5101:3-11-08 Reimbursement for laboratory, portable x-ray supplier, and independent diagnostic testing facilities.

(A) Payment for services is the provider's billed charges or the medicaid maximum payment schedule (sometimes referred to as the medicaid maximum or the fee schedule) as specified in this rule, whichever is lower.

(B) Medicaid maximum for laboratory services.

(1) For a laboratory service that is payable under the medicare laboratory fee schedule, the medicaid payment for the service shall not exceed the medicare carrier's laboratory fee schedule for that service.

(2) The maximum amount payable for clinical laboratory procedures is specified in appendix DD of rule 5101:3-1-60 of the Administrative Code.

(3) The maximum amount payable for the total procedure of an anatomical pathology procedure is specified in rule 5101:3-1-60 of the Administrative Code.

(4) The maximum amount payable for the professional component of anatomical pathology procedures is specified by the corresponding professional/technical indicator in appendix DD of rule 5101:3-1-60 of the Administrative Code.

(5) The maximum amount payable for the technical component of anatomical pathology procedures is specified by the corresponding professional/technical indicator in appendix DD of rule 5101:3-1-60 of the Administrative Code.

(C) Medicaid maximum for radiology services.

(1) The maximum amount payable for the total procedure for a radiology service is specified in rule 5101:3-4-25 of the Administrative Code.

(2) The maximum amount payable for the professional component of a radiology service is specified of rule 5101:3-4-25 of the Administrative Code.

(3) The maximum amount payable for the technical component of a radiology service is specified in rule 5101:3-4-25 of the Administrative Code.

(D) Medicaid maximum for other independent diagnostic testing facilities.

For independent diagnostic testing facilities services not included in those services referred to in paragraph (C) of this rule:

(1) The maximum amount payable for those procedures for which the department recognizes professional and technical components is specified in rule 5101:3-4-11 of the Administrative Code.

(2) The maximum amount payable for all other procedures is specified in appendix DD of rule 5101:3-1-60 of the Administrative Code.

(E) Laboratory, radiology, and diagnostic and therapeutic services provided to hospital inpatients.

(1) The following services furnished to hospital inpatients are covered under the medicaid program as inpatient hospital services and are reimbursed in accordance with provisions governing payment for inpatient services as set forth in Chapter 5101:3-2 of the Administrative Code:

(a) Clinical laboratory services;

(b) The technical component of anatomical pathology procedures; and

(c) The technical component of radiology, and diagnostic and therapeutic services.

(2) The department will deny separate charges made by providers, or will recoup separate payments made to providers, for services specified in paragraph (E) of this rule which were rendered for hospital inpatients.

Eff 10-1-84; 10-1-84 (Emer.); 12-30-84; 5-9-86; 2-17-91; 2-1-96 (Emer.); 4-4-96; 8-1-01; 4-1-04
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01 , 5111.02
RC 119.032 review dates: 4/6/01, 4/6/06, 1/16/04, 4/1/09