5101:3-13-01.1 Fee-for-service ambulatory health care clinics (AHCCs): primary care clinics.

Requirements outlined in rule 5101:3-13-01 of the Administrative Code apply to all fee-for-service AHCCs.

(A) Definitions.

(1) "Primary care clinic" is an AHCC that provides primary care services in one location. This type of clinic may be administered by a number of different types of agencies/organizations, including community action agencies, or independent and un-affiliated local agencies/foundations.

(2) "Primary care" is health care rendered by licensed health care providers delivering services within their scope of practice, who are specifically trained for and skilled in comprehensive first contact and continuing care for persons with any sign, symptom, or health concern not limited by problem origin, organ system, or diagnosis. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses, appropriate medication management in a variety of health care settings and in coordination/collaboration with other health care professionals and systems (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.).

(3) "Primary care physician" is a generalist physician who provides definitive care to the undifferentiated patient at the point of first contact and takes continuing responsibility for providing the patient's care. Such a physician must be specifically trained to provide primary care services. Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient's medical and health care needs - not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.

(4) "Primary health care" is a method of health care delivery in which teams of providers are accountable for providing comprehensive services to their patients.

(B) Any organization applying to be a medicaid fee-for-service ambulatory health care primary care clinic provider on and after January 1, 2008 must:

(1) Meet the criteria for fee-for-service AHCC providers in accordance with paragraph (C) of rule 5101:3-13-01 of the Administrative Code;

(2) Meet the definition of a primary care clinic, in accordance with paragraph (A) of this rule; and

(3) Be certified or accredited by:

(a) The joint commission;

(b) The accreditation association for ambulatory health care (AAAHC);

(c) The healthcare facilities accreditation program of the American osteopathic association;

(d) The community health accreditation program (CHAP); or

(4) Receive state or federal grant funds for the provision of health services.

(C) A primary care clinic may provide all or some of the covered services identified in and provided in accordance with paragraph (D) of rule 5101:3-13-01 of the Administrative Code.

(1) If a primary care clinic does not provide a service, it must have a formal working arrangement with other medical providers for the services needed by the individual beyond the capability of the clinic.

(2) Primary care clinic services must be provided in accordance with the limitations identified in paragraph (E) of rule 5101:3-13-01 of the Administrative Code.

(D) Federally qualified health centers (FQHCs), rural health clinics (RHCs), and outpatient health facilities (OHFs) may submit claims as a primary care clinic only when billing for services that are not covered under the prospective payment system (PPS) base rate, in accordance with Chapters 5101:3-28, 5101:3-16, and 5101:3-29 of the Administrative Code. These services include:

(1) Inpatient hospital surgery;

(2) Inpatient hospital visits or consultations;

(3) Services provided to dual-eligibles when medicare cross-over claims for services are not paid through the automatic medicare crossover process in accordance with rule 5101:3-1-05 of the Administrative Code; and

(4) Services submitted as disability medical assistance claims.

Replaces: Part of 5101:3-13-01, Part of 5101:3-13-03

Effective: 01/01/2008
R.C. 119.032 review dates: 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 4/1/88