(4) “Medicare benefits” is as defined in rule 5101:3-1-05 of the Administrative Code.

(5) “Third party (TP)” is as defined in section 5101.571 of the Revised Code.

(6) “Third party payer (TPP)” means an entity, other than the medicaid or medicare programs, responsible for adjudicating and paying claims for third party benefits rendered to an eligible medicaid consumer.

(7) “Third party benefit” means any health care service(s) available to consumers through any medical insurance policy or through some other resource that covers medical benefits and the payment for those services is either completely the obligation of the TPP or in part the obligation of the consumer, the TPP and/or medicaid. (Examples of a third party benefit include private health or accidental insurance, medicare, CHAMPUS or worker’s compensation.)

(8) “Third party liability (TPL)” means the payment obligations of the TPP for health care services rendered to eligible medicaid consumers when the consumer also has third party benefits as described in paragraph (A)(7) of this rule.

(9) “Third party claim” means any claim(s) submitted to ODJFS for reimbursement after all TPPs have met their payment obligations. In addition, the following will be considered third party claims by ODJFS:

(a) Any claim received by ODJFS that shows no prior payment by a TPP, but, ODJFS’s records indicate the consumer has third party benefits.

(b) Any claim received by ODJFS that shows no prior payment by a TPP, but, the provider’s records indicate the medicaid consumer has third party benefits.

(B) If the existence of a third party benefit is known to ODJFS, a code number that represents the name of the third party payer covering the consumer will be indicated on the consumer’s medicaid card. Providers may use this code to obtain third party benefit information found in the ODJFS provider billing instructions (rev. 7/1/2006 and located on the internet at http://emanuals.odjfs.state.oh.us/emanuals). The “Third Party Carrier Table” in the provider billing instructions contains the names, code numbers, and addresses of third party payers who can be matched to the code number on the medicaid card. Providers can use the appropriate TPP name and address found in the billing instructions to bill the third party insurer prior to billing medicaid. If the TPP is not provided on the list, the provider may obtain from the consumer the name and address of the insurance company, and any other necessary information, and bill the insurance company prior to billing ODJFS.

(C) The provider must always review the consumer’s Ohio medicaid card for evidence of third party benefits. Whether there is or is not an indication of a TPP on the medicaid card, the provider must always request from the consumer or his or her representative information about any third party benefit(s). If the consumer specifies no TP coverage and the medicaid card does not indicate TP coverage, the provider may submit a claim to medicaid (and the claim for the service is not considered a TP claim). If, as a result of this process, the provider determines that TP liability exists, the provider may only submit a claim for reimbursement if it first takes reasonable measures to obtain TP payments as set forth in paragraph (D) of this rule.

(D) The medicaid program must be the last payer to receive and adjudicate the claim, except as determined by rule 5101:3-1-03 of the Administrative Code, and the state sponsored program awarding reparations to victims of crime under sections 2743.51 to 2743.72 of the Revised Code. ODJFS reimburses for covered services only after the provider takes reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing ODJFS. Providers who have gone through reasonable measures to obtain all third party payments, but who have not received payment from a TPP, or have gone through reasonable measures and received partial payment, may use an appropriate code on the claim to obtain payment and submit a claim to ODJFS requesting reimbursement for the rendered service(s).

(1) Providers are considered by ODJFS to have taken reasonable measures to obtain all third party payments if they comply with one of the following requirements:

(a) The provider submits a claim first to the TPP and receives a remittance advice indicating that a valid reason for non-payment applies for the service as described in paragraph (D)(2) of this rule.

(b) The provider submits a claim first to the TPP for the rendered service(s) no less than three times within a ninety-day period and does not receive a remittance advice or other communication from the TPP within ninety days of the last submission to the TPP. Providers must be able to document each claim submission and the date of the submission.

(c) The provider followed the process described in paragraph (C) of this rule for the billed service and meets the following requirements:

(i) The provider did not find a change in third party coverage;

(ii) The billed service was previously rendered to the medicaid consumer by the provider within the last three hundred sixty-five days; and

(iii) The claim for the previously rendered service met the requirements of paragraph (D)(1)(a) or (D)(1)(d) of this rule.

(d) The provider did not send a claim to the TPP, but has received and retained at least one of the following types of documentation that indicates a valid reason for non-payment for the service(s) as set forth in paragraph (D)(2) of this rule:

(i) Written documentation from the TPP;

(ii) Written documentation from the TPPs automated eligibility and claim verification system;

(iii) Written documentation from the TPPs member benefits reference guide/manual; or

(iv) Any other reliable method for obtaining information and/or documentation from the TPP that there is no third party benefit coverage for the rendered service(s).

(e) The provider submits a claim first to the TPP and receives a partial payment along with a remittance advice documenting the allocation of the billed charges.

(2) Valid reasons for non-payment from a third party payer to the provider for a third party benefit claim include, but are not limited to, the following:

(a) The service(s) is not covered under the medicaid consumer’s third party benefits.

(b) The medical expenses for the medicaid consumer were incurred prior to the third party benefits coverage dates.

(c) The medical expenses for the medicaid consumer were incurred after the third party benefits coverage was terminated.

(d) The medicaid consumer does not have third party benefits through the TPP for the date of service.

(e) All of the provider’s billed charges or the TPPs approved rate was applied to the consumer’s third party benefit deductible amount.

(f) All of the provider’s billed charges or the TPPs approved rate was applied in total across the consumer’s deductible, coinsurance and/or co-payment for the third party benefit.

(g) The medicaid consumer has not met eligibility, out-of-pocket expenses, required waiting periods or residency requirements for his/her third party benefits.

(h) The medicaid consumer is a dependent of the individual with third party benefits, but the benefits do not cover the individual’s dependents.

(i) The medicaid consumer has reached the lifetime benefit maximum for the medical service being billed to the third party payer.

(j) The medicaid consumer has reached the benefit maximum of his/her third party benefits.

(k) The TPP is disputing or contesting its liability to pay the claim or cover the service.

(E) Providers who have gone through reasonable measures as described in paragraph (D) of this rule to obtain all third party payments, but who have not received payment from a TPP, or received a partial payment, may submit a claim to ODJFS requesting reimbursement for the rendered service(s). If payment from the TPP is received after ODJFS has made payment, the provider is required to repay ODJFS any overpaid amount. The provider must not reimburse any overpaid amounts to the consumer.

(F) Information on how to submit a claim that will have a zero paid amount in the third party field on the claim can be found in the billing instructions on the electronic manuals website.

(G) Medicaid reimbursement for third party claims will not exceed the medicaid maximum payment for the service, determined in accordance with applicable rules for the service, less all third party payments for the service. If the result is less than or equal to zero dollars, there will be no further medicaid payment for the service.

(H) ODJFS will reject a TP claim when a third party claim indicates coverage by a TPP, or when the existence of third party benefits is known to ODJFS, and the submitted claim does not indicate collection of the third party payment or does not indicate compliance with paragraph (D) of this rule. Providers should complete their investigation of available third party benefits before submitting a TP claim to ODJFS for payment.

(1) Providers and/or trading partners must maintain documentation to support all required information submitted on a third party claim (for example, if the submitted information indicates one hundred per cent of approved charges were allocated to the plan deductible, then the provider must have documentation to support the TPP allocated the approved charges to the plan deductible).

(2) Providers and/or trading partners must not omit from a TP claim any required TP claim information issued to them by the TPP, by the consumer or any other source (for example, the omission of the payment denial reasons that were issued by the TPP).

(I) ODJFS will make audit exceptions if a post-payment review reveals that the provider and/or trading partner did not maintain documentation to support the information submitted on a TP claim or reveals that the omission of required TP claim information resulted in an overpayment or an inappropriate payment of the claim.

(J) The provider is prohibited from billing the consumer any charges in accordance with paragraph (A) of rule 5101:3-1-60 of the Administrative Code.

(K) If the consumer states his/her private health insurance has changed or been terminated, the provider should advise the consumer to contact his/her county caseworker to correct the case record. Once the case record has been corrected, the provider may bill ODJFS directly.

(L) ODJFS has right of recovery pursuant to section 5101.58 of the Revised Code (medicaid, or any federal or state funded public health program) against the liability of a third party for the cost of medical services paid by ODJFS, or billable to ODJFS for payment at a later date. Section 5101.58 of the Revised Code requires that a medicaid consumer provide notice to ODJFS prior to initiating any action against a liable third party. ODJFS will take steps to protect its rights of recovery if that notice is not provided. If any person, whether the consumer or an individual acting on the behalf of a consumer, requests a financial statement (a claim) from a medicaid provider for services paid by ODJFS or to be billed to ODJFS on behalf of the medicaid consumer, the provider shall meet all of the following four requirements:

(1) Require that the consumer or the consumer’s representative make his/her request for access to financial statements in writing.

(2) Notify ODJFS immediately upon receipt of the consumer’s written request and forward a copy of the request to ODJFS, bureau of plan operations, benefit and recovery section.

(3) Release the financial statement to the consumer or the consumer’s representative no later than thirty days after the date the request is received.

(4) Stamp or type on each page of the financial statement in bold font “SUBJECT TO RIGHT OF RECOVERY PURSUANT TO SECTION 5101.58 OF THE OHIO REVISED CODE. FAILURE TO COMPLY MAY RESULT IN PERSONAL LIABILITY.”

This rule applies to financial statements whether or not the provider has received reimbursement from ODJFS. This rule is not intended to prevent or restrict the provider from furnishing records of medical treatment and condition to the consumer.

(M) When the medicaid consumer is covered by medicare, in addition to other third party payers, medicaid is the payer of last resort. Whether or not a TPP is the primary payer, providers must bill all other third party payers and medicare prior to submitting a claim to ODJFS in accordance with rule 5101:3-1-05 of the Administrative Code.

Replaces: 5101:3-1-08

Effective: 12/18/2006

R.C. 119.032 review dates: 12/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 4/1/79, 10/1/84, 10/1/87, 7/7/02, 5/1/03, 1/1/04

Requirements in this rule regarding the medicaid co-payment program do not include medicaid consumers who are enrolled in a medicaid managed health care program. Co-payment program requirements specific to recipients enrolled in medicaid managed health care programs are set forth in accordance with Chapter 3-26 of the Administrative Code. Consumers eligible for the disability medical assistance program as defined in rule 5101:3-23-01 of the Administrative Code will be subject to co-payments in accordance with this rule.

(A) Beginning on and after January 1, 2006, the Ohio department of job and family services (ODJFS) shall institute a co-payment program under medicaid. The co-payment program shall establish a co-payment requirement for only dental services, vision services, non-emergency emergency department services, and prescription drugs, other than generic drugs.

(B) The co-payment program shall provide for all of the following with regard to any providers participating in the medicaid program:

(1) No provider may deny services to a consumer who is eligible for the services on account of the consumer’s inability to pay the medicaid co-payment. Consumers who are unable to pay their medicaid co-payment may declare their inability to pay for services or medication and receive their services or medication without paying their medicaid co-payment amount.

(2) Paragraph (B)(1) of this rule shall not be considered to do either of the following with regard to a medicaid consumer who is unable to pay a required medicaid co-payment:

(a) Relieve the medicaid consumer from the obligation to pay a medicaid co-payment;

(b) Prohibit the provider from attempting to collect an unpaid medicaid co-payment.

(3) No provider shall waive a medicaid consumer’s obligation to pay the provider a medicaid co-payment.

(4) No provider or drug manufacturer, including the manufacturer’s representative, employee, independent contractor, or agent, shall pay any co-payment on behalf of a medicaid consumer.

(5) If it is the routine business practice of the provider to refuse service to any individual who owes an outstanding debt to the provider, the provider may consider an unpaid medicaid co-payment imposed by the co-payment program as an outstanding debt and may refuse service to a medicaid consumer who owes the provider an outstanding debt. If the provider intends to refuse service to a medicaid consumer who owes the provider an outstanding debt, the provider shall notify the individual of the provider’s intent to refuse services.

(a) A provider’s decision to continue rendering services to a medicaid consumer who has an unpaid co-payment shall not be considered to be out of compliance with paragraph (B)(3) of this rule.

(b) Charges which are prohibited in accordance with paragraph (A) of rule 5101:3-1-60 of the Administrative Code may not be considered an outstanding debt of a medicaid consumer.

(C) Exclusions to the co-payment requirement in accordance with the provisions of 42 C.F.R. 447.53 for dental, vision, non-emergency emergency department services and prescription medications include:

(1) Children. Consumers who are under the age of twenty-one are excluded from co-payment obligations.

(a) For pharmacy claims, the provisions of rule 5101:3-9-09 of the Administrative Code also apply.

(b) For all other claims, the provider may use the consumer’s date of birth to identify if this exclusion applies; or the provider may submit the claim to the department, during the adjudication of the claim the department will identify those consumers under the age of twenty-one through the department’s recipient master file, and will not reduce the medicaid payment by the co-payment amount.

(2) Pregnant women. With the exception of paragraph (C)(2)(a) of this rule, all services provided to pregnant women during their pregnancy and the post partum period are excluded from a co-payment. The post-partum period is the immediate post-partum period which begins on the last day of pregnancy and extends through the end of the month in which the sixty day period following termination of pregnancy ends.

(a) Routine eye examinations and the dispensation of eyeglasses during a consumer’s pregnancy or post partum period are subject to the medicaid co-payment.

(b) For pharmacy claims, the provisions of rule 5101:3-9-09 of the Administrative Code also apply.

(c) For all other claims, the provider may accept the consumer’s selfdeclaration of their pregnancy or post partum period or the practice’s medical records to determine if the pregnancy/post partum co-payment exclusion applies. If the provider reports on the claim as specified in the ODJFS billing instructions (rev. 1/1/2006 and located on the internet at http://emanuals.odjfs.state.oh.us/emanuals) that the pregnancy/post partum exclusion applies, the medicaid payment will not be reduced by the medicaid co-payment amount.

(3) Institutionalized consumers. Consumers receiving services or medications who are a resident in a nursing facility (NF) or intermediate care facilities for the mentally retarded (ICFs-MR) are excluded from co-payment.

(a) For pharmacy claims, the provisions of rule 5101:3-9-09 of the Administrative Code also apply.

(b) For all other claims, the provider may determine if the institutional co-payment exclusion applies by obtaining the consumers address to validate the consumer resides in a NF or ICFs-MR; or the provider may submit the claim to the department, during the adjudication of the claim the department will identify those consumers who reside in a NF or ICFs-MR through the department’s recipient master file, and will not reduce the medicaid payment by the co-payment amount.

(4) Emergency. Consumers receiving emergency services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily part or organ, are excluded from co-payment obligations.

(a) Except for non-emergency emergency department services as set for in rule 5101:3-2-21.1 of the Administrative Code, hospital services are excluded from co-payments.

(b) For pharmacy claims, the provisions of rule 5101:3-9-09 of the Administrative Code also apply.

(c) For all other claims, the provider may determine on the basis of their professional judgment if the emergency co-payment exclusion applies. If the provider reports on the claim as specified in the ODJFS billing instructions (rev. 1/1/2006) that the emergency co-payment exclusion applies, the medicaid payment will not be reduced by the medicaid co-payment amount.

(5) Family planning. Any service identified by the department as a family planning service in accordance with rule 5101:3-4-07 of the Administrative Code and provided to a woman of child-bearing age is not subject to a co-payment.

(a) For pharmacy claims, the provisions of rule 5101:3-9-09 of the Administrative Code also apply.

(b) For all other claims, the provider may determine on the basis of their professional judgment that the consumer is receiving family planning services and that the family planning co-payment exclusion applies. If the provider reports on the claim as specified in the ODJFS billing instructions (rev. 1/1/2006 and located on the internet at http://emanuals.odjfs.state.oh.us/emanuals) that the family planning co-payment exclusion applies, or itemizes a service identified as a family planning service in the ODJFS claims processing system, the medicaid payment will not be reduced by the medicaid co-payment amount

(6) Hospice. Consumers receiving services for hospice care are excluded from co-payment obligations.

(a) For pharmacy claims, the provisions of rule 5101:3-9-09 of the Administrative Code also apply.

(b) For all other claims, the provider may accept the consumer’s self-declaration that they are enrolled in hospice or check the information stamped on their Ohio medicaid card in accordance with rule 5101:3-56-03 of the Administrative Code to determine if the hospice co-payment exclusion applies. If the provider reports on the claim as specified in the ODJFS billing instructions (rev. 1/1/2006) that the consumer is enrolled in hospice, the medicaid payment will not be reduced by the medicaid co-payment amount.

(D) In addition to the exclusions in section (C) of this rule, medicare cross-over claims defined in accordance with rule 5101:3-1-05 of the Administrative Code will not be subject to medicaid co-payments.

(E) Information regarding co-payment amounts for dental, vision, non-emergency emergency department services and prescription services, can be found in the following Ohio Administrative Code rules:

(1) Co-payment amounts for dental services are determined in accordance with rule 5101:3-5-01 of the Administrative Code.

(2) Co-payment amounts for vision services are determined in accordance with rule 5101:3-6-01 of the Administrative Code.

(3) Co-payment amounts for non-emergency emergency department services are determined in accordance with rule 5101:3-2-21.1 of the Administrative Code.

(4) Co-payment amounts for prescription services are determined in accordance with rule 5101:3-9-09 of the Administrative Code.

Effective: 01/01/2006

R.C. 119.032 review dates: 01/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.0112

Rule Amplifies: 5111.01, 5111.02, 5111.0112

(A) Out-of-state providers must be licensed, accredited, or certified by their respective states to be considered eligible to provide services to Ohio medicaid consumers. Any standards applicable to the provision of the service in the state in which the service is being furnished must be met, as well as those standards set forth in the Ohio medicaid program and in the Ohio Administrative Code. Out-of-state providers must enroll as Ohio medicaid providers in order to obtain reimbursement and must follow appropriate billing procedures in accordance with Chapter 5101:3-1 of the Administrative Code and Chapter 5101:3-3 of the Administrative Code for long term care nursing facility services.

(B) Ohio medicaid covered services will be reimbursed when rendered by out-of-state providers only under the following circumstances:

(1) The medically necessary services are not available within the state of Ohio, and the use of out-of-state providers to perform the services is prior-authorized by the department or its’ designee in accordance with rule 5101:3-1-31 of the Administrative Code; or

(2) The medical need arose as a result of an emergency, an accident, and/or an illness which occurred during the period the consumer was temporarily absent from Ohio and the consumers’ health would have been endangered if care was postponed until the consumer returned to Ohio or attempted to return to Ohio; or

(3) The provider location for the medically necessary service is in a bordering state, and it is the usual practice of residents in that community to utilize out-of-state providers, so long as the cost of the service does not exceed the cost of the service provided by in-state providers; or

(4) The state determines on the basis of medical advice, that the needed medical services or necessary supplementary resources are more readily available in another state.

Effective: 07/01/2005

R.C. 119.032 review dates: 04/15/2005 and 07/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 5/30/02

(A) The medicaid payment for a covered service constitutes payment-in-full and may not be construed as a partial payment when the reimbursement amount is less than the provider’s charge. The provider may not collect and/or bill the consumer for any difference between the medicaid payment and the provider’s charge or request the consumer to share in the cost through a deductible, coinsurance, co-payment or other similar charge, other then medicaid co-payments as defined in rule 5101:3-1-09 of the Administrative Code. The provider may not charge the consumer a down payment, refundable or otherwise.

(B) A medicaid consumer cannot be billed when a medicaid claim has been denied due to:

(1) Unacceptable or untimely submissions of claims;

(2) Failure to request a prior authorization; or

(3) A peer review organization (PRO) retroactively denying services for lack of medical necessity.

(C) Providers are not required to bill the Ohio department of job and family services (ODJFS) for medicaid-covered services rendered to eligible consumers. However, providers may not bill consumers in lieu of the ODJFS unless:

(1) The consumer is notified in writing prior to the service being rendered that the provider will not bill the ODJFS for the covered service; and

(2) The consumer agrees to be liable for payment of the service and signs a written statement to that effect prior to the service being rendered; and

(3) The provider explains to the consumer that the service is a covered medicaid service and other medicaid providers may render the service at no cost to the consumer.

(D) Services that are not covered by the medicaid program, including services requiring prior authorization that have been denied by the ODJFS, may be billed to the consumer when the provisions in paragraphs (C)(1) and (C)(2) of this rule are met.

Effective: 01/06/2006

R.C. 119.032 review dates: 10/20/2005 and 01/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.0112

Rule Amplifies: 5111.01, 5111.02, 5111.0112

Prior Effective Dates: 06/03/83, 02/11/84, 10/01/84, 07/01/85 (Emer), 09/30/85, 10/01/87, 05/30/02, 1/1/04, 7/1/05

(A) All eligible medicaid consumers are issued a medicaid card as evidence of eligibility to be used when requesting medical services. Medicaid consumers who are enrolled in a managed care plan (MCP) are issued a MCP identification card from the managed care plan in place of a medicaid card. The medicaid card is valid for a period of one month only, and should be examined by the provider on each occasion that a service is requested to ensure that the consumer is currently eligible. The Ohio department of job and family services (ODJFS) will not pay for services rendered to ineligible consumers. If the eligible consumer does not have a medicaid card in his/her possession, the provider should contact the county department of job and family services (CDJFS) to verify eligibility.

(B) The medicaid card lists consumers eligible for medicaid, indicating the twelve-digit Ohio medicaid billing number for each member of the case. Medicaid providers are required to take reasonable steps to check the identity of the consumer for whom services are being provided.

(C) The medicaid card also supplies information identifying any third-party insurance coverage known to ODJFS. Requirements regarding third party insurance coverage are described in rule 5101:3-1-08 of the Administrative Code.

(D) In addition to the medicaid card, ODJFS also issues the following medical cards:

(1) “Ohio Disability Assistance” card. Certain individuals who are ineligible for medicaid may be eligible for the state and county funded disability medical assistance (DMA) program as defined in Chapter 5101:3-23 of the Administrative Code.

(2) “Ohio Disability Assistance Restricted Status” card. Consumers covered under this program are eligible for services provided under the DMA program with certain program restrictions as defined in Chapter 5101:3-23 of the Administrative Code.

(3) “Healthy Start Healthy Families Medicaid” card. This card is used by families who qualify for medicaid coverage under income eligibility guidelines established by the federal government as defined in Chapter 5101:1-40 of the Administrative Code.

(4) “PACT Medicaid” card. This card is used by consumers enrolled in the department’s primary alternative care and treatment (PACT) program as defined in Chapter 5101:3-20 of the Administrative Code.

(5) “Ohio Qualified Medicare Beneficiary” (QMB) card, Medicaid benefits for QMBs are limited to payments toward medicare cost-sharing expenses. Requirements regarding QMB coverage are described in rule 5101:3-1-05 of the Administrative Code.

(6) “Expedited Medicaid Limited Coverage” card. Expedited medicaid provides eligible pregnant women with outpatient medical coverage, as described in rule 5101:1-40-60 of the Administrative Code, while they wait for the CDJFS to complete the eligibility determination process that may permit them to receive coverage through other programs such as medicaid for the aged, blind or disabled, healthy start medicaid, or healthy families medicaid.

Effective: 12/18/2006

R.C. 119.032 review dates: 09/01/2006 and 12/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 7/1/80, 10/1/87, 5/30/02

(A) “Eligible provider” means any individual, group practice, other corporation or health care institution that:

(1) Meets the applicable provider requirements and standards in division 5101:3 of the Administrative Code that address the applicable provider types and service categories covered under the Ohio medicaid program;

(2) Meets the additional requirements and standards set forth in this rule; and

(3) Is approved for participation in the medicaid program by the Ohio department of job and family services (ODJFS) as evidenced by the issuance of both a signed “Provider Agreement” and an Ohio medicaid legacy number.

(B) Eligible providers enrolled in the Ohio medicaid program will each be classified as a “Typical” provider or an “Atypical” provider and will also be classified as an “Entity Type 1” provider or an “Entity Type 2” provider.

(1) “Typical Provider” means any provider assigned a provider type that ODJFS has determined is eligible to provide covered services that meet the definition of health care services in accordance with 45 C.F.R. 160.103 (2/2006).

(2) “Atypical Provider” means any provider assigned a covered provider type that ODJFS has determined is eligible to provide covered services that are non-health care services (i.e., those services that do not meet the definition of health care services in accordance with 45 C.F.R. 160.103 (2/2006)).

(3) “Entity Type 1” means a provider assigned a covered provider type that is for an individual health care provider. An individual health care provider cannot be a subpart and cannot designate a subpart. A sole proprietorship is a form of business that, in terms of a national provider identifier (NPI) assignment, is an entity type 1 that is eligible for a single NPI. As an individual, a sole proprietor/sole proprietorship cannot have subparts and cannot designate subparts.

(4) “Entity Type 2” means:

(a) Any provider enrolled that is assigned a covered professional group provider type as specified in paragraph (C) of this rule; or

(b) Any provider enrolled that is assigned any provider type that is neither an individual provider type nor a professional group provider type.

(C) A provider can be assigned a professional group provider type only if it is organized for the sole purpose of providing professional services authorized under Chapters 4715., 4725., 4731., 4732., 4734., 4755.04 to 4755.56, or 4723.41 to 4723.485 of the Revised Code; meets the requirements in either paragraph (C)(1) or (C)(2) of this rule, and meets the other requirements set forth in paragraphs (C)(3) and (C)(4) of this rule. The specific group practice provider type assigned to the group practice must match the corresponding professional type of the individual provider or individual providers that are members of the professional group practice.

(1) An professional practice that is owned by an individual may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraphs (C)(3)(a) to (C)(3)(d) of this rule and the owner (member) of the practice possesses a valid license, certificate or other legal authorization issued under Chapters 4715., 4725., 4731., 4732., 4734., 4755.04 to 4755.56, or 4723.41 to 4723.485 of the Revised Code and also meets the respective requirements in paragraph (A)(1) of this rule.

An individual provider enrolling with the medicaid program that does not meet the provisions listed in paragraph (C) of this rule may only be enrolled as an individual provider.

(2) Any group of two or more individuals may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule, the practice consists of two or more members, and each member possesses the same type of license, certificate or other legal authorization (with the exception of occupational and physical therapists) issued under Chapters 4715., 4725., 4731., 4732., 4734., or 4723.43 to 4723.59 of the Revised Code (i.e., each member is the same professional provider type.)

Occupational and physical therapists may form a professional group practice of mixed licensure if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule, the practice consists of two or more members and each member possesses a license, certificate or other legal authorization issued under Chapters 4755.04 to 4755.56 of the Revised Code.

(3) For purposes of the Ohio medicaid program, a professional group may be organized in accordance with one of the following organizational structures:

(a) A corporation formed under Chapter 1701. of the Revised Code;

(b) A limited liability corporation formed under Chapter 1705. of the Revised Code;

(c) A non-profit corporation formed under Chapter 1702. of the Revised Code;

(d) A professional association formed under Chapter 1785. of the Revised Code; or

(e) A partnership formed under Ohio law.

(4) Each member or each employee of the professional group practice (including an individual that is incorporated) that possesses a license, certificate or other legal authorization issued under Chapters 4715., 4725., 4731., 4732., 4734., 4755.04 to 4755.56, or 4723.41 to 4723.485 of the Revised Code and also meets the respective requirements in paragraph (A)(1) of this rule must have an individual provider agreement with ODJFS.

(D) Requirements for an NPI and the consequences of not having an NPI when an NPI is required.

(1) A typical provider must obtain an NPI.

(a) With the exception of NPI requirements for long term care facilities described in paragraph (D)(1)(b) of this rule:

(i) A typical provider enrolled prior to the effective date of this rule who intends to continue to do business under the existing provider agreement, or provider agreements, will be required to obtain a unique NPI for each approved and existing provider agreement and unique medicaid legacy number.

(ii) A typical provider enrolling on or after the effective date of this rule is required to obtain a unique NPI in order to be approved as an eligible provider under the medicaid program.

(b) A provider of nursing facility services is required to obtain an NPI.

(2) An atypical provider is not required to obtain an NPI unless the provider determines it provides health care services in accordance with 45 C.F.R. 160.103 (2/2006).

(a) Each atypical provider must self-assess the services it provides and determine if it provides health care services.

(b) An atypical provider that determines it provides any health care services is required to obtain an NPI, regardless of the type of services the provider performs under the medicaid program.

(3) Typical providers and atypical providers that have been issued an NPI must disclose each NPI they have been issued to ODJFS in accordance with rule 5101:3-1-17.3 of the Administrative Code.

(4) Typical providers and atypical providers that are required to obtain an NPI will have claims denied for payment if any of the following apply:

(a) Providers submit a claim without an NPI present on the claim when an NPI is required on the claim by the billing instructions or guidelines as referenced in paragraph (B) of rule 5101:3-1-19 of the Administrative Code.

(b) Providers submit a claim without the medicaid legacy number, or without both a medicaid legacy number and an NPI when both are required, when it is required on the claim by the billing instructions or guidelines as referenced in paragraph (B) of rule 5101:3-1-19 of the Administrative Code.

(c) Providers submit a claim with an NPI that is not recognized by ODJFS as a valid NPI based on the information disclosed in accordance with rule 5101:3-1-17.3 of the Administrative Code.

(d) Providers do not submit claims to ODJFS within the timely filing limitations in accordance with rule 5101:3-1-19 of the Administrative Code. ODJFS will not make exceptions for providers that do not submit claims within the timely filing limitations because the provider failed to get an NPI or failed to disclose an NPI to ODJFS per rule 5101:3-1-17.3 of the Administrative Code.

(5) Covered organization health care providers are responsible for determining if they have components or subparts and the covered organization health care provider must ensure that their subparts obtain their own unique NPI, or they must obtain one for them. A subpart is not itself a separate legal entity, but is part of a covered organization health care provider that is a legal entity. A subpart must furnish health care as defined in 45 C.F.R. 160.103 (2/2006).

(E) If an “Entity Type 2” health care provider consists of subparts that are issued a unique NPI but the subpart does not meet the requirements to be an eligible provider as set forth in this rule, all transactions must be submitted under the NPI of the “Entity Type 2” medicaid provider under which it is a subpart. ODJFS will make exceptions for automatic crossover claims received from the medicare coordination of benefits administrator for those NPIs issued to a subpart of an “Entity Type 2” provider if the subpart is enrolled as an eligible provider under medicare.

“Entity Type 1” (individual) providers can never be a subpart of an “Entity Type 2” provider.

(F) Not all health care providers providing health care services in accordance with 45 C.F.R. 160.103 (2/2006) are eligible to enroll as providers under the Ohio medicaid program. The receipt of an NPI does not guarantee enrollment as an Ohio medicaid provider.

Effective: 01/01/2008

R.C. 119.032 review dates: 05/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.029

Prior Effective Dates: 4/7/77, 10/1/87, 1/1/95, 12/31/96 (Emer), 3/22/97, 5/30/02, 8/11/05, 05/23/07

For purposes of this rule for the medicaid and the disability medical assistance programs, services and benefits are covered in accordance with the provisions set forth in division-level 5101:3 of the Administrative Code.

A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid and/or the disability medical assistance programs.

A provider agreement is a contract between the Ohio department of job and family services (ODJFS) and a provider of medicaid covered services. By signing this agreement the provider agrees to comply with the terms of the provider agreement, Revised Code, Administrative Code, and federal statutes and rules; and the provider certifies and agrees:

(A) To render medical services as medically necessary for the patient and only in the amount required by the patient without regard to race, creed, color, age, sex, national origin, source(s) of payment, or handicap; submit claims only for services actually performed; and, bill ODJFS for no more than the usual and customary fee charged other patients for the same service.

(B) To ascertain and recoup any third-party resource(s) available to the consumer prior to billing ODJFS. ODJFS will then pay any unpaid balance up to the lesser of the provider’s billed charge or the maximum allowable reimbursement as set forth in division-level 5101:3 of the Administrative Code.

(C) To accept the allowable reimbursement for all covered services as payment-in-full, except as required in paragraph (B) of this rule. The provider will not seek reimbursement for that service, except as defined in rule 5101:3-1-09 of the Administrative Code, from the patient, any member of the family, or any other person.

(D) To maintain all records necessary and in such form so as to fully disclose the extent of services provided and significant business transactions. The provider will maintain such records for a period of six years from the date of receipt of payment based upon those records or until any audit initiated within the six year period is completed.

(E) To furnish to ODJFS, the secretary of the department of health and human services, or the Ohio medicaid fraud control unit or their designees any information maintained under paragraph (D) of this rule for audit and review purposes. Audits may use statistical sampling. Failure to supply requested records within thirty days shall result in withholding of medicaid or disability medical assistance payments and may result in termination from the medicaid and disability medical assistance programs.

(F) To inform ODJFS within thirty days of any changes in licensure, certification, or registration status; ownership; specialty; additions, deletions, or replacements in group membership and hospital-based physician affiliations; and address.

(G) To disclose ownership and control information, and to disclose the identity of any person who has been convicted of a criminal offense related to medicare, medicaid, disability medical assistance, or Title XX services, as specified in rule 5101:3-1-17.3 of the Administrative Code.

(H) That neither the individual practitioner, nor the company, nor any owner, director, officer, or employee of the company, nor any independent contractor retained by the company, is currently subject to sanction under medicare, medicaid, disability medical assistance, or Title XX; or, is otherwise prohibited from providing services to medicare, medicaid, disability medical assistance, or Title XX beneficiaries.

(I) To provide to ODJFS, through the court of jurisdiction, notice of any bankruptcy action brought by the provider. Notice shall be mailed to: office of legal services, Ohio department of job and family services.

(J) To comply with the appropriate advance directives requirements for hospitals, providers of home health care, personal care services, and hospices as specified in Chapter 3701-83 of the Administrative Code.

(K) To comply with the confidentiality safeguards and the use and release of information regarding public assistance recipients as described in section 5101.27 of the Revised Code.

(L) To comply with section 121.36 of the Revised Code and rule 5101: 3-1-39 of the Administrative Code when providing home care services.

Effective: 03/27/2006

R.C. 119.032 review dates: 08/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 1/1/93, 5/30/02, 1/1/04, 9/26/04, 8/11/05, 12/30/05 (Emer)

(A) Providers shall disclose to the Ohio department of job and family services (ODJFS) or its designee full and complete information concerning the name and address of each person:

(1) Who, with respect to the provider:

(a) Is an officer or director;

(b) Is a partner;

(c) Has a direct or indirect ownership interest totaling five per cent or more; or

(d) Has an interest of five per cent or more in any mortgage, deed of trust, note, or other obligation secured by the provider if that interest equals at least five per cent of the value of the property or assets of the provider.

(2) Who, with respect to any subcontractor in which the provider has a direct or indirect ownership or control interest of five per cent or more:

(a) Is an officer or director;

(b) Is a partner;

(c) Has a direct or indirect ownership interest totaling five per cent or more; or

(d) Has an interest or five per cent or more in any mortgage, deed of trust, note, or other obligation secured by the provider if that interest equals at least five per cent of the value of the property or assets of the provider.

(3) Who has been convicted or indicted of a criminal offense related to involvement in any program operated under Title XVIII, XIX, or XX of the Social Security Act and who has an ownership or control interest in the provider, or is an agent or managing employee (i.e., an individual, including a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control or who directly or indirectly conducts the day-to-day operations).

(B) Providers shall supply ODJFS, or its designee, within thirty-five days of the date of a specific request, full and complete information concerning:

(1) The ownership of any subcontractor with which the provider has had, during the twelve months prior to the date of the request, business transactions in an aggregate amount of twenty-five thousand dollars; and

(2) Any significant business transactions occurring during the five-year period ending on the date of such request, between the facility and any wholly owned supplier or any subcontractor.

(C) Disclose whether any of the persons named, in compliance with paragraphs (A)(2) and (A)(3) of this rule, are related to another as spouse, parent, child, or sibling.

(D) Disclose the name of any other disclosing entity in which a person with an ownership or control interest in the provider also has an ownership or control interest.

(1) This requirement applies to the extent that the provider can obtain this information by requesting it in writing from the person.

(2) The provider must:

(a) Keep copies of all these requests and the responses to them;

(b) Make them available to the secretary of health and human services or ODJFS upon request; and

(c) Advise the secretary of health and human services or ODJFS when there is no response to a request.

(E) Providers shall disclose their national provider identifier (NPI) by supplying ODJFS a copy of the national plan and provider enumeration system (NPPES) NPI notification received. Upon receipt of written notification from NPPES, a provider shall report any additions, change in ownership, or change in the assignment of the provider’s NPI to ODJFS.

Effective: 05/23/2007

R.C. 119.032 review dates: 03/06/2007 and 05/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 5/30/02, 8/11/05

(A) Provider agreements are one of three types:

(1) Open-ended provider agreements have no specific termination date and continue to be in effect as long as agreeable by both parties.

(2) Time-limited provider agreements are for a specific period of time and will expire on a designated date unless renewed in accordance with the Ohio department of job and family services (ODJFS) re-enrollment process. The time-limited provider agreements will be limited to no longer than three years from the effective date.

(3) Provider agreements with managed care plans (MCPs) are administered in accordance with Chapter 5101:3-26 of the Administrative Code, and are not subject to the provisions of this rule.

(B) The following providers shall have open-ended agreements:

(1) Nursing facilities, as defined in section 5111.20 of the Revised Code.

(2) Intermediate care facilities for the mentally retarded, as defined in section 5111.20 of the Revised Code.

(3) Providers that were enrolled prior to January 1, 2008 and have not been converted to a time-limited agreement in accordance with paragraph (C) of this rule.

(C) The following agreements shall be time-limited agreements or will be converted to time-limited agreements pursuant to section 5111.028 of the Revised Code:

(1) Any new provider agreement shall be time-limited in accordance with this rule with the exceptions listed in paragraphs (B)(1) and (B)(2) of this rule.

(2) Any existing open-ended provider agreement shall be converted to a time-limited agreement over a period of three years in accordance with this rule with the exceptions listed in paragraphs (B)(1) and (B)(2) of this rule.

(a) ODJFS shall select the provider agreements to be converted and automatically phase in time-limited agreements in a manner and for a time determined by ODJFS.

(b) ODJFS shall notify the provider by sending a conversion notice by regular mail to the address on file that the provider has been automatically converted to a time-limited-agreement in accordance with this rule. Providers are not required to respond to the ODJFS conversion notice.

(c) Providers that have been selected and converted to time-limited agreements may not request that the proposed expiration be altered, either to an earlier or later date.

(3) ODJFS may convert any existing open-ended provider agreement to a time-limited provider agreement whenever the conversion is in the best interest of the medicaid consumers or the state of Ohio.

(4) The conversion from an open-ended to a time-limited provider agreement does not affect the amount or scope of medicaid reimbursement.

(5) The length of time-limited agreements is decided by ODJFS and is determined by provider type. The length of time-limited agreements may vary by provider type but will be consistent for all providers within like provider types. ODJFS may change the length of time-limited agreements by provider type and the length of these agreements may change or vary upon the discretion of ODJFS.

(6) ODJFS will notify the provider when its time-limited provider agreement is close to expiration and when the re-enrollment process is required, as described in paragraph (D) of this rule.

(D) Re-enrollment is the process in which a provider with a time-limited agreement is required to follow to renew its provider agreement. The re-enrollment process does not apply to MCPs or open-ended agreements. The re-enrollment process is as follows:

(1) ODJFS shall send a re-enrollment notice by regular mail ninety days prior to the expiration date of the provider’s time-limited agreement to the provider’s address on file notifying the provider that it is required to renew its agreement.

(2) The re-enrollment notice shall instruct the provider what is required to complete the re-enrollment process. Providers are expected to meet all conditions for participation as an eligible provider that are in effect in division 5101:3 of the Administrative Code at the time of re-enrollment.

(3) The provider shall submit all required information before the re-enrollment deadline date specified in the re-enrollment notice.

(4) A provider shall not initiate re-enrollment prior to the receipt of the re-enrollment notification sent by ODJFS as specified in paragraph (D) of this rule. This rule does not negate the requirement that a provider must disclose any changes to its provider agreement in accordance with rule 5101:3-1-17.3 of the Administrative Code. The reporting of changes in accordance with rule 5101:3-1-17.3 of the Administrative Code does not constitute the initiation of re-enrollment and remains the provider’s responsibility.

(5) When a provider fails to re-enroll in the time and the manner required by ODJFS, as specified in this rule and in accordance with the re-enrollment notice referred to in paragraph (D)(2) of this rule, ODJFS may deny an application for re-enrollment or terminate a time-limited provider agreement. The denial or termination will take effect thirty days after ODJFS mails a written notice to the provider by regular mail to the address on file notifying the provider of the decision. ODJFS shall specify in the notice the date on which the provider is required to cease operating under a terminated provider agreement.

In lieu of denying an application for re-enrollment or terminating a time-limited agreement when a provider fails to re-enroll in the time and manner required and the agreement expires, ODJFS may deny claims submitted by the provider until the provider completes the re-enrollment process and the re-enrollment application is approved by ODJFS. Once the re-enrollment application is approved by ODJFS, ODJFS may allow the provider to re-submit any claims that were denied while its re-enrollment application pended ODJFS approval. ODJFS will not deny claims when a provider has re-enrolled in the time and the manner required by ODJFS.

(6) If a provider files an application for re-enrollment within the time and in the manner required, as specified in this rule, but the provider agreement expires before ODJFS acts on the application or before the effective date of the ODJFS decision on the application, the provider may continue operating under the terms of the expired agreement until the effective date of the ODJFS decision.

(7) If a provider files an application for re-enrollment in the time and manner required, as specified in this rule, but has not been able to obtain a renewal of its licensure, certification, accreditation, or registration due to a delay in processing by an official, board, commission, department, division, bureau or other agency of state or federal government:

(a) ODJFS shall not deny the application for re-enrollment or deny payment of services if the provider has included documentation with the re-enrollment application that the licensure, certification, accreditation, or registration has been delayed for processing by an official, board, commission, department, division, bureau or other agency of state or federal government; and

(b) When the decision is made by an official, board, commission, department, division, bureau or other agency of state or federal government to approve or reject an application for renewal of required licensure, certification, accreditation, or registration, the provider is obligated to notify ODJFS within thirty days in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(8) ODJFS may deny retroactive eligibility to a provider for failure to meet re-enrollment requirements as specified in this rule.

(E) The effective date of a new provider agreement is the date on which the provider signs the application and meets all of the federal and state requirements. The effective date of a new provider agreement may be made retroactive for up to twelve months prior to the date of application. A retroactive period will be counted when assigning a time-limit to a new provider agreement to encompass dates on which the provider furnished covered services to a medicaid consumer for which the provider has not been reimbursed. Upon ODJFS approval of the application and the effective date of the agreement, ODJFS will accept claims submitted timely for the retroactive period. Exceptions to the twelve month retroactive period include:

(1) When required licensure, certification, accreditation, or registration is obtained by the provider within the twelve months prior to the application date, the effective date will be that date on which the required license, certification, accreditation, or registration was obtained.

(2) Claims submitted within the twelve month retroactive period will be denied for any service provided if the provider did not meet all ODJFS program requirements for participation on the date the service was provided.

(F) Pursuant to section 5111.06 of the Revised Code, ODJFS is not required to issue a notice of hearing rights, in accordance with Chapter 119. of the Revised Code, when converting a provider agreement to a time-limited agreement or when terminating a time-limited provider agreement due to the provider’s failure to file an application for re-enrollment.

(G) To ensure program integrity ODJFS reserves the right to conduct pre-enrollment on-site reviews.

Replaces: 5101:3-1-17.4

Effective: 01/01/2008

R.C. 119.032 review dates: 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.028

Rule Amplifies: 5111.01, 5111.02, 5111.028

Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 1/1/95, 5/30/02, 8/11/05

(A) For purposes of this rule, the following definitions apply:

(1) “Non-agency provider” has the same meaning as independent provider, as defined in section 5111.034 of the Revised Code, and means an individual who is submitting an application for a provider agreement or who has an existing provider agreement as a non-agency provider in an Ohio department of job and family services (ODJFS) administered home and community based services program providing home and community based waiver services to consumers with disabilities.

(2) “Non-institutional provider” means any person or entity with a medicaid provider agreement other than a hospital, long-term care nursing facility, intermediate care facility for the mentally retarded, or medicaid contracting managed care plans (MCPs). MCPs are subject to rules in accordance with Chapter 5101:3-26 of the Administrative Code.

(3) “Owner” means any person having at least five percent ownership, or interest, either directly, indirectly, or in any combination in a non-institutional provider who must be disclosed in accordance with rule 5101:3-1-17.3 of the Administrative Code.

(B) ODJFS shall suspend the medicaid provider agreement held by the non-institutional provider, other than a non-agency provider, upon receiving notice and a copy of an indictment issued on or after October 1, 2007 that charges a medicaid provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense that would be a felony or misdemeanor under the laws of this state and the act relates to or results from either of the following:

(1) Prescribing, furnishing or billing for medical care, services, or supplies under the medicaid program; or

(2) Participating in the performance of management or administrative services relating to prescribing, billing, or furnishing medical care, services, or supplies under the medicaid program.

(C) ODJFS shall suspend the medicaid provider agreement of a non-institutional provider that is a non-agency provider upon receiving notice and a copy of an indictment issued on or after October 1, 2007 that charges a non-agency provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense specified in division (D) of section 5111.034 of the Revised Code.

(D) When subject to a suspension, a provider, its owner or owners, officer, authorized agent, associate, manager, or employee shall not own or provide services to any other medicaid provider or risk contractor or arrange for, render, or order services for medicaid recipients during the period of suspension. During the period of suspension, the provider, owner or owners, officer, authorized agent, associate, manager, or employee shall not receive reimbursement in the form of direct payments from ODJFS or indirect payments of medicaid funds in the form of a salary, shared fees, contracts, kick backs, or rebates or through any participating provider or risk contractor.

(E) The termination of medicaid reimbursement applies only to payments for medicaid services rendered subsequent to the date on which the notice required in paragraph (G) of this rule is sent. Claims for reimbursement for medicaid services rendered by the provider prior to the issuance of the notice may be subject to prepayment review in accordance with rule 5101:3-1-27 of the Administrative Code.

(F) The suspension shall continue in effect until the proceedings in the criminal case are completed through conviction, dismissal of the indictment, plea, or finding of not guilty. If ODJFS commences a process to terminate the suspended provider agreement, the suspension shall continue in effect until the termination process is concluded. Pursuant to section 5111.06 of the Revised Code, ODJFS is not required to take action under this provision by issuing an order pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code.

(G) ODJFS shall send notice of the suspension to the affected provider, owner or owners no later than five days after suspending a provider agreement in accordance with this rule. ODJFS shall send the notice by certified mail, return receipt requested. If such a notice is returned because the provider has failed to claim the notice or there is a failure of delivery for another reason, ODJFS shall send the notice by ordinary mail to the provider’s last known address and shall obtain a certificate of mailing. Service by certified mail is complete when the return receipt is obtained by ODJFS. Service by ordinary mail is complete when the certificate of mailing is obtained by ODJFS, unless the notice is returned showing failure of delivery. In providing the notice, ODJFS shall:

(1) Describe the indictment that was the cause of the suspension, without necessarily disclosing specific information concerning any ongoing civil or criminal investigation;

(2) State that the suspension of the provider agreement will continue in effect until the proceedings in the criminal case are completed through conviction, dismissal of the indictment, pleas, or finding of not guilty and, if ODJFS commences to terminate the suspended provider agreement, until the termination process is concluded; and

(3) Inform the provider, owner or owners of the opportunity to submit to ODJFS a request for a reconsideration in accordance with this rule no later than thirty days after receiving the certified notice from ODJFS.

(H) Claims paid prior to indictment or any claims paid while under indictment are subject to post payment review and recovery in accordance with rule 5101:3-1-27 of the Administrative Code.

(I) A provider, owner or owners subject to a suspension may request a reconsideration. A request for reconsideration is not subject to a hearing pursuant to Chapter 119. of the Revised Code. The request shall be made not later than thirty days after receipt of the notice provided in accordance with paragraph (G) of this rule. The notice will be deemed received by the provider on the date that the return receipt from certified mail is signed. If the provider has failed to claim the notice, the notice will be deemed received by the provider on the date that ODJFS receives a certificate of mailing. In requesting a reconsideration, the provider, owner or owners shall submit written information and documents to ODJFS. The information and documents may pertain to any of the following issues:

(1) Whether the determination to suspend the provider agreement was based on a mistake of fact, other than the validity of the indictment;

(2) Whether any offense charged in the indictment resulted from an offense specified in paragraphs (B) and (C) of this rule.

(3) Whether the provider, owner or owners can demonstrate that the provider, owner or owners did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee that resulted in the indictment.

(J) ODJFS shall not suspend a provider agreement or terminate medicaid reimbursement if the provider, owner or owners can demonstrate that the provider, owner or owners did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee that resulted in the indictment.

(1) If ODJFS has knowledge at the time of indictment that the alleged criminal activity is limited to the individual(s) indicted, and that the provider, owner or owners did not directly or indirectly sanction the action of the individual(s) indicted, ODJFS may use that knowledge in determining that the non-institutional provider will not be suspended.

(2) If ODJFS does not have sufficient knowledge at the time of indictment to determine whether the criminal activity is limited to the individual(s) indicted, ODJFS shall notify the provider, owner or owners of the opportunity to present documentation sufficient to establish that the criminal activity is limited to the individual(s) indicted and that the provider, owner or owners did not directly or indirectly sanction this activity.

(a) The provider, owner or owners shall submit such documentation to ODJFS within thirty days after receipt of the notice provided in accordance with paragraph (G) of this rule.

(b) ODJFS shall have discretion not to impose a suspension during the period specified in paragraph (J)(2)(a) of this rule. During this period, ODJFS may place the provider on prepayment review in accordance with rule 5101:3-1-27 of the Administrative Code.

(K) ODJFS shall review the information and documents submitted in the request for reconsideration. After the review, the suspension may be affirmed, reversed, or modified, in whole or in part. ODJFS shall notify the affected provider, owner or owners of the results of the review. The review and notification of its results shall be completed not later than forty-five days after receiving the information and documents submitted in a request for reconsideration. The review shall be conducted by the ODJFS deputy director in the office where the contestation arose. The deputy director may designate a third party to hear the reconsideration provided that the designee was not involved in the original decision. Decisions made by the deputy director of ODJFS are not appealable or subject to further reconsideration.

Effective: 01/01/2008

R.C. 119.032 review dates: 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.031

Rule Amplifies: 5111.01, 5111.02, 5111.031

(A) For purposes of this rule, the following definitions apply:

(1) “Owner” means any person who has at least five per cent ownership, or interest, either directly, indirectly, or in any combination, as a medicaid provider or person who must be disclosed in accordance with rule 5101:3-1-17.3 of the Administrative Code.

(2) “Provider” means any individual, group practice, other corporation, or health care institution as defined in rule 5101:3-1-17 of the Administrative Code or any rule contained in division 5101:3 of the Administrative Code.

(3) “Provider Agreement” means an agreement as defined in rule 5101:3-1-17.2 of the Administrative Code or any rule contained in division 5101:3 of the Administrative Code.

(B) A provider may voluntarily terminate a provider agreement upon notice thirty days before the termination date. The Ohio department of job and family services (ODJFS) may waive the thirty day requirement if appropriate.

(C) ODJFS may terminate a provider agreement upon thirty days written notice prior to the termination date. When the termination of a provider agreement is based upon a denial, suspension, revocation, limitation, or failure to renew any license, permit, certificate or certification, the provider is ineligible for reimbursement for services provided after the effective date of the denial, suspension, revocation, failure to renew or imposition of limitation imposed by an official, board, commission, department, division, bureau, or other agency of state of federal government.

(D) ODJFS may propose termination or denial of a provider agreement at any time it is determined that continuation or assumption of provider status is not in the best interest of consumers or the state of Ohio. The phrase “not in the best interest” shall include, but not be limited to, the following circumstances or occurrences:

(1) The provider has not billed or otherwise submitted a medicaid claim to ODJFS for two years or longer.

(2) The provider, or any person having an ownership or controlling interest in the provider, or who is an agent or employee of the provider, has been indicted or granted immunity from prosecution for, or has pled guilty to, or has been convicted of, any criminal offense against the state of Ohio or any other state or territory.

(3) The provider has made false representations, by omission or commission, on the provider enrollment application or does not fully and accurately disclose to ODJFS information as required by the provider agreement or any rule contained in division 5101:3 of the Administrative Code.

(4) The provider has been determined liable for negligent performance of professional services to its clientele or patients.

(5) As determined by ODJFS, the provider has departed from or failed to conform to accepted standards of care of similar practitioners under the same or similar circumstances, whether or not actual injury to a patient is established.

(6) The provider has been formally reprimanded or censured, placed on probation, suspended or placed on practice limitations for unethical conduct or improper practices by a state licensure board or by an association of its peers.

(7) The provider fails to file cost reports as required.

(8) The provider makes false statements, provides false information, or alters records, documents, charts, or prescriptions, or fails to cooperate or provide records or documentation upon request during an audit or review of provider activity by staff or contracting entity of ODJFS, any county department of job and family services, the attorney general’s office, the auditor of state, the department of health and human services, or any other state or federal agency which, by law, has authorized access to records or documents. An alteration of provider records does not include records for which there is a properly documented correction.

(9) The provider has not corrected deficiencies after receiving a written notice of operational deficiencies from ODJFS.

(10) The provider fails to abide by or have the capacity to comply with the terms and conditions of the provider agreement, and/or rules and regulations promulgated by ODJFS.

(11) The provider has been suspended or terminated from participation in another government medical program other than a program that requires automatic termination.

(12) The provider is found in violation of section 504 of the Rehabilitation Act of 1973, as amended, or the Civil Rights Act of 1964, as amended, in relation to the employment of individuals, the provision of services or in the purchase of goods and services.

(13) The provider, by any act or omission, has negatively affected the health, safety, or welfare of the medicaid consumers or the fiscal or programmatic integrity of the medicaid program.

(14) The office of the attorney general, auditor of state, or any board, bureau, commission, or department has recommended that ODJFS terminate the provider agreement where the reason for the request bears a reasonable relationship to the administration of the medicaid program, or the integrity of state and/or federal funds.

(15) As determined by ODJFS, the provider fails to use reasonable care or discretion in the storage, administration, dispensing, or prescribing of drugs, or fails to employ acceptable scientific methods in the selection of drugs or other modalities of treatment of disease.

(16) As determined by ODJFS, the provider sells, gives away, personally furnishes, prescribes, or administers drugs for other than legal and legitimate therapeutic purposes.

(17) The United States drug enforcement agency has suspended or revoked the provider’s registration for any act or acts which would constitute a violation of paragraph (D)(5), (D)(15), or (D)(16) of this rule.

(18) After ODJFS has provided written billing instructions, the provider or the provider’s staff misrepresents the type and/or units of service, inflates billing codes to increase payments, or bills for, or receives payments for services not rendered, or any other practice that is a violation of any rule contained in the division 5101:3 of the Administrative Code.

(19) As determined by ODJFS, the provider, or the provider’s staff prescribes, authorizes, bills for, or receives payments for, services that are not medically necessary as defined in rule 5101:3-1-01 of the Administrative Code.

(20) The provider or the provider’s staff lack the ability or legal authority to provide services for which the provider has billed, because of lack of equipment or material, or a failure to comply with minimal requirements under state and federal law.

(21) The provider consistently violates the prohibition against billing medicaid consumers or assigning provider claims to a factor, as found in rule 5101:3-1-13.1 or 5