5101:3-41-22 Transitions developmental disabilities - payment standards.

(A) Definitions of terms used for billing and calculating rates.

(1) "Base rate," as used in appendix A to this rule, means the amount paid for up to the first four units of service delivered.

(2) "Billing unit," as used in appendix A to this rule, means a single fixed item, amount of time or measurement (e.g., a meal, a day, or mile, etc.).

(3) "Group rate," as used in paragraph (D)(1) of this rule, means the amount that waiver nursing and personal care aide service providers are reimbursed when the service is provided in a group setting.

(4) "Group setting" means a situation where a waiver nursing and/or personal care aide service provider furnishes the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of waiver service, or a combination of waiver services.

(5) "Medicaid maximum rate" means the maximum amount that will be paid by medicaid for the service rendered.

(a) The medicaid maximum rate is set forth in appendix A to this rule.

(b) For the billing codes in appendix A to this rule, the medicaid maximum rate is:

(i) The base rate as defined in paragraph (A)(1) of this rule, or

(ii) The base rate as defined in paragraph (A)(1) of this rule plus the unit rate as defined in paragraph (A)(7) of this rule for each additional unit of service delivered.

(iii) The base rate as defined in paragraph (A)(1) of this rule plus the unit rate as defined in paragraph (A)(7) of this rule for each additional unit of service delivered.

(6) "Modifier," as used in paragraph (E) of this rule, means the additional two-alpha-numeric-digit billing codes that providers are required to use to provide additional information regarding service delivery.

(7) "Unit rate," as used in appendix A to this rule, means the amount paid for each fifteen minute unit following the base rate paid for the first four units of service provided.

(B) In order for a provider to submit a claim for transitions developmental disabilities waiver services, the services must be provided in accordance with Chapter 5123:2-9 of the Administrative Code.

(C) The amount of reimbursement for a service shall be the lesser of the provider's billed charge or the medicaid maximum rate.

(D) Required modifiers.

(1) The "HQ" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 if the service was delivered in a group setting. Reimbursement at a group rate shall be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum.

(2) The "U" modifier must be used when a provider submits a claim for billing code T1002 and the consumer is receiving infusion therapy.

(3) The "U2" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for a second visit to a consumer for the same date of service.

(4) The "U3" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for three or more visits to a consumer for the same date of service.

(5) The "U4" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(E) Claims shall be submitted to, and reimbursement shall be provided by, the office of medical assistance (OMA).

(F) Monitoring.

The OMA shall monitor reimbursement made under authority of this rule as necessary to ensure that the funding applicable to home and community-based services (HCBS) is used for authorized purposes in compliance with laws, regulations and provisions governing the medicaid program.

(G) OMA authority.

The OMA retains the final authority to establish payment rates for waiver services approved under the transitions developmental disabilities waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Replaces: 5101:3-47-06

Click to view Appendix

Effective: 01/01/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0213 , 5111.85
Rule Amplifies: 5111.02 , 5111.021 , 5111.213, 5111.85 , 5111.871
Prior Effective Dates: 11/1/04, 7/1/06, 7/1/08, 1/1/10, 4/1/11, 10/01/2011