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Ohio Laws and Rules
(A) All medicaid claims must be submitted in one of the following billing methods: cartridge tape, electronic data interchange (EDI), paper claim form, or pharmacy point-of-sale. Claims that require attachments for processing must be submitted hard copy on the appropriate paper claim form for the service rendered.
(B) All submitted claims must meet the following criteria:
(1) The claim must meet the requirements for that type of billing claim form as set forth in this rule and in rules 5101:3-1-19.1 and 5101:3-1-19.2 of the Administrative Code.
(2) The claim must meet the requirements for cartridge tape, electronic data interchange (EDI), paper claim form, or pharmacy point-of-sale.
(3) The dates of service on the claim or date of discharge for inpatient hospital services must not be more than three hundred sixty-five days from the date the claim is received by the department (i.e., the date the transaction control number (TCN) is issued) unless provisions of paragraphs (E) and (F) of this rule apply.
(C) Claims that do not meet the department’s standards of a clean claim shall not be subject to the prompt payment provisions of rule 5101:3-1-19.7 of the Administrative Code, but may be processed by the department. Claims that cannot be processed solely through automated claims processing systems, are not completed fully or properly, require aid of manual intervention by the department, or do not indicate collection of a third-party resource are not considered clean claims and may be denied by the department. When a claim is denied the department will notify the provider on the remittance advice. Omission of the provider number, improper placement of the provider number, or an invalid provider number will result in the deletion of the claim without notice to the provider.
(D) Claims submitted to the department must include the appropriate procedure and/or service code in accordance with the coding system adopted by the department. The department requires that providers use the health care financing administration’s common procedure coding system (HCPCS) to indicate the procedure and service rendered on professional, dental, and certain institutional claims. HCPCS, as used in this rule and in all rules in division 5101:3 of the Administrative Code, is defined in the “HCPCS 2009” guide published by the American medical association effective January 1, 2009 for dates of service January 1, 2009 through December 31, 2009 and the “HCPCS 2008” guide published by the American medical association effective January 1, 2008 for dates of service January 1, 2008 through December 31, 2008. The HCPCS coding system consists of three levels of coding.
(1) Level I is the “Current Procedural Terminology (CPT).” CPT, as used in this rule and in all rules in division 5101:3 of the Administrative Code, is defined in the “CPT 2009” guide published by the American medical association effective January 1, 2009 for dates of service January 1, 2009 through December 31, 2009 and the “CPT 2008” guide published by the American medical association effective January 1, 2008 for dates of service January 1, 2008 through December 31, 2008. The codes are five-digit codes.
(2) Level II consists of five-digit codes that consist of one alphabetic character followed by four numeric digits.
(3) Level III consists of local level codes assigned by health insurance payers including medicare and medicaid and begin with one alphabetic code followed by four numeric digits. Local level codes assigned by Ohio medicaid will be eliminated by January 1, 2004.
(E) Claims must be received by the department within three hundred sixty-five days of the actual date the service was provided, unless the provisions in paragraph (E)(1) or (E)(2) of this rule apply. In the case of inpatient services for hospital providers, initial claims must be received within three hundred sixty-five days from the date of discharge. Initial claims received beyond the three hundred sixty-five day time limit shall not be processed for payment by the department. The “date of receipt,” for purposes of this rule, is the date the department receives a claim and assigns a transaction control number (TCN).
(1) When the claim submittal is delayed due to the pendency of either an administrative hearing decision by the department or an eligibility determination by a county department of human services (CDJFS), payment will be made if the claim is received within one hundred eighty days of the date of the administrative decision by the department or eligibility determination by the CDJFS. Claims must be submitted under this provision with documentation from the CDJFS or the district office that verifies the date of service and the date of the hearing decision or eligibility determination, whichever applies. In no case shall a delay in processing eligibility information at the county level (as required in rule 5101:1-38-02 of the Administrative Code) be a basis for denial of payment under this provision.
(2) When the claim cannot be submitted within three hundred sixty- five days due to the coordination of benefits with medicare and/or other third-party payers, pursuant to rule 5101:3-1-08 of the Administrative Code, payment will be made if the claim is received within one hundred eighty days of medicare’s and/or other third-party payers’ adjudication.
(F) Providers may resubmit claims that have been denied. Resubmitted claims without attachments may be submitted electronically to the department if they are received by the department within three hundred sixty-five days of the actual date the service was provided. Providers resubmitting claims for reconsideration must meet the following provisions:
(1) The original claim was submitted within three hundred sixty-five days of the actual date the service was provided unless the provisions in paragraph (E)(1) or (E)(2) of this rule apply.
(2) The resubmission must be within three hundred sixty-five days from the actual date of service or within one hundred eighty days from the date the claim was denied. The department will not process a resubmitted claim if the claim is received more than seven hundred thirty days after the date of service or discharge except as set forth in paragraph (E)(1) or (E)(2) of this rule.
(3) The resubmitted claim must be in accordance with the specifications defined in paragraphs (B)(1) to (B)(3) of this rule.
(G) Resubmitted claims are not eligible for interest provisions as defined in rule 5101:3-1-19.7 of the Administrative Code.
Effective: 03/31/2009
R.C. 119.032 review dates: 03/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 6/3/83, 2/1/84, 10/1/84, 7/1/85 (Emer), 9/30/85, 10/1/87, 5/1/89, 7/1/90, 7/1/02, 7/1/03, 10/16/03 (Emer), 1/1/04, 12/30/04 (Emer), 3/28/05, 12/30/05 (Emer), 3/27/06, 12/29/06 (Emer), 3/29/07, 12/31/07 (Emer), 3/30/08, 12/31/08 (Emer)