5101:3-1-17 Eligible providers.

This rule sets forth the eligibility requirements for medicaid providers. Provider eligibility requirements for medicaid managed care plans can be found in Chapter 5101:3-26 of the Administrative Code.

(A) "Eligible provider" means any individual, group practice, corporation, organization, 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;

(3) Has met the provider screening requirements and paid the associated application fee in accordance with rule 5101:3-1-17.8 of the Administrative Code; and

(4) 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 provider 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.

(1) A 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. ODJFS recognizes two kinds of professional group practices, a professional medical group and a professional dental group.

(a) A professional medical group is a group that consists of individual practitioners recognized by ODJFS as eligible members. The types of individual practitioners recognized by ODJFS as eligible members include: advanced practice nurses, optometrists, opticians, chiropractors, occupational therapists, physical therapists, physicians, osteopaths, anesthesia assistants, podiatrists, and psychologists. The practice must consist of two or more members, of like or different licensure, or only an incorporated individual organized in accordance with paragraph (C)(3)(b) of this rule. Dentists may not enroll as a member of a professional medical group.

(b) A professional dental group is a group that consists only of dentists. The practice must consist of two or more dentists, or only an incorporated individual dentist organized in accordance with paragraph (C)(3)(b) of this rule.

(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 paragraphs (D)(1)(b) and (D)(1)(c) of this rule, a typical provider enrolling with ODJFS 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.

(c) A provider of intermediate care facility for the mentally retarded (ICF-MR) services is not 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 does not provide health care services and does not obtain a NPI will be issued a Ohio medicaid legacy number to be submitted on claims for payment.

(c) 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.

(b) 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.

(c) 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.

(G) ODJFS does not enroll providers outside of the United States and its territories.

Effective: 03/31/2012
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.029 , 5111.063
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, 5/23/07, 1/1/08, 8/2/11