5101:3-1-23 Assignment of provider claims.

Payment for medicaid covered services rendered to medicaid consumers may be made only to a medicaid provider except as provided in this rule. (A) Payment for medicaid covered services may be made in accordance with paragraphs (A)(1) to (A)(3) of this rule:

(1) Payment may be made to or through a billing agency or accounting firm that prepares invoices or receives payments in the name of the medicaid provider if the compensation meets the following requirements:

(a) It is related to the cost of processing the billing;

(b) It is not related on a percentage or other basis to the amount that is billed or collected; and

(c) It is not dependent upon the collection of the payment.

(2) For individual practitioners, payment may be made as follows:

(a) To the employer of the practitioner, if the practitioner requires as a condition of employment to turn over his or her fees to the employer;

(b) To the facility in which the service is provided, if the practitioner has a contract under which the facility submits the claim; or

(c) To a foundation, plan, or similar organization operating an organized health care delivery system, such as a managed care organization, if the practitioner has a contract under which the organization submits the claim.

(3) Payment may be made by reassignment from the medicaid provider to a government agency or reassignment by a court order.

(B) Medicaid providers are responsible for any payment received under their provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code. The assignment of provider claims must be in accordance with services rendered by valid providers under Chapter 5101:3-1 of the Administrative Code. Medicaid providers that receive payment for any assignment of provider claims that is false or misleading may be prosecuted under federal and state law.

(C) Payment for any covered service rendered to a medicaid consumer may not be made to or through a factor. A "factor" is defined as an individual or an organization such as a collection agency or service bureau that advances money to a provider for accounts receivable that have been assigned, sold, or otherwise transferred to such an organization or an individual for an added fee or a deduction of a portion of such accounts receivable.

Replaces: 5101:3-1-23

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 6/3/83, 2/1/84, 10/1/84, 7/1/85 (Emer), 9/30/85, 10/1/87, 5/30/02