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Ohio Laws and Rules
(A) All claims submitted on paper media for medicaid reimbursement must be made on the appropriate claim form. A list of forms for specific services follows.
(1) The “CMS 1500 Form (rev. 8/2005)” is for:
(a) Ambulance and ambulette services;
(b) Ambulatory surgery facility services;
(c) Ambulatory clinic services, with the exception of free standing dialysis clinic services;
(d) Chiropractor services;
(e) Hospice services;
(f) Durable medical equipment (DME) and medical supply services;
(g) Optometry and optician services;
(h) Outpatient health facility services;
(i) Physical therapy services;
(j) Physician services;
(k) Podiatry services;
(l) Private duty nursing services;
(m) Independent psychology services;
(n) Rural health clinic services;
(o) Federally qualified health center services;
(p) Advanced practice nurse services;
(q) Waiver services;
(r) Home health services;
(s) Independent laboratory services;
(t) Independent x-ray laboratory services;
(u) Osteopathic physician services;
(v) Certified registered nurse anesthetist CRNA services;
(w) Anesthesiology assistant services; and
(x) Independent diagnostic testing facility services.
(2) Medicare crossover claims as defined in rule 5101:3-1-05 of the Administrative Code are billed on the JFS 06780 Medicaid Claim Form (rev. 10/2001)” for all services listed in paragraph (A) of this rule.
(3) The Ohio department of job and family services (ODJFS) does not process paper JFS 06780 claims on or after April 1, 2004 with the exception of medicare crossover claims.
(4) Dental services must be billed on the American dental association form (rev. 2006).
(5) Pharmacies must bill for services through the Ohio medicaid pharmacy point-of-sale program in accordance with the “ODJFS Point-of-Sale Pharmacy Provider Manual Policy and Procedure Guide (rev. 5/2007).”
(6) The UB-04 form (rev. 2004) is for hospitals, skilled nursing facilities when billing only for therapy services, free standing dialysis clinics, and institutional medicare crossover claims. The UB-04 form is maintained by the national uniform billing committee. Please note that all room and board medicare part A nursing facility coinsurance services must be billed separately using the 837I transaction in accordance with rule 5101:3-1-19.2 and Chapter 5101:3-3 of the Administrative Code.
(B) Paper claims with attachments must be submitted on standard size paper (eight and one-half by eleven inches). Attachments must be originals or legible copies. ODJFS will not accept paper claims or attachments that are folded. Claims that do not comply with these requirements will be returned. Claims requiring attachments cannot be submitted through electronic data interchange.
(C) Paper claims submitted to ODJFS must meet optical character recognition standards. Only upon approval by ODJFS will claims be accepted by facsimile.
(D) Providers may order a supply of the JFS 06780 online at http://www.odjfs.state.oh.us/forms/inter.asp or by completing the “JFS 09510 Forms Requisition (rev. 3/2006),” including their provider identifier on the order form and faxing the order blank to ODJFS. Providers are responsible for obtaining claim form supplies from appropriate vendors.
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: 6/1/78, 10/1/87, 7/1/02, 10/16/03 (Emer), 1/1/04, 4/1/05, 7/1/05