5101:3-1-19.2 Medicaid claim formats for the submission of claims via electronic data interchange (EDI) [except for services provided through a medicaid managed care program].

(A) Providers submitting claims electronically in compliance with EDI standards established under the Health Insurance Portability and Accountability Act of 1996 will use the 837 electronic transaction sets as follows:

(1) When billing ODJFS in an EDI format, the following services must be submitted in the “837 Health Care Claim Professional (837P)” electronic format:

(a) Physician services provided by individual physician practices, physician group practices, hospice organizations, and ambulatory surgery centers;

(b) Hospice services;

(c) Ambulatory surgery center facility services;

(d) Ambulatory clinic services provided by fee-for-service clinics, federally qualified health centers, rural health clinics, and outpatient health facilities with the exception of free standing dialysis clinic services;

(e) Home health services;

(f) Waiver services;

(g) Private duty nursing services;

(h) Podiatry services;

(i) Diagnostic facility services;

(j) Ambulance services;

(k) Ambulette services;

(l) Chiropractic services;

(m) Durable medical equipment services;

(n) Medical supply services;

(o) Vision, optometric, optician and eyewear services;

(p) Medicare crossover claims for professional services;

(q) Independent psychology services;

(r) Independent physical therapy services;

(s) Independent laboratory services;

(t) Independent portable x-ray facility services;

(u) Advanced practice nurse services;

(v) Anesthesiology assistant services; and

(w) Certified registered nurse anesthetist (CRNA) services.

(2) When billing ODJFS in an EDI format, the following services must be submitted in the “837 Health Care Claim Institutional (8371)” electronic format:

(a) Inpatient and outpatient hospital services;

(b) Inpatient and outpatient hospital medicare crossover claims;

(c) Nursing facility therapy services;

(d) Nursing facility medicare crossover claims;

(e) Nursing facility services in accordance with Chapter 5101:3-3 of the Administrative Code; and

(f) Free standing dialysis clinic services.

(3) When billing ODJFS in an EDI format dental services must be submitted in the “837 Health Care Claim Dental (837D)” electronic format.

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: 10/16/03 (Emer), 1/1/04, 4/1/05