5101:3-1-31 Prior authorization [except for services provided through medicaid contracting managed care plans (MCPs)].

(A) Reimbursement for some items and/or services covered under the medicaid program is available only upon obtaining prior authorization from the Ohio department of job and family services (ODJFS). Prior authorization must be obtained from ODJFS or its designee by the provider before the services are rendered or the items delivered,unless the services meet the provisions in paragraph (F) of this rule. .

(B) Services, supplies or prescription drugs that require prior authorization by the department are identified in Chapters 5101:3-2 to 5101:3-56 of the Administrative Code.

(C) All prior authorization requests must be submitted through the medicaid information technology system (MITS) web portal. Paper prior authorization requests will be returned to the provider unprocessed.

(D) When the prior authorization request has been processed by ODJFS or its designee, the provider will receive notification indicating the decision for each service, supply or prescription drug. Only those services, supplies or prescription drugs approved in the prior authorization notice will be reimbursed.

(E) When a request for prior authorization has been approved, the notification will include a prior authorization (PA) number. In order for the provider to be reimbursed, the provider must use the assigned PA number when submitting the claim for payment.

(F) In situations where the provider considers a delay in providing services, supplies or prescription drugs requiring prior authorization to be detrimental to the health of the consumer, the services, supplies or prescription drugs may be rendered or delivered and approval for reimbursement sought after the fact.

(G) When a request for prior authorization is denied, ODJFS or its designee will issue a notice of medical determination and a right to a state hearing to the consumer. A copy of this denial notice will be sent to the county department of job and family services to be filed in the consumer's case record. Providers will also be notified of the denial.

Effective: 08/02/2011
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 7/1/91 (Emer), 9/30/91, 5/30/02, 8/11/05