(A) Provider claims, billing, payment and reimbursement are addressed in division 5101:3 of the Administrative Code.
(B) The medicaid maximum amount payable to non-institutional providers is specified in rule 5101:3-1-60 of the Administrative Code.
(1) When a non-physician practitioner provides and bills the department for a service, a physician may be reimbursed for any direct services provided (e.g., physical evaluation and approval of plan of treatment), but may not be reimbursed for the services provided by a licensed therapist or group therapy practice eligible to bill for these services directly.
(2) Providers must select and bill the appropriate code in accordance with code definitions. Codes that do not include time descriptions are considered a single service and cannot be billed for more than one unit of service per date of service.
(3) Evaluation services cannot be billed more than once per injury or condition.
(4) Re-evaluation services cannot be billed more than once per sixty day period of treatment for rehabilitative services or once per six-month period of treatment for developmental services.
(5) Skilled therapy cannot be billed for dates of service beyond twelve months of the initial evaluation or re-evaluation, per injury or condition.
(6) The services billed must correspond to the services listed in the documented plan of care and treatment, described in paragraph (C)(1)(c) of rule 5101:3-34-01.2 of the Administrative Code.
(C) The medicaid amount payable to hospital providers is specified in Chapter 5101:3-2 of the Administrative Code.
(D) Therapy services are not directly reimbursable for consumers residing in a nursing facility (NF) as defined in section 5111.20 of the Revised Code. Such services are the responsibility of the NF and are reimbursed to the NF through the facility per diem. The provisions in Chapter 5101:3-34 of the Administrative Code do not apply to therapy services supplied to the residents of nursing facilities.
R.C. 119.032 review dates: 08/13/2009 and 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021, 5111.029, 5111.262, 5111.20
Prior Effective Dates: 1/1/08, 7/31/09 (Emer)