LAW
Writer®
Ohio Laws and Rules
(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