5101:3-12-07 Reimbursement: exceptions.

Home health and private duty nursing (PDN) service providers may be reimbursed when circumstances outside the provider's control result in any of the exceptions set forth in this rule. The provider shall maintain written documentation that includes the date, the time (if available), the content of the communication, the contact name, and the contact information (e.g., telephone number, fax number, email address, or mailing address).

(A) Requirements of paragraphs (D)(2) of rule 5101:3-12-01 and (C)(2) of rule 5101:3-12-02 of the Administrative Code do not have to be met if either paragraph (A)(1), (A)(2), or (A)(3) of this rule applies:

(1) Services are not identified on the all services plan when the consumer is enrolled in an ODJFS-administered waiver, and the provider has documented attempts to work with the case manager and the case manager's supervisors to identify the services on the all services plan. Documentation shall include written proof of the provider's attempts to obtain the all services plan that identifies the services. This exception does not extend to instances in which the provider disagrees with the amounts of service identified on the all services plan.

(2) Services are not documented on the services plan when the consumer is enrolled in an ODA- or ODMR/DD-administered waiver, and the provider has documented attempts to work with the case manager and the case manager's supervisors to identify the services on the services plan. Documentation shall include written proof of the provider's attempts to obtain the services plan that identifies the services. This exception does not extend to instances in which the provider disagrees with the amounts of service identified on the services plan.

(3) The provider verified and documented before providing services that either paragraph (A)(3)(a) or (A)(3)(b) of this rule applies.

(a) The consumer was not enrolled in a home and community-based services (HCBS) waiver at the initiation of services and every six months thereafter. And the case manager cannot produce documentation that the provider was notified that the consumer had become enrolled in an HCBS waiver.

(b) The consumer was not enrolled in an HBCS waiver and subsequently, at any point during, the delivery of services, the provider became aware of the consumer's enrollment and the provider notified the case manager and requested that the services be identified on the plan. And the case manager cannot produce documentation that the provider was notified that the consumer had become enrolled in an HCBS waiver.

(B) Requirements of paragraphs (F) of rule 5101:3-12-05 and (F) of rule 5101:3-12-06 of the Administrative Code do not have to be met if either paragraph (B)(1) or (B)(2) of this rule applies.

(1) The provider has written documentation from a facility/home (i.e., an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility) stating that the facility/home is not responsible for providing the same or similar home health or PDN services to the consumer.

(2) Home health and/or PDN services provided to the consumer enrolled in the assisted living HCBS waiver in accordance with rule 5101:3-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

Effective: 08/02/2007
R.C. 119.032 review dates: 08/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.85