5101:3-4-01 Eligible providers of physician services.

(A) Definitions.

(1) “Physician” means an individual currently licensed under state of Ohio law or under another state’s law to practice medicine and surgery or osteopathic medicine and surgery. Interns and residents are explicitly excluded from the definition of “physician” and are covered as a part of hospital services. This exclusion applies whether or not the intern or resident may be authorized to practice as a physician under the laws of the state in which he or she performs services. Residents having a staff or faculty appointment or designated as a “fellow” are also excluded from the definition of physician.

(2) Providers of physician services may form or enter into a professional medical group with the provisions set forth in rule 5101:3-1-17 of the Administrative Code. The professional medical group may bill for physician services performed by the physicians who are a part of the medical group practice.

(3) “Provider-based physician” means any physician who is under the fiscal, administrative, and professional control of a hospital, a fee-for-service clinic, a cost-based clinic, a long term care facility, or other medicaid participating provider through an employment, a contractual, or other legally binding arrangement to provide hospital (or provider) services in addition to the professional services he or she provides directly to, or for the benefit of, individual hospital (provider) patients.

(B) Physicians as defined in paragraphs (A)(1) and (A)(2) of this rule are eligible to participate in Ohio’s medicaid program and provide covered physician services upon execution of the standard Ohio medicaid provider agreement.

(C) Physicians licensed under another state’s law to practice medicine and surgery or osteopathic medicine and surgery are eligible to participate in Ohio’s medicaid program and provide covered physician services as long as:

(1) The services are rendered to eligible Ohio recipients in the state in which the provider is licensed to practice; and

(2) The provider of physician services has a currently valid provider agreement with the department.

(D) Eligible providers of physician services also include the following Ohio medicaid providers:

(1) Ambulatory health care centers (clinics) as defined in Chapter 5101:3-13 of the Administrative Code;

(2) Rural health clinics (RHC) as defined in Chapter 5101:3-16 of the Administrative Code;

(3) Outpatient health facilities (OHF) as defined in Chapter 5101:3-29 of the Administrative Code; and

(4) Federally qualified health centers (FQHC) as defined in Chapter 5101:3-28 of the Administrative Code.

(E) Provider-based physician.

(1) A provider-based physician may be reimbursed for services rendered directly to, or for the benefit of, individual patients, if the following requirements are met:

(a) The services are personally furnished for an individual patient by a physician who is enrolled as an Ohio medicaid provider;

(b) The services contribute directly to the diagnosis or treatment of an individual patient;

(d) In the case of anesthesiology, laboratory, or radiology services, the additional requirements in rules 5101:3-4-21 and 5101:3-4-25 of the Administrative Code; and

(e) The portion of the expenses associated with the provision of the service are excluded from the hospital or provider-based cost report.

(2) Services provided by a provider-based physician including teaching; research; administration; supervision of professional or technical personnel; supervision of residents, interns, or fellows; service on provider committees; and other provider-based activities that are of benefit to patients generally are reimbursable only as a hospital (provider) service to the hospital (provider). Payments for these services provided at hospitals are bundled into the hospital inpatient or outpatient facility payment in accordance with Chapter 5101:3-2 of the Administrative Code. Payments for services provided at another provider-based practice are included in the payment made to the employing or contacting provider.

(3) Services provided by provider-based physicians are reimbursable only to the employing or contracting provider.

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, 5111.021

Prior Effective Dates: 4/7/77, 10/1/83 (Emer), 12/29/83, 9/1/89, 3/26/01, 9/1/05, 10/25/08