5101:3-30-03 Billable services.

(A) All covered services are to be billed on a unit rate basis in accordance with definitions, standards, and eligible providers of service set forth in rule 5101:3-30-02 of the Administrative Code.

(B) For purposes of alcohol and drug addiction treatment services unless otherwise noted, a “billable unit of service” is defined as an hour-measured face-to-face contact between a client and a professional authorized to provide services delineated in rule 5101:3-30-02 of the Administrative Code as covered under the medicaid program. For an alcohol and drug addiction treatment service to be defined as a unit, it must meet the definition set forth in this paragraph and must be recorded in the individual client record(ICR). Case management services can be delivered face-to-face or by telephone and be a “billable unit of service.” Billable case management services may include face-to-face or telephone contact with persons other than the client; such services must be recorded in the clients ICR.

(1) Billable units of services are limited to those which take place at the site certified for participation in the alcohol and drug addiction treatment program or at a site deemed appropriate according to the standard referenced in rule 5101:3-30-02 of the Administrative Code as relative to the covered service.

(2) Units of service with individuals other than the client (e.g., conferences and consultations with a family member) are not billable. However, counseling and diagnostic assessment may include face-to-face interaction with family members and/or parent, guardian and significant other of a child or adolescent when the intended outcome is improved functioning of the child or adolescent and when such intervention is part of the individualized treatment plan. It is recognized also that case management services include contact with individuals other than the client and is billable as a unit of service.

(3) Covered services delineated in rule 5101:3-30-02 of the Administrative Code, with the exception of intensive outpatient services, are considered hour-measured billable services. Intensive outpatient services are considered day-measured billable services and drug screening/urinalysis services are considered a per screening billable unit for purposes of the alcohol and drug addiction treatment services program.

(4) The billable unit of service criterion is not met nor is coverage available under medicaid for costs involved when a provider participates in community meetings or group sessions which are not designed to provide alcohol and drug addiction treatment services to program users. Examples of such activities include orientation sessions for new clients, presentations to community groups (high school classes, PTA, etc.), and informal presentations about alcohol and drug addiction treatment programs.

(C) It is recognized that eligible providers may wish to augment staff delivered services through contractual arrangements. Such arrangements are recognized to the extent that the conditions set forth in paragraphs (C)(1) and (C)(2) of this rule are met. Services provided by contract may either be included as a cost item in determining the prospective rates or may be billed independently by the contract provider. If the contract provider bills independently, any such services will not be subject to prospective cost-related reimbursement, but will instead be reimbursed in accordance with methods established under 5101:3 of the Administrative Code other than the provisions set forth in Chapter 5101:3-30 of the Administrative Code (e.g., physician psychiatric services will be reimbursed under provisions set forth in Chapter 5101:3-4 of the Administrative Code). In order for contractual arrangements to be recognized, eligible providers must provide the following information to Ohio department of alcohol and drug addiction services at the point of entry into the program and any subsequent point when new contracts are negotiated or when existing contracts are revised:

(1) Identification by name and, where applicable, medicaid provider number of each individual practitioner providing services under contractual arrangements. Where the contract is let with a legal entity other than the individual practitioner, both the name of the legal entity and the name(s) of any individual practitioner(s) involved must be furnished.

(2) A written statement indicating, for each legal entity or individual practitioner, whether the contracted services are:

(a) To be included as a cost item and reimbursed under the applicable prospective rate for the type of service provided; or

(b) To be billed independently by the legal entity or individual practitioner under contract.

Eff 7-1-91 (Emer.); 9-30-91

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5111.02

Rule amplifies: RC 3793.06, 3793.11, 5111.01, 5111.02