(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.
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