Chapter 5160-1 General Provisions

5160-1-01 Medicaid: medical necessity.

(A) "Medical necessity" is a fundamental concept underlying the medicaid program. Physicians, dentists, and limited practitioners render, authorize, or prescribe medical services within the scope of their licensure and based on their professional judgment regarding medical services needed by an individual. Unless a more specific definition regarding medical necessity for a particular category of service is included within division-level 5101:3 of the Administrative Code, "medically necessary services" are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. A medically necessary service must:

(1) Meet generally accepted standards of medical practice;

(2) Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;

(3) Be appropriate to the intensity of service and level of setting;

(4) Provide unique, essential, and appropriate information when used for diagnostic purposes;

(5) Be the lowest cost alternative that effectively addresses and treats the medical problem; and

(6) Meet general principles regarding reimbursement for medicaid covered services found in rule 5101:3-1-02 of the Administrative Code.

(B) Preventive health care, though not customarily thought of as a "medically necessary" service, is available through the department's early periodic screening, diagnosis and treatment (EPSDT, also known as healthchek) program or through managed care plans (MCPs) that have contracted with the department.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/24/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 12/30/77, 7/1/80, 2/19/82, 10/1/84, 10/1/87, 6/1/91, 5/30/02

5160-1-02 General reimbursement principles.

This rule describes general principles regarding reimbursement of services by medicaid. Reimbursement may be subject to additional administrative criteria as described in division 5101:3 of the Administrative Code.

(A) A medical service is reimbursable if:

(1) The service is determined medically necessary as defined in rule 5101:3-1-01 of the Administrative Code.

(2) The request for the service is originated by the consumer or the consumer's authorized representative.

(3) The service is rendered to an eligible medicaid consumer as defined in division 5101:1 of the Administrative Code.

(4) The service is provided within the limits of the consumer's medicaid or medicaid managed care plan benefit package.

(5) The service is provided within the scope of practice of the rendering provider as defined by applicable federal, state, and local laws and regulations.

(6) The service is rendered by a provider assigned to or selected by the consumer or consumer's authorized representative, with the exception of consumers enrolled in the coordinated services program as defined in Chapter 5101:3-20 of the Administrative Code.

(7) The service is rendered by an eligible provider or panel provider for managed care plan participating provider.

(B) A medical service is not reimbursable if:

(1) The service is charged to medicaid at a rate greater than the provider's usual and customary charge to other patients.

(a) Inpatient hospital services billed by hospitals reimbursed on a prospective payment basis, as defined in Chapter 5101:3-2 of the Administrative Code, will not pay, in the aggregate, more than the provider's customary and prevailing charges for comparable services.

(b) Chapter 5101:3-3 of the Administrative Code defines these provisions as they apply to providers of long-term care services.

(2) The service is free to the public, except when medicaid reimbursement for such services is prescribed by federal law.

(3) The service is a provider-preventable condition as defined in 42 CFR 447.26 . The prohibition on provider-preventable conditions shall not result in a loss of access to care or services for medicaid consumers.

(C) As required by the centers for medicare and medicaid services (CMS), habilitation services (as defined in 42. U.S.C. 1396n (c) (5)) are covered under medicaid only when:

(1) They are a part of services provided in an intermediate care facility for persons with mental retardation (ICF/MR), or

(2) They are included under a federally approved home and community-based services (HCBS) waiver, and are medically necessary services identified in an enrollee's particular HCBS waiver. Special education and related services that otherwise are available to the individual through a local educational agency and vocational rehabilitation services that otherwise are available to the individual through a program funded under 29 U.S.C. 730 are not reimbursable through federally approved waivers.

(D) Additional reimbursement principles applicable to services delivered through medicaid managed care plans are described in Chapter 5101:3-26 of the Administrative Code.

Replaces: 5101:3-1-02

Effective: 08/02/2011
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 12/30/77, 7/1/80, 2/19/82, 10/1/84, 10/1/87, 6/1/91, 5/30/02, 7/1/06

5160-1-03 Medicaid: relationship to the children with medical handicaps program under Title V of the Social Security Act.

(A) For persons eligible under both medicaid, administered by the Ohio department of medicaid (ODM), and the children with medical handicaps (CMH) program, administered by the Ohio department of health (ODH), medicaid is the first payer of health care claims (unless a consumer has third party insurance and/or is a medicare beneficiary, then rules 5160-1-05 and 5160-1-08 of the Administrative Code regarding coordination of benefits with a primary payer apply) and its payment constitutes payment in full.

(B) As long as eligibility has been established under the CMH program and services were authorized by the CMH, medicaid providers shall submit all claims for services to persons eligible under both medicaid and the CMH program first to ODM for adjudication under the medicaid program (unless there is a primary payer as described in paragraph (A) of this rule). .

Effective: 11/02/2014
Five Year Review (FYR) Dates: 08/05/2014 and 11/02/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 3/5/82, 10/1/87, 7/7/02, 09/01/2007

5160-1-05 Medicaid coordination of benefits with the medicare program (Title XVIII).

Paragraphs (A)(7) to (F)(4) of this rule do not apply to pharmacy services covered under the medicare part D program. Pharmacy services covered under the medicare part D program should be billed in accordance with rule 5101:3-9-06 of the Administrative Code.

(A) Definitions.

(1) "Medicare" is a federally financed program of hospital insurance (part A) and supplemental medical insurance (also called SMI and/or part B) for aged and disabled persons.

(2) "Medicare Benefits" means the health care services available to the consumer through the medicare program where payment for the services are either completely the obligation of the medicare program or in part the obligation of the medicare program with the remaining payment (cost sharing) obligations belonging to the consumer, some other third party payer and/or medicaid.

(3) "Original Medicare (also known as traditional medicare)" is a health plan that pays for medicare benefits provided to beneficiaries on a fee-for-service basis.

(4) "Medicare Advantage Plan (also known as medicare part C plan)" is a managed care delivery system that includes coverage for both hospital insurance and SMI, but the delivery of health care services are contracted to and provided by an approved medicare managed care plan, preferred provider organization, private fee-for-service plans or medicare specialty plans.

(5) "Medicare Cost Sharing" means the portion of a medicare crossover claim paid by medicaid.

(6) "Dual Eligibles or Dually Eligible Consumers" are individuals who are entitled to medicare hospital insurance and/or SMI and are eligible for medicaid to pay some form of medicare cost sharing. The following is a list of dual eligibles that qualify to have medicaid pay all or part of the cost sharing portion of a paid medicare claim:

(a) "Qualified Medicare Beneficiaries without Other Medicaid (QMB Only)" are individuals entitled to medicare hospital insurance, have income of one hundred per cent of the federal poverty level (FPL) or less and resources that do not exceed twice the limit for supplemental security income (SSI) eligibility, and are not otherwise eligible for full medicaid benefits.

(b) "QMBs with Full Medicaid (QMB Plus)" are individuals entitled to medicare hospital insurance, have incomes of one hundred per cent FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full medicaid benefits.

(c) "Specified Low-Income Medicare Beneficiaries with Full Medicaid (SLMB Plus)" are individuals entitled to medicare hospital insurance, have income of greater than one hundred per cent FPL, but less than one hundred twenty per cent FPL and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full medicaid benefits.

(d) "Medicaid Only Dual Eligibles (for example Non QMB)" are individuals entitled to medicare hospital insurance and/or SMI and are eligible for full medicaid benefits. They are not eligible for medicaid in any of the other dual eligible categories (for example QMB). Typically, these individuals need to spend down to qualify for medicaid or fall into a medicaid eligibility poverty group that exceeds the limits of other dual eligible categories.

(7) "Medicare Crossover Claim" means any claim that has been submitted to the Ohio department of job and family services (ODJFS) for medicare cost sharing payments after the claim has been adjudicated and paid by the medicare central processor, medicare carrier/intermediary or the medicare managed care plan and the medicare central processor or medicare carrier/intermediary has determined the deductible, coinsurance and/or co-payment amounts. Claims denied by the medicare carrier/intermediary or the medicare managed care plan are not considered medicare crossover claims. See paragraphs (E) and (F) of this rule for policy on services denied or not covered by medicare.

(a) "Automatic Crossover Claim" is a medicare claim submitted to ODJFS via the automatic medicare crossover process described in paragraph (B) (2)(a) of this rule.

(b) "Provider-Submitted Crossover Claim" means a medicare crossover claim submitted to ODJFS as described in paragraph (B) (2)(b) of this rule.

(B) Medicare crossover process.

(1) ODJFS will no longer accept the JFS 06780 "Medicaid Claim Billing" form (rev. 10/2001) for processing and payment of medicare crossover claims. Medicare crossover claims must meet the claim submission guidelines in accordance with rule 5101:3-1-19 of the Administrative Code.

(2) The medicare program determines the portion of medicare cost sharing, if any, due to the provider based on medicare's business rules and submits the claim for payment to ODJFS using the automatic medicare crossover process.

(a) The "Automatic Medicare Crossover Process" is the coordination of benefit (COB) process whereby the provider bills medicare for services provided to the patient who meets the criteria described in paragraphs (A)(6)(a) to (A)(6)(d) of this rule or is a dual eligible described in paragraph (A)(6) of this rule. Medicare adjudicates the claim, pays the provider and electronically submits the claim to ODJFS for the medicare cost sharing amounts. Then, the provider is paid by medicaid within ninety days from the date of payment by medicare.

(b) When the automatic medicare crossover process does not work (i.e., the provider has received payment by medicare, has not received a payment from medicaid for the medicare cost sharing portion and at least ninety days has elapsed from the date of the receipt of the medicare payment), the provider may submit a medicare crossover claim directly to ODJFS. This is considered the "Provider-Submitted Crossover Claim Process."

(3) For a provider to receive reimbursement through the automatic medicare crossover process, all of the following criteria must be met:

(a) The provider must be recognized as both a medicare and medicaid provider;

(b) The provider must accept medicare assignment; and

(c) The consumer must be receiving health care benefits under the original medicare part A and part B program (i.e., the consumer is not enrolled in a medicare managed care plan). At this time ODJFS does not have payer-to-payer COB arrangements with medicare managed care plans.

(4) For medicare crossover claims, the total sum of the payments made by ODJFS, medicare and/or all other third party payers is considered payment in full and no additional payment may be requested from the consumer with the exception of medicare co-payments as specified in paragraph (E)(5) of this rule. This is true whether or not the provider normally accepts assignment under medicare.

(a) When the provider's total reimbursement from medicare and all other third party payers equals or exceeds the medicare approved (allowed/covered) amount, no additional payment will be made by ODJFS.

(b) If payment (other than the cost sharing amounts) is inadvertently received from both medicare and medicaid for the same service, the ODJFS claims adjustment unit must be notified in accordance with the provisions set forth in rule 5101:3-1-19 of the Administrative Code.

(5) Provider submitted crossover claims must be submitted timely in accordance with rule 5101:3-1-19 of the Administrative Code.

(6) Crossover claims are not subject to medicaid co-payments in accordance with rule 5101:3-1-09 of the Administrative Code.

(C) When the medicaid consumer is covered by other third party payers, in addition to medicare, medicaid is the payer of last resort. Whether or not medicare is the primary payer, providers must bill all other third party payers prior to submitting a crossover claim to ODJFS in accordance with rule 5101:3-1-08 of the Administrative Code.

(D) ODJFS will not pay for services denied by medicare for lack of medical necessity, but may pay claims denied for reasons other then medical necessity in accordance with paragraph (F) of this rule as long as the services are covered under the medicaid program. ODJFS will not pay for any service payable by, but not billed to, medicare.

(E) Reimbursement for medicare cost sharing on medicare crossover claims.

Reimbursement for medicare crossover claims is limited to the dual eligibles listed in paragraph (A)(6) of this rule.

(1) The medicaid maximum reimbursement for the medicare cost sharing of hospital inpatient, outpatient or emergency room services is set forth in rule 5101:3-2-25 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(2) The medicaid maximum reimbursement for the medicare cost sharing of nursing facility services included in the nursing facility per diem is set forth in Chapter 5101:3-3 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(3) The medicaid maximum reimbursement for the medicare cost sharing of all other part B services not included in paragraph (E)(1) or (E)(2) of this rule is set forth in rule 5101:3-1-05.3 of the Administrative Code for consumers that elected to receive medicare benefits under original medicare.

(4) The medicaid maximum reimbursement for the medicare cost sharing of all advantage plan (part C) services is set forth in rule 5101:3-1-05.1 of the Administrative Code for consumers that elected to receive medicare benefits under a medicare advantage plan.

(5) Cost sharing for medicare part D services is not reimbursable by ODJFS in accordance with rule 5101:3-9-06 of the Administrative Code. Dually eligible consumers may be required to pay medicare co-payments for prescription drugs that are covered by medicare part D.

(F) Services that are not covered by medicare must be submitted to ODJFS as a regular medicaid claim and should never be submitted as a medicare crossover claim.

With the exception of long term care nursing facilities, when the service is denied by medicare, and is also denied by medicaid with an error message indicating that the service is covered under medicare and the provider has documentation to support the service is not covered under medicare, the provider must do all of the following when requesting payment consideration from ODJFS:

(1) Submit the appropriate claim in accordance with rule 5101:3-1-19 of the Administrative Code;

(2) Attach the summary notice of medicare benefits that shows the denied medicare services, and the denial reason code with the denial reason code explanation from the medicare summary of benefits, the provider is requesting ODJFS to consider for payment;

(3) Attach a completed "JFS 06653 Medical Claim Review Request Form (rev.05/2010)"; and

(4) Submit all forms together to the address indicated on the JFS 06653 form.

(G) Long term care nursing facility providers must submit the appropriate claim in accordance with Chapter 5101:3-3 of the Administrative Code.

Effective: 08/02/2011
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.20 , 5111.262
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 4/1/79, 10/1/84, 10/1/87, 1/9/89 (Emer), 4/10/89, 5/1/90 (Emer), 7/1/90, 5/30/02, 12/18/06, 7/31/09 (Emer), 10/29/09

5160-1-05.1 Payment for "Medicare Part C" cost sharing.

(A) For qualified medicare beneficiaries and medicaid consumers enrolled in medicare part C managed health care plans (medicare advantage plans) the department will pay as cost sharing the lesser of:

(1) The provider's billed charges for the service (except for hospital and nursing facility services); or

(2) The deductible, coinsurance and co-payment amount as provided by the medicare part C plan; or

(3) The difference between the medicare part C plan's payment to a provider for a service or services identified and the medicaid maximum allowable reimbursement rate for the same identified service or services; or

(4) The medicaid liability for the cost sharing if the service had been rendered under medicare part A or part B.

(B) This payment arrangement applies to qualified medicare beneficiaries and medicaid consumers enrolled in a medicare part C plan.

(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims submitted for payment.

(1) Providers submitting medicare part C crossover claims to the medicaid program must be able to provide upon request documentation that supports that the information provided on the claim matches the information on the part C plan's remittance advice.

(2) Providers submitting medicare part C crossover claims to the medicaid program who are paid under a capitation arrangement with the medicare part C plan, and do not submit claims to the plan for services rendered, must be able to provide upon request documentation of the capitation arrangement including specific details about the plan's cost sharing requirements.

Effective: 11/09/2014
Five Year Review (FYR) Dates: 08/05/2014 and 11/09/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 5-14-04 (Emer.) ; 7-30-04

5160-1-05.3 Payment for "Medicare Part B" cost sharing.

(A) The reimbursement methodology set forth in paragraph (B) of this rule is limited to medicare part B services that meet all of the following criteria:

(1) Are not hospital services defined in accordance with Chapter 5160-2 of the Administrative Code;

(2) Are not nursing facility services included in the nursing facility per diem as defined in accordance with Chapter 5160-3 of the Administrative Code;

(3) Are covered as supplemental medical insurance benefits under the medicare program; and

(4) Are provided to dual eligibles, defined in accordance with paragraph (A)(6) of rule 5160-1-05 of the Administrative Code, who elect to receive their medicare part B benefits through the original medicare program.

(B) The Ohio department of medicaid (ODM) will pay the lesser of the following calculations for part B cost sharing described in this rule:

(1) The sum of the deductible and coinsurance medicare specifies ODM is obligated to pay for crossover claims; or

(2) The difference between the medicare approved amount and the sum of the amount medicare paid and all other third party (insurance other than medicare or medicaid) payments ; or

(3) Except for physician services, the difference between the sum of the amount medicare paid and any third party payments, and the medicaid maximum allowable reimbursement rate for the same identified service or services.

(C) When payment for part B cost sharing is made using the method described in paragraph (B)(2) or (B)(3) of this rule and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid approved amount, ODM will not make any additional payment to the provider, or will make a payment of zero dollars, and the service(s) are considered to be paid in full to the provider.

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013 and 01/01/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: Section 323.230 ofAm. Sub.HB59
Prior Effective Dates: 12/18/06, 7/31/09 (Emer), 10/29/2009

5160-1-06 Home and community-based service waivers: general description.

(A) Section Section Section 2176 of Public Law 97-35, the Omnibus Budget Reconciliation Act of 1981, established a waiver program under which states can be reimbursed for providing home and community-based services (HCBS). Under the HCBS waivers, states can designate specific target populations who can receive a wider range of HCBS than normally covered under the state plan. Waiver requests submitted by the states to the secretary of the department of health and human services may be approved for a three-year period; each waiver may be renewed for five-year periods.

(B) Eligibility for HCBS waiver programs is limited to medicaid recipients who, in the absence of home and community services, would require long-term care in a nursing facility (NF), intermediate care facility for the mentally retarded (ICF-MR) or hospital as designated by the specific waiver.

(C) HCBS waivers must be limited to one of the following target groups or any subgroup thereof that the state may define:

(1) Aged or disabled, or both; or

(2) Mentally retarded or developmentally disabled, or both; or

(3) Mentally ill.

(D) At no time during the term of a HCBS waiver may the number of individuals approved to receive waiver services exceed the specific number annually allocated in the waiver.

(E) Descriptions, approval information and reimbursement rates for each of the HCBS waivers can be found as follows:

(1) PASSPORT HCBS waiver information can be found in rule 5101:3-1-06.1 of the Administrative Code.

(2) The payment standards governing reimbursement for HCBS waiver programs administered by the Ohio department of mental retardation and developmental disabilities (ODMR/DD) can be found in rule 5101:3-41-11 of the Administrative Code.

(3) Ohio home care waiver reimbursement rates and billing procedures are set forth in rule 5101:3-46-06 of the Administrative Code.

(4) Transitions MR/DD waiver reimbursement rates and billing procedures are set forth in rule 5101:3-47-06 of the Administrative Code.

(5) Transitions carve-out waiver reimbursement rates and billing procedures are set forth in rule 5101:3-50-06 of the Administrative Code.

(6) Choices HCBS waiver information can be found in rule 5101:3-1-06.4 of the Administrative Code.

(7) Assisted living HCBS waiver information can be found in rule 5101:3-1-06.5 of the Administrative Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/24/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.01 , 5111.02 , 5111.85
Prior Effective Dates: 10/1/87, 7/1/98, 1/1/04

5160-1-06.1 Home and community-based service waivers: PASSPORT.

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the preadmission screening system providing options and resources today (PASSPORT) medicaid waiver program. ODA will administer the waiver pursuant to an interagency agreement with the Ohio department of medicaid in accordance with section 5162.35 of the Revised Code.

(B) The PASSPORT waiver provides home and community based services to persons aged sixty and over that require an intermediate or skilled care level of care as set forth in rule 5160-3-08 of the Administrative Code and are enrolled in the waiver.

(C) The PASSPORT HCBS waiver services and program eligibility criteria are set forth in Chapter 5160-31 of the Administrative Code.

(D) The maximum allowable reimbursement rates for PASSPORT HCBS waiver program services are listed in appendix A to this rule.

(E) PASSPORT HCBS reimbursement must be provided in accordance with paragraphs (A) to (C) of rule 5160-1-60 of the Administrative Code.

(F) A consumer may not receive community transition services with a cumulative or singular value in excess of one thousand four hundred seventy-seven dollars and fifty cents. The consumer may only access the goods and services available through the community transition service as set forth in rule 173-39- 02.17 of the Administrative Code.

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Effective: 07/01/2014
R.C. 119.032 review dates: 03/01/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5166.02 , 173.52
Prior Effective Dates: 1/1/04, 7/1/06, 7/2/07 (Emer.), 10/1/07, 7/1/08 (Emer.), 9/30/08, 7/1/11 (Emer.), 9/29/11, 7/1/13 (Emer.), 9/27/13, 3/1/14

5160-1-06.4 Home and community-based services (HCBS) waivers: choices.

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the choices (HCBS) waiver. ODA will administer the waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM), in accordance with section 5162.35 of the Revised Code.

(B) The choices waiver provides HCBS to persons aged sixty and over that reside in the service area defined in the approved 1915(c) waiver for the choices program and who require an intermediate or skilled care level of care as set forth in rule 5101:3-3-08 of the Administrative Code and are enrolled in the waiver.

(1) The choices HCBS waiver services and program eligibility criteria are set forth in Chapter 5101:3-32 of the Administrative Code.

(2) The maximum allowable reimbursement rates for choices HCBS waiver program services are listed in appendix A to this rule and are effective on September 27, 2013.

(3) Choices HCBS reimbursement must be provided in accordance with of rule 5101:3-1-60 of the Administrative Code.

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Effective: 09/27/2013
R.C. 119.032 review dates: 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85 , 173.403
Prior Effective Dates: 1/1/04, 7/1/05, 7/1/06, 7/1/07, 7/2/07(Emer.), 10/1/07, 7/1/08(Emer.), 7/1/11(Emer.), 9/29/11, 7/1/13 (Emer.)

5160-1-06.5 Home and community based services (HCBS) waivers: assisted living.

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the assisted living HCBS waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM), in accordance with section 5162.35 of the Revised Code.

(B) The assisted living HCBS waiver is an alternative to nursing facility placement for persons age twenty-one and over who require an intermediate level of care or a skilled level of care as set forth in rule 5101:3-3-08 of the Administrative Code and are enrolled in the waiver.

(1) The assisted living HCBS waiver's services and program eligibility criteria are set forth in Chapter 5101:3-33 of the Administrative Code.

(2) The maximum allowable reimbursement rates for assisted living HCBS waiver program services are listed in appendix A to this rule and are effective on September 27, 2013.

(3) Assisted living HCBS reimbursement shall be provided in accordance with rule 5101:3-1-60 of the Administrative Code.

(4) The billing maximum for the community transition service listed in appendix A to this rule represents the cumulative maximum for the items purchased or deposits made through the community transition service as set forth in rule 173-39-02.17 of the Administrative Code.

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Effective: 09/27/2013
R.C. 119.032 review dates: 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.89
Rule Amplifies: 5111.85 , 5111.89
Prior Effective Dates: 7/1/06, 3/22/08, 7/1/11(Emer.), 9/29/11, 7/1/13(Emer.)

5160-1-08 Coordination of benefits.

(A) Definitions.

(1) "Coordination of benefits (COB)" means the process of determining which health plan or insurance policy will pay first and/or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits for a medicaid consumer.

(2) "Explanation of benefits (EOB)" or "remittance advice" means the information sent to providers and/or plan beneficiaries (consumers) by any other third party payer, medicare and/or medicaid to explain the adjudication of the claim.

(3) "COB claim" means any claim that meets either the definition of third party claim as described in paragraph (A)(9) of this rule or the definition of medicare crossover claim as described in rule 5101:3-1-05 of the Administrative Code.

(4) "Medicare benefits" is as defined in rule 5101:3-1-05 of the Administrative Code.

(5) "Third party (TP)" is as defined in section 5101.571 of the Revised Code.

(6) "Third party payer (TPP)" means an entity, other than the medicaid or medicare programs, responsible for adjudicating and paying claims for third party benefits rendered to an eligible medicaid consumer.

(7) "Third party benefit" means any health care service(s) available to consumers through any medical insurance policy or through some other resource that covers medical benefits and the payment for those services is either completely the obligation of the TPP or in part the obligation of the consumer, the TPP and/or medicaid. (Examples of a third party benefit include private health or accidental insurance, medicare, CHAMPUS or worker's compensation.)

(8) "Third party liability (TPL)" means the payment obligations of the TPP for health care services rendered to eligible medicaid consumers when the consumer also has third party benefits as described in paragraph (A)(7) of this rule.

(9) "Third party claim" means any claim(s) submitted to ODJFS for reimbursement after all TPPs have met their payment obligations. In addition, the following will be considered third party claims by ODJFS:

(a) Any claim received by ODJFS that shows no prior payment by a TPP, but, ODJFS's records indicate the consumer has third party benefits.

(b) Any claim received by ODJFS that shows no prior payment by a TPP, but, the provider's records indicate the medicaid consumer has third party benefits.

(B) If the existence of a third party benefit is known to ODJFS, a code number that represents the name of the third party payer covering the consumer will be indicated on the consumer's medicaid card. http://emanuals.odjfs.state.oh.us/emanuals The provider shall obtain from the consumer the name and address of the insurance company, and any other necessary information, and bill the insurance company prior to billing ODJFS.

(C) The provider must always review the consumer's Ohio medicaid card for evidence of third party benefits. Whether there is or is not an indication of a TPP on the medicaid card, the provider must always request from the consumer or his or her representative information about any third party benefit(s). If the consumer specifies no TP coverage and the medicaid card does not indicate TP coverage, the provider may submit a claim to medicaid (and the claim for the service is not considered a TP claim). If, as a result of this process, the provider determines that TP liability exists, the provider may only submit a claim for reimbursement if it first takes reasonable measures to obtain TP payments as set forth in paragraph (D) of this rule.

(D) The medicaid program must be the last payer to receive and adjudicate the claim, except as determined by rule 5101:3-1-03 of the Administrative Code, and the state sponsored program awarding reparations to victims of crime under sections 2743.51 to 2743.72 of the Revised Code. ODJFS reimburses for covered services only after the provider takes reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing ODJFS. Providers who have gone through reasonable measures to obtain all third party payments, but who have not received payment from a TPP, or have gone through reasonable measures and received partial payment, may use an appropriate code on the claim to obtain payment and submit a claim to ODJFS requesting reimbursement for the rendered service(s).

(1) Providers are considered by ODJFS to have taken reasonable measures to obtain all third party payments if they comply with one of the following requirements:

(a) The provider submits a claim first to the TPP and receives a remittance advice indicating that a valid reason for non-payment applies for the service as described in paragraph (D)(2) of this rule.

(b) The provider submits a claim first to the TPP for the rendered service(s) no less than three times within a ninety-day period and does not receive a remittance advice or other communication from the TPP within ninety days of the last submission to the TPP. Providers must be able to document each claim submission and the date of the submission.

(c) The provider followed the process described in paragraph (C) of this rule for the billed service and meets the following requirements:

(i) The provider did not find a change in third party coverage;

(ii) The billed service was previously rendered to the medicaid consumer by the provider within the last three hundred sixty-five days; and

(iii) The claim for the previously rendered service met the requirements of paragraph (D)(1)(a) or (D)(1)(d) of this rule.

(d) The provider did not send a claim to the TPP, but has received and retained at least one of the following types of documentation that indicates a valid reason for non-payment for the service(s) as set forth in paragraph (D)(2) of this rule:

(i) Written documentation from the TPP;

(ii) Written documentation from the TPPs automated eligibility and claim verification system;

(iii) Written documentation from the TPPs member benefits reference guide/manual; or

(iv) Any other reliable method for obtaining information and/or documentation from the TPP that there is no third party benefit coverage for the rendered service(s).

(e) The provider submits a claim first to the TPP and receives a partial payment along with a remittance advice documenting the allocation of the billed charges.

(2) Valid reasons for non-payment from a third party payer to the provider for a third party benefit claim include, but are not limited to, the following:

(a) The service(s) is not covered under the medicaid consumer's third party benefits.

(b) The medical expenses for the medicaid consumer were incurred prior to the third party benefits coverage dates.

(c) The medical expenses for the medicaid consumer were incurred after the third party benefits coverage was terminated.

(d) The medicaid consumer does not have third party benefits through the TPP for the date of service.

(e) All of the provider's billed charges or the TPPs approved rate was applied to the consumer's third party benefit deductible amount.

(f) All of the provider's billed charges or the TPPs approved rate was applied in total across the consumer's deductible, coinsurance and/or co-payment for the third party benefit.

(g) The medicaid consumer has not met eligibility, out-of-pocket expenses, required waiting periods or residency requirements for his/her third party benefits.

(h) The medicaid consumer is a dependent of the individual with third party benefits, but the benefits do not cover the individual's dependents.

(i) The medicaid consumer has reached the lifetime benefit maximum for the medical service being billed to the third party payer.

(j) The medicaid consumer has reached the benefit maximum of his/her third party benefits.

(k) The TPP is disputing or contesting its liability to pay the claim or cover the service.

(E) Providers who have gone through reasonable measures as described in paragraph (D) of this rule to obtain all third party payments, but who have not received payment from a TPP, or received a partial payment, may submit a claim to ODJFS requesting reimbursement for the rendered service(s). If payment from the TPP is received after ODJFS has made payment, the provider is required to repay ODJFS any overpaid amount. The provider must not reimburse any overpaid amounts to the consumer.

(F) Third party claims must meet the claim submission guidelines in accordance with rule 5101:3-1-19 of the Administrative Code.

(G) Medicaid reimbursement for third party claims will not exceed the medicaid maximum payment for the service, determined in accordance with applicable rules for the service, less all third party payments for the service. If the result is less than or equal to zero dollars, there will be no further medicaid payment for the service.

(H) ODJFS will reject a TP claim when a third party claim indicates coverage by a TPP, or when the existence of third party benefits is known to ODJFS, and the submitted claim does not indicate collection of the third party payment or does not indicate compliance with paragraph (D) of this rule. Providers should complete their investigation of available third party benefits before submitting a TP claim to ODJFS for payment.

(1) Providers and/or trading partners must maintain documentation to support all required information submitted on a third party claim (for example, if the submitted information indicates one hundred per cent of approved charges were allocated to the plan deductible, then the provider must have documentation to support the TPP allocated the approved charges to the plan deductible).

(2) Providers and/or trading partners must not omit from a TP claim any required TP claim information issued to them by the TPP, by the consumer or any other source (for example, the omission of the payment denial reasons that were issued by the TPP).

(I) ODJFS will make audit exceptions if a post-payment review reveals that the provider and/or trading partner did not maintain documentation to support the information submitted on a TP claim or reveals that the omission of required TP claim information resulted in an overpayment or an inappropriate payment of the claim.

(J) The provider is prohibited from billing the consumer any charges in accordance with paragraph (A) of rule 5101:3-1-60 of the Administrative Code.

(K) If the consumer states his/her private health insurance has changed or been terminated, the provider should advise the consumer to contact his/her county caseworker to correct the case record. Once the case record has been corrected, the provider may bill ODJFS directly.

(L) ODJFS has right of recovery pursuant to section 5101.58 of the Revised Code (medicaid, or any federal or state funded public health program) against the liability of a third party for the cost of medical services paid by ODJFS, or billable to ODJFS for payment at a later date. Section 5101.58 of the Revised Code requires that a medicaid consumer provide notice to ODJFS prior to initiating any action against a liable third party. ODJFS will take steps to protect its rights of recovery if that notice is not provided. If any person, whether the consumer or an individual acting on the behalf of a consumer, requests a financial statement (a claim) from a medicaid provider for services paid by ODJFS or to be billed to ODJFS on behalf of the medicaid consumer, the provider shall meet all of the following four requirements:

(1) Require that the consumer or the consumer's representative make his/her request for access to financial statements in writing.

(2) Notify ODJFS immediately upon receipt of the consumer's written request and forward a copy of the request to ODJFS, bureau of consumer and operational support, coordination of benefits section.

(3) Release the financial statement to the consumer or the consumer's representative no later than thirty days after the date the request is received.

(4) Stamp or type on each page of the financial statement in bold font "SUBJECT TO RIGHT OF RECOVERY PURSUANT TO SECTION 5101.58 OF THE OHIO REVISED CODE. FAILURE TO COMPLY MAY RESULT IN PERSONAL LIABILITY."

This rule applies to financial statements whether or not the provider has received reimbursement from ODJFS. This rule is not intended to prevent or restrict the provider from furnishing records of medical treatment and condition to the consumer.

(M) When the medicaid consumer is covered by medicare, in addition to other third party payers, medicaid is the payer of last resort. Whether or not a TPP is the primary payer, providers must bill all other third party payers and medicare prior to submitting a claim to ODJFS in accordance with rule 5101:3-1-05 of the Administrative Code.

(N) Medicaid managed care plans (MCPs) are exempt from this rule. MCPs are responsible for coordination of benefits pursuant to Chapter 5101:3-26 of the Administrative Code.

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
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 4/1/79, 10/1/84, 10/1/87, 7/7/02, 5/1/03, 1/1/04, 12/18/06

5160-1-09 Co-payments.

This rule sets forth requirements regarding co-payments by consumers for medicaid-covered services.

(A) Certain medicaid services are subject to consumer co-payments. Information regarding these services and co-payment amounts can be found in the following Administrative Code rules:

(1) Co-payments for dental services are described in rule 5101:3-5-01 of the Administrative Code.

(2) Co-payments for vision services are described in rule 5101:3-6-01 of the Administrative Code.

(3) Co-payments for non-emergency emergency department services are described in rule 5101:3-2-21.1 of the Administrative Code.

(4) Co-payments for pharmacy services are described in rule 5101:3-9-09 of the Administrative Code.

(5) Co-payment requirements for services provided through a medicaid managed care plan are described in Chapter 5101:3-26 of the Administrative Code.

(B) With regard to the application of consumer payments, the following apply:

(1) No provider may deny services to a consumer who is eligible for the services on account of the consumer's inability to pay the medicaid co-payment. Consumers who are able to pay their medicaid co-payment may declare their inability to pay for services or medication and receive their services or medication without paying their medicaid co-payment amount. With regard to a consumer who is unable to pay a required medicaid co-payment in accordance with this paragraph, this does not:

(a) Relieve the medicaid consumer from the obligation to pay a medicaid co-payment; or

(b) Prohibit the provider from attempting to collect an unpaid medicaid co-payment.

(2) No provider shall waive a medicaid consumer's obligation to pay a provider a medicaid co-payment except when paragraph (A)(5) of this rule applies.

(3) No provider or drug manufacturer, including the manufacturer's representative, employee, independent contractor, or agent, shall pay any co-payment on behalf of a medicaid consumer.

(4) If it is the routine business practice of the provider to refuse service to any individual who owes an outstanding debt to the provider, the provider may consider an unpaid medicaid co-payment as an outstanding debt and refuse service to a medicaid consumer who owes the provider an outstanding debt. If the provider intends to refuse service to a medicaid consumer who owes the provider an outstanding debt, the provider shall notify the individual of the provider's intent to refuse services. In determining outstanding debt of a medicaid consumer, the following apply:

(a) A provider's decision to continue rendering services to a medicaid consumer who has an unpaid co-payment shall not be considered an outstanding debt of a medicaid consumer.

(b) Charges which are prohibited in accordance with paragraph (A) of rule 5101:3-1-60 of the Administrative Code may not be considered an outstanding debt of a medicaid consumer.

(C) The following consumers are excluded from the co-payment requirement for dental, vision, non-emergency emergency department services and pharmacy services:

(1) Children and youth under the age of twenty-one.

(a) The provider may use the consumer's date of birth to identify if this exclusion applies; or

(b) The provider may submit the claim to the department. During adjudication of the claim, if the department identifies the consumer as a child or youth under the age of twenty-one, the department will not reduce the medicaid payment by the co-payment amount.

(2) Pregnant women during pregnancy and women with post-partum coverage as defined in Chapter 5101:1-40 of the Administrative Code. The following also apply:

(a) Routine eye examinations and the dispensation of eyeglasses during a consumer's pregnancy are subject to co-payment.

(b) For all other claims, the provider may accept the consumer's self-declaration of her pregnancy if the pregnancy/ post-partum co-payment exclusion applies. If the provider reports this exclusion applies, the medicaid payment will not be reduced by the co-payment amount.

(3) Residents of a nursing facility (NF) or intermediate care facility for the mentally retarded (ICF/MR).

(a) The provider may use the consumer's address to validate whether the consumer resides in a NF or ICF/MR; or

(b) The consumer may submit the claim to the department. During the adjudication of the claim, if the department identifies the consumer as a resident of a NF or ICF/MR, the department will not reduce the medicaid payment by the co-payment amount.

(4) Consumers receiving emergency services are excluded from co-payment when they are provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy;

(5) Consumers receiving family planning services defined as pregnancy/contraception management services in rule 5101:3-21-02 of the Administrative Code are excluded from co-payment when these services are provided to an individual of child-bearing age. The provider may determine on the basis of his or her professional judgment that the consumer is receiving pregnancy prevention/ contraceptive services and the co-payment exclusion applies.

(6) Consumers receiving hospice services are excluded from co-payment obligations. The provider may accept the consumer's self-declaration that he or she is enrolled in hospice. If the provider reports that the consumer is enrolled in hospice, the medicaid payment will not be reduced by the co-payment amount.

(D) Medicare cross-over claims as defined in rule 5101:3-1-05 of the Administrative Code are not subject to medicaid co-payments.

Replaces: 5101:3-1-09

Effective: 10/01/2011
R.C. 119.032 review dates: 10/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0112
Rule Amplifies: 5111.01 , 5111.02 , 5111.0112 , 5111.172 , section 309.37.50 of Am. Sub. H.B. 153, 129th G.A.
Prior Effective Dates: 1/1/06, 7/1/09, 2/1/10

5160-1-11 Out-of-state coverage [except as provided through medicaid contracting managed care plans (MCPs)].

(A) Out-of-state providers must be licensed, accredited, or certified by their respective states to be considered eligible to provide services to Ohio medicaid consumers. Any standards applicable to the provision of the service in the state in which the service is being furnished must be met, as well as those standards set forth in the Ohio medicaid program and in the Ohio Administrative Code. Out-of-state providers must enroll as Ohio medicaid providers in order to obtain reimbursement and must follow appropriate billing procedures in accordance with Chapter 5160-1 of the Administrative Code and Chapter 5160-3 of the Administrative Code for long term care nursing facility services.

(B) Ohio medicaid covered services will be reimbursed when rendered by out-of-state providers only under the following circumstances:

(1) The medically necessary services are not available within the state of Ohio, and the use of out-of-state providers to perform the services is prior-authorized by the department or its designee in accordance with rule 5160-1-31 of the Administrative Code; or

(2) The medical need arose as a result of an emergency, an accident, and/or an illness which occurred during the period the consumer was temporarily absent from Ohio, and the consumers' health would have been endangered if care was postponed until the consumer returned to Ohio or attempted to return to Ohio; or

(3) The provider location for the medically necessary service is in a bordering state, and it is the usual practice of residents in that community to utilize out-of-state providers, so long as the cost of the service does not exceed the cost of the service provided by in-state providers; or

(4) The state determines on the basis of medical advice, that the needed medical services or necessary supplementary resources are more readily available in another state.

Effective: 11/02/2014
Five Year Review (FYR) Dates: 08/05/2014 and 11/02/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 5/30/02, 07/01/2005

5160-1-13.1 Medicaid consumer liability.

(A) The medicaid payment for a covered service constitutes payment-in-full and may not be construed as a partial payment even when the reimbursement amount is less than the provider's charge. The provider may not collect and/or bill the consumer for any difference between the medicaid payment and the provider's charge or request the consumer to share in the cost through a deductible, coinsurance, co-payment or other similar charge, other then medicaid co-payments as defined in rule 5160-1-09 of the Administrative Code. The provider may not charge the consumer a down payment, refundable or otherwise.

(B) A medicaid consumer cannot be billed when a medicaid claim has been denied due to:

(1) Unacceptable or untimely submissions of claims;

(2) Failure to request a prior authorization; or

(3) A peer review organization (PRO) retroactively denying services for lack of medical necessity.

(C) Providers are not required to bill the Ohio department of medicaid (ODM) for medicaid-covered services rendered to eligible consumers. However, providers may not bill consumers in lieu of ODM unless:

(1) The consumer is notified in writing prior to the service being rendered that the provider will not bill ODM for the covered service; and

(2) The consumer agrees to be liable for payment of the service and signs a written statement to that effect prior to the service being rendered; and

(3) The provider explains to the consumer that the service is a covered medicaid service and other medicaid providers may render the service at no cost to the consumer.

(D) Services that are not covered by the medicaid program, including services requiring prior authorization that have been denied by ODM, may be billed to the consumer when the provisions in paragraphs (C)(1) and (C)(2) of this rule are met.

Effective: 11/28/2014
Five Year Review (FYR) Dates: 09/08/2014 and 11/28/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 6/3/83, 2/11/84, 10/1/84, 7/1/85 (Emer), 9/30/85, 10/1/87, 5/30/02, 1/1/04, 7/1/05, 1/6/06, 02/01/2010

5160-1-15 [Rescinded] Medicaid card.

Effective: 08/02/2011
R.C. 119.032 review dates: 05/17/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 7/1/80, 10/1/87, 5/30/02, 12/18/06

5160-1-17 Eligible providers.

This rule sets forth the eligibility requirements for medicaid providers. Provider eligibility requirements for medicaid managed care plans can be found in Chapter 5101:3-26 of the Administrative Code.

(A) "Eligible provider" means any individual, group practice, corporation, organization, or health care institution that:

(1) Meets the applicable provider requirements and standards in division 5101:3 of the Administrative Code that address the applicable provider types and service categories covered under the Ohio medicaid program;

(2) Meets the additional requirements and standards set forth in this rule;

(3) Has met the provider screening requirements and paid the associated application fee in accordance with rule 5101:3-1-17.8 of the Administrative Code; and

(4) Is approved for participation in the medicaid program by the Ohio department of job and family services (ODJFS) as evidenced by the issuance of both a signed "Provider Agreement" and an Ohio medicaid provider number.

(B) Eligible providers enrolled in the Ohio medicaid program will each be classified as a "Typical" provider or an "Atypical" provider and will also be classified as an "Entity Type 1" provider or an "Entity Type 2" provider.

(1) "Typical Provider" means any provider assigned a provider type that ODJFS has determined is eligible to provide covered services that meet the definition of health care services in accordance with 45 C.F.R. 160.103 (2/2006).

(2) "Atypical Provider" means any provider assigned a covered provider type that ODJFS has determined is eligible to provide covered services that are non-health care services (i.e., those services that do not meet the definition of health care services in accordance with 45 C.F.R. 160.103 (2/2006)).

(3) "Entity Type 1" means a provider assigned a covered provider type that is for an individual health care provider. An individual health care provider cannot be a subpart and cannot designate a subpart. A sole proprietorship is a form of business that, in terms of a national provider identifier (NPI) assignment, is an entity type 1 that is eligible for a single NPI. As an individual, a sole proprietor/sole proprietorship cannot have subparts and cannot designate subparts.

(4) "Entity Type 2" means:

(a) Any provider enrolled that is assigned a covered professional group provider type as specified in paragraph (C) of this rule; or

(b) Any provider enrolled that is assigned any provider type that is neither an individual provider type nor a professional group provider type.

(C) A provider can be assigned a professional group provider type only if it is organized for the sole purpose of providing professional services authorized under Chapters 4715., 4725., 4731., 4732., 4734., 4755.04 to 4755.56 , or 4723.41 to 4723.485 of the Revised Code, meets the requirements in either paragraph (C)(1) or (C)(2) of this rule, and meets the other requirements set forth in paragraphs (C)(3) and (C)(4) of this rule.

(1) A professional practice that is owned by an individual may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraphs (C)(3)(a) to (C)(3)(d) of this rule and the owner (member) of the practice possesses a valid license, certificate or other legal authorization issued under Chapters 4715., 4725., 4731., 4732., 4734., 4755.04 to 4755.56 , or 4723.41 to 4723.485 of the Revised Code and also meets the respective requirements in paragraph (A)(1) of this rule.

An individual provider enrolling with the medicaid program that does not meet the provisions listed in paragraph (C) of this rule may only be enrolled as an individual provider.

(2) Any group of two or more individuals may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule. ODJFS recognizes two kinds of professional group practices, a professional medical group and a professional dental group.

(a) A professional medical group is a group that consists of individual practitioners recognized by ODJFS as eligible members. The types of individual practitioners recognized by ODJFS as eligible members include: advanced practice nurses, optometrists, opticians, chiropractors, occupational therapists, physical therapists, physicians, osteopaths, anesthesia assistants, podiatrists, and psychologists. The practice must consist of two or more members, of like or different licensure, or only an incorporated individual organized in accordance with paragraph (C)(3)(b) of this rule. Dentists may not enroll as a member of a professional medical group.

(b) A professional dental group is a group that consists only of dentists. The practice must consist of two or more dentists, or only an incorporated individual dentist organized in accordance with paragraph (C)(3)(b) of this rule.

(3) For purposes of the Ohio medicaid program, a professional group may be organized in accordance with one of the following organizational structures:

(a) A corporation formed under Chapter 1701. of the Revised Code;

(b) A limited liability corporation formed under Chapter 1705. of the Revised Code;

(c) A non-profit corporation formed under Chapter 1702. of the Revised Code;

(d) A professional association formed under Chapter 1785. of the Revised Code; or

(e) A partnership formed under Ohio law.

(4) Each member or each employee of the professional group practice (including an individual that is incorporated) that possesses a license, certificate or other legal authorization issued under Chapters 4715., 4725., 4731., 4732., 4734., 4755.04 to 4755.56 , or 4723.41 to 4723.485 of the Revised Code and also meets the respective requirements in paragraph (A)(1) of this rule must have an individual provider agreement with ODJFS.

(D) Requirements for an NPI and the consequences of not having an NPI when an NPI is required.

(1) A typical provider must obtain an NPI.

(a) With the exception of NPI requirements for long term care facilities described in paragraphs (D)(1)(b) and (D)(1)(c) of this rule, a typical provider enrolling with ODJFS is required to obtain a unique NPI in order to be approved as an eligible provider under the Medicaid program.

(b) A provider of nursing facility services is required to obtain an NPI.

(c) A provider of intermediate care facility for the mentally retarded (ICF-MR) services is not required to obtain an NPI.

(2) An atypical provider is not required to obtain an NPI unless the provider determines it provides health care services in accordance with 45 C.F.R. 160.103 (2/2006).

(a) Each atypical provider must self-assess the services it provides and determine if it provides health care services.

(b) An atypical provider that determines it does not provide health care services and does not obtain a NPI will be issued a Ohio medicaid legacy number to be submitted on claims for payment.

(c) An atypical provider that determines it provides any health care services is required to obtain an NPI, regardless of the type of services the provider performs under the medicaid program.

(3) Typical providers and atypical providers that have been issued an NPI must disclose each NPI they have been issued to ODJFS in accordance with rule 5101:3-1-17.3 of the Administrative Code.

(4) Typical providers and atypical providers that are required to obtain an NPI will have claims denied for payment if any of the following apply:

(a) Providers submit a claim without an NPI present on the claim when an NPI is required on the claim.

(b) Providers submit a claim with an NPI that is not recognized by ODJFS as a valid NPI based on the information disclosed in accordance with rule 5101:3-1-17.3 of the Administrative Code.

(c) Providers do not submit claims to ODJFS within the timely filing limitations in accordance with rule 5101:3-1-19 of the Administrative Code. ODJFS will not make exceptions for providers that do not submit claims within the timely filing limitations because the provider failed to get an NPI or failed to disclose an NPI to ODJFS per rule 5101:3-1-17.3 of the Administrative Code.

(5) Covered organization health care providers are responsible for determining if they have components or subparts and the covered organization health care provider must ensure that their subparts obtain their own unique NPI, or they must obtain one for them. A subpart is not itself a separate legal entity, but is part of a covered organization health care provider that is a legal entity. A subpart must furnish health care as defined in 45 C.F.R. 160.103 (2/2006).

(E) If an "Entity Type 2" health care provider consists of subparts that are issued a unique NPI but the subpart does not meet the requirements to be an eligible provider as set forth in this rule, all transactions must be submitted under the NPI of the "Entity Type 2" medicaid provider under which it is a subpart. ODJFS will make exceptions for automatic crossover claims received from the medicare coordination of benefits administrator for those NPIs issued to a subpart of an "Entity Type 2" provider if the subpart is enrolled as an eligible provider under medicare.

"Entity Type 1" (individual) providers can never be a subpart of an "Entity Type 2" provider.

(F) Not all health care providers providing health care services in accordance with 45 C.F.R. 160.103 (2/2006) are eligible to enroll as providers under the Ohio medicaid program. The receipt of an NPI does not guarantee enrollment as an Ohio medicaid provider.

(G) ODJFS does not enroll providers outside of the United States and its territories.

Effective: 03/31/2012
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.029 , 5111.063
Prior Effective Dates: 4/7/77, 10/1/87, 1/1/95, 12/31/96 (Emer), 3/22/97, 5/30/02, 8/11/05, 5/23/07, 1/1/08, 8/2/11

5160-1-17.1 Notification of rule and program changes.

(A) Before the effective date of the final adoption, amendment or rescission of a rule in division 5101:3 of the Administrative Code, the Ohio department of job and family services (ODJFS) shall make a reasonable effort to notify persons affected by the rule adoption, amendment or rescission. "Reasonable effort to notify persons" means posting the full text of a new or amended rule on the ODJFS website.

(B) ODJFS may use electronic mail (e-mail) to communicate notice of final rule action. Persons may voluntarily submit an e-mail address on an ODJFS-maintained website in order to receive an electronic communication of any final rule adoption, amendment or rescission. ODJFS shall maintain the electronic distribution list, but is not responsible for the validity of any e-mail address on the list. The sole responsibility for the validity of any e-mail address maintained on the distribution list is that of the person who submitted the address.

Effective: 08/01/2009
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 119.03(E)

5160-1-17.2 Provider agreement for providers.

Provisions of provider agreements for long term care nursing facilities are defined in Chapter 5101:3-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5101:3-26 of the Administrative Code.

A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid program. All medicaid provider applications must be submitted through the medicaid information technology system (MITS) web portal. Provider applications submitted in paper format will be returned to the provider unprocessed.

If a provider application requires additional supporting documentation by the department for the application process to be completed, the supporting documentation may be sent through the MITS web portal or sent to the department through regular mail service.

A provider agreement is a contract between the Ohio department of job and family services (ODJFS) and a provider of medicaid covered services. By signing this agreement the provider agrees to comply with the terms of the provider agreement, Revised Code, Administrative Code, and federal statutes and rules; and the provider certifies and agrees:

(A) To render medical services as medically necessary for the patient and only in the amount required by the patient without regard to race, creed, color, age, sex, national origin, source(s) of payment, or handicap; submit claims only for services actually performed; and, bill ODJFS for no more than the usual and customary fee charged other patients for the same service.

(B) To ascertain and recoup any third-party resource(s) available to the consumer prior to billing ODJFS. ODJFS will then pay any unpaid balance up to the lesser of the provider's billed charge or the maximum allowable reimbursement as set forth in division-level 5101:3 of the Administrative Code.

(C) To accept the allowable reimbursement for all covered services as payment-in-full, except as required in paragraph (B) of this rule. The provider will not seek reimbursement for that service, except as defined in rule 5101:3-1-09 of the Administrative Code, from the patient, any member of the family, or any other person.

(D) To maintain all records necessary and in such form so as to fully disclose the extent of services provided and significant business transactions. The provider will maintain such records for a period of six years from the date of receipt of payment based upon those records or until any audit initiated within the six year period is completed.

(E) To furnish to ODJFS, the secretary of the department of health and human services, or the Ohio medicaid fraud control unit or their designees any information maintained under paragraph (D) of this rule for audit and review purposes. Audits may use statistical sampling. Failure to supply requested records within thirty days shall result in withholding of medicaid payments and may result in termination from the medicaid program.

(F) To inform ODJFS within thirty days of any changes in licensure, certification, or registration status; ownership; specialty; additions, deletions, or replacements in group membership and hospital-based physician affiliations; and address.

(G) To disclose ownership and control information, and to disclose the identity of any person who has been convicted of a criminal offense related to medicare, medicaid, or services provided under Title XX of the Social Security Act (as in effect 12/07/2010) (Title XX), as specified in rule 5101:3-1-17.3 of the Administrative Code.

(H) That neither the individual practitioner, nor the company, nor any owner, director, officer, or employee of the company, nor any independent contractor retained by the company, is currently subject to sanction under medicare, medicaid, or Title XX; or, is otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries.

(I) To provide to ODJFS, through the court of jurisdiction, notice of any bankruptcy action brought by the provider. Notice shall be mailed to: office of legal services, Ohio department of job and family services.

(J) To comply with the appropriate advance directives requirements for hospitals, providers of home health care, personal care services, and hospices as specified in Chapter 3701-83 of the Administrative Code.

(K) To comply with the confidentiality safeguards and the use and release of information regarding public assistance recipients as described in section 5101.27 of the Revised Code.

(L) To comply with section 121.36 of the Revised Code and rule 5101:3-1-39 of the Administrative Code when providing home care services.

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
Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 1/1/93, 5/30/02, 1/1/04, 9/26/04, 8/11/05, 12/30/05 (Emer), 3/27/06

5160-1-17.3 Provider disclosure requirements.

(A) Providers shall disclose to the Ohio department of job and family services (ODJFS) or its designee full and complete information concerning the name and address of each person:

(1) Who, with respect to the provider:

(a) Is an officer or director;

(b) Is a partner;

(c) Has a direct or indirect ownership interest totaling five per cent or more; or

(d) Has an interest of five per cent or more in any mortgage, deed of trust, note, or other obligation secured by the provider if that interest equals at least five per cent of the value of the property or assets of the provider.

(2) Who, with respect to any subcontractor in which the provider has a direct or indirect ownership or control interest of five per cent or more:

(a) Is an officer or director;

(b) Is a partner;

(c) Has a direct or indirect ownership interest totaling five per cent or more; or

(d) Has an interest or five per cent or more in any mortgage, deed of trust, note, or other obligation secured by the provider if that interest equals at least five per cent of the value of the property or assets of the provider.

(3) Who has been convicted or indicted of a criminal offense related to involvement in any program operated under Title XVIII, XIX, or XX of the Social Security Act and who has an ownership or control interest in the provider, or is an agent or managing employee (i.e., an individual, including a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control or who directly or indirectly conducts the day-to-day operations).

(B) Providers shall supply ODJFS, or its designee, within thirty-five days of the date of a specific request, full and complete information concerning:

(1) The ownership of any subcontractor with which the provider has had, during the twelve months prior to the date of the request, business transactions in an aggregate amount of twenty-five thousand dollars; and

(2) Any significant business transactions occurring during the five-year period ending on the date of such request, between the facility and any wholly owned supplier or any subcontractor.

(C) Disclose whether any of the persons named, in compliance with paragraphs (A)(2) and (A)(3) of this rule, are related to another as spouse, parent, child, or sibling.

(D) Disclose the name of any other disclosing entity in which a person with an ownership or control interest in the provider also has an ownership or control interest.

(1) This requirement applies to the extent that the provider can obtain this information by requesting it in writing from the person.

(2) The provider must:

(a) Keep copies of all these requests and the responses to them;

(b) Make them available to the secretary of health and human services or ODJFS upon request; and

(c) Advise the secretary of health and human services or ODJFS when there is no response to a request.

(E) Providers shall disclose their national provider identifier (NPI) by supplying ODJFS a copy of the national plan and provider enumeration system (NPPES) NPI notification received. Upon receipt of written notification from NPPES, a provider shall report any additions, change in ownership, or change in the assignment of the provider's NPI to ODJFS.

Effective: 05/23/2007
R.C. 119.032 review dates: 03/06/2007 and 05/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 5/30/02, 8/11/05

5160-1-17.4 Conversion to time-limited provider agreements and re-enrollment.

(A) Definitions:

(1) Open-ended provider agreement. This type of provider agreement has no specific termination date and continues to be in effect as long as agreeable by both parties.

(2) Time-limited provider agreement. This type of provider agreement is for a specific period of time and will expire on a designated date unless renewed in accordance with the Ohio department of job and family services (ODJFS) re-enrollment process. A time-limited provider agreement will be limited to no longer than seven years from the effective date.

(B) The use of time-limited provider agreements pursuant to this rule does not apply to provider agreements issued to the following, including any provider agreements issued to the following that are otherwise time-limited under the medicaid program:

(1) Nursing facilities, as defined in section 5111.20 of the Revised Code ;

(2) Intermediate care facilities for the mentally retarded, as defined in section 5111.20 of the Revised Code ;

(3) Managed care organizations under contract with the department pursuant to section 5111.17 of the Revised Code; and

(4) Hospitals.

(C) The following agreements shall be time-limited agreements or will be converted to time-limited agreements pursuant to section 5111.028 of the Revised Code,unless the provider is one of the provider types listed in paragraphs (B)(1) to (B)(4) of this rule:

(1) Any new provider agreement shall be time-limited in accordance with this rule .

(2) Any existing open-ended provider agreement held by a provider that was enrolled before January 1, 2008, shall be converted to a time-limited agreement on or before January 1, 2015, in accordance with this rule .

(a) ODJFS shall select the provider agreements to be converted and automatically phase in time-limited agreements in a manner and for a time determined by ODJFS.

(b) ODJFS shall notify the provider by sending a conversion notice by regular mail to the address on file that the provider has been automatically converted to a time-limited-agreement in accordance with this rule. Providers are not required to respond to the ODJFS conversion notice.

(c) Providers that have been selected and converted to time-limited agreements may not request that the proposed expiration be altered, either to an earlier or later date.

(3) ODJFS may convert any existing open-ended provider agreement to a time-limited provider agreement whenever the conversion is in the best interest of the medicaid consumers or the state of Ohio.

(4) The conversion from an open-ended to a time-limited provider agreement does not affect the amount or scope of medicaid reimbursement.

(5) The length of time-limited agreements is decided by ODJFS and is determined by provider type. The length of time-limited agreements may vary by provider type but will be consistent for all providers within like provider types. ODJFS may change the length of time-limited agreements by provider type and the length of these agreements may change or vary upon the discretion of ODJFS.

(6) ODJFS will notify the provider when its time-limited provider agreement is close to expiration and when the re-enrollment process is required, as described in paragraph (D) of this rule.

(D) Re-enrollment is the process that a provider with a time-limited agreement is required to follow to renew its provider agreement. The re-enrollment process does not apply to MCPs or open-ended agreements. The re-enrollment process is as follows:

(1) ODJFS shall send a re-enrollment notice by regular mail ninety days prior to the expiration date of the provider's time-limited agreement to the provider's address on file notifying the provider that it is required to renew its agreement.

(2) The re-enrollment notice shall instruct the provider what is required to complete the re-enrollment process. Providers are expected to meet all conditions for participation as an eligible provider that are in effect in division 5101:3 of the Administrative Code at the time of re-enrollment.

(3) The provider shall submit all required information before the re-enrollment deadline date specified in the re-enrollment notice.

(4) A provider shall not initiate re-enrollment prior to the receipt of the re-enrollment notification sent by ODJFS as specified in paragraph (D) of this rule. This rule does not negate the requirement that a provider must disclose any changes to its provider agreement in accordance with rule 5101:3-1-17.3 of the Administrative Code. The reporting of changes in accordance with rule 5101:3-1-17.3 of the Administrative Code does not constitute the initiation of re-enrollment and remains the provider's responsibility.

(5) When a provider fails to re-enroll in the time and the manner required by ODJFS, as specified in this rule and in accordance with the re-enrollment notice referred to in paragraph (D)(2) of this rule, ODJFS may deny an application for re-enrollment or terminate a time-limited provider agreement. The denial or termination will take effect thirty days after ODJFS mails a written notice to the provider by regular mail to the address on file notifying the provider of the decision. ODJFS shall specify in the notice the date on which the provider is required to cease operating under a terminated provider agreement.

In lieu of denying an application for re-enrollment or terminating a time-limited agreement when a provider fails to re-enroll in the time and manner required and the agreement expires, ODJFS may deny claims submitted by the provider until the provider completes the re-enrollment process and the re-enrollment application is approved by ODJFS. Once the re-enrollment application is approved by ODJFS, ODJFS may allow the provider to re-submit any claims that were denied while its re-enrollment application pended ODJFS approval. ODJFS will not deny claims pursuant to this paragraph when a provider has re-enrolled in the time and the manner required by ODJFS.

(6) If a provider files an application for re-enrollment within the time and in the manner required, as specified in this rule, but the provider agreement expires before ODJFS acts on the application or before the effective date of the ODJFS decision on the application, the provider may continue operating under the terms of the expired agreement until the effective date of the ODJFS decision.

(7) If a provider files an application for re-enrollment in the time and manner required, as specified in this rule, but has not been able to obtain a renewal of its licensure, certification, accreditation, or registration due to a delay in processing by an official, board, commission, department, division, bureau or other agency of state or federal government:

(a) ODJFS shall not deny the application for re-enrollment or deny payment of services if the provider has included documentation with the re-enrollment application that the licensure, certification, accreditation, or registration has been delayed for processing by an official, board, commission, department, division, bureau or other agency of state or federal government; and

(b) When the decision is made by an official, board, commission, department, division, bureau or other agency of state or federal government to approve or reject an application for renewal of required licensure, certification, accreditation, or registration, the provider is obligated to notify ODJFS within thirty days of the date of approval or rejection in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(E) The effective date of a new provider agreement is the date on which the provider signs the application and meets all of the federal and state requirements for participation in the medicaid program. The effective date of a new provider agreement may be made retroactive for up to twelve months prior to the date of application. A retroactive period will be counted when assigning a time-limit to a new provider agreement to encompass dates on which the provider furnished covered services to a medicaid consumer for which the provider has not been reimbursed. Upon ODJFS approval of the application and the effective date of the agreement, ODJFS will accept claims submitted timely for the retroactive period. Exceptions to the twelve month retroactive period include:

(1) When required licensure, certification, accreditation, or registration is obtained by the provider within the twelve months prior to the application date, the effective date will be that date on which the required license, certification, accreditation, or registration was obtained.

(2) Claims submitted within the twelve month retroactive period will be denied for any service provided if the provider did not meet all ODJFS program requirements for participation on the date the service was provided.

(3) ODJFS may deny retroactive eligibility to a provider for failure to meet re-enrollment requirements as specified in this rule.

(F) Pursuant to section 5111.06 of the Revised Code, ODJFS is not required to issue a notice of hearing rights, in accordance with Chapter 119. of the Revised Code, when converting a provider agreement to a time-limited agreement or when terminating a time-limited provider agreement due to the provider's failure to file an application for re-enrollment.

(G) In processing an application for re-enrollment, ODJFS may conduct an on-site review at the provider's facility, place of business, or both, as ODJFS deems necessary to ensure program integrity.

Effective: 05/01/2010
R.C. 119.032 review dates: 02/09/2010 and 05/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.028
Rule Amplifies: 5111.01 , 5111.02 , 5111.028
Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79,
7/1/80, 7/7/80, 10/1/87, 1/1/95, 5/30/02, 8/11/05,
1/1/08

5160-1-17.5 Suspension of medicaid provider agreements.

(A) For purposes of this rule, the following definitions apply:

(1) "Non-agency provider" has the same meaning as independent provider, as defined in section 5111.034 of the Revised Code, and means an individual who is submitting an application for a provider agreement or who has an existing provider agreement as a non-agency provider in an Ohio department of job and family services (ODJFS) administered home and community based services program providing home and community based waiver services to consumers with disabilities.

(2) "Non-institutional provider" means any person or entity with a medicaid provider agreement other than a hospital, long-term care nursing facility, intermediate care facility for the mentally retarded, or medicaid contracting managed care plans (MCPs). MCPs are subject to rules in accordance with Chapter 5101:3-26 of the Administrative Code.

(3) "Owner" means any person having at least five percent ownership, or interest, either directly, indirectly, or in any combination in a non-institutional provider who must be disclosed in accordance with rule 5101:3-1-17.3 of the Administrative Code.

(B) ODJFS shall suspend the medicaid provider agreement held by the non-institutional provider, other than a non-agency provider, upon receiving notice and a copy of an indictment issued on or after October 1, 2007 that charges a medicaid provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense that would be a felony or misdemeanor under the laws of this state and the act relates to or results from either of the following:

(1) Prescribing, furnishing or billing for medical care, services, or supplies under the medicaid program; or

(2) Participating in the performance of management or administrative services relating to prescribing, billing, or furnishing medical care, services, or supplies under the medicaid program.

(C) ODJFS shall suspend the medicaid provider agreement of a non-institutional provider that is a non-agency provider upon receiving notice and a copy of an indictment issued on or after October 1, 2007 that charges a non-agency provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense specified in division (D) of section 5111.034 of the Revised Code.

(D) When subject to a suspension, a provider, its owner or owners, officer, authorized agent, associate, manager, or employee shall not own or provide services to any other medicaid provider or risk contractor or arrange for, render, or order services for medicaid recipients during the period of suspension. During the period of suspension, the provider, owner or owners, officer, authorized agent, associate, manager, or employee shall not receive reimbursement in the form of direct payments from ODJFS or indirect payments of medicaid funds in the form of a salary, shared fees, contracts, kick backs, or rebates or through any participating provider or risk contractor.

(E) The termination of medicaid reimbursement applies only to payments for medicaid services rendered subsequent to the date on which the notice required in paragraph (G) of this rule is sent. Claims for reimbursement for medicaid services rendered by the provider prior to the issuance of the notice may be subject to prepayment review in accordance with rule 5101:3-1-27 of the Administrative Code.

(F) The suspension shall continue in effect until the proceedings in the criminal case are completed through conviction, dismissal of the indictment, plea, or finding of not guilty. If ODJFS commences a process to terminate the suspended provider agreement, the suspension shall continue in effect until the termination process is concluded. Pursuant to section 5111.06 of the Revised Code, ODJFS is not required to take action under this provision by issuing an order pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code.

(G) ODJFS shall send notice of the suspension to the affected provider, owner or owners no later than five days after suspending a provider agreement in accordance with this rule. ODJFS shall send the notice by certified mail, return receipt requested. If such a notice is returned because the provider has failed to claim the notice or there is a failure of delivery for another reason, ODJFS shall send the notice by ordinary mail to the provider's last known address and shall obtain a certificate of mailing. Service by certified mail is complete when the return receipt is obtained by ODJFS. Service by ordinary mail is complete when the certificate of mailing is obtained by ODJFS, unless the notice is returned showing failure of delivery. In providing the notice, ODJFS shall:

(1) Describe the indictment that was the cause of the suspension, without necessarily disclosing specific information concerning any ongoing civil or criminal investigation;

(2) State that the suspension of the provider agreement will continue in effect until the proceedings in the criminal case are completed through conviction, dismissal of the indictment, pleas, or finding of not guilty and, if ODJFS commences to terminate the suspended provider agreement, until the termination process is concluded; and

(3) Inform the provider, owner or owners of the opportunity to submit to ODJFS a request for a reconsideration in accordance with this rule no later than thirty days after receiving the certified notice from ODJFS.

(H) Claims paid prior to indictment or any claims paid while under indictment are subject to post payment review and recovery in accordance with rule 5101:3-1-27 of the Administrative Code.

(I) A provider, owner or owners subject to a suspension may request a reconsideration. A request for reconsideration is not subject to a hearing pursuant to Chapter 119. of the Revised Code. The request shall be made not later than thirty days after receipt of the notice provided in accordance with paragraph (G) of this rule. The notice will be deemed received by the provider on the date that the return receipt from certified mail is signed. If the provider has failed to claim the notice, the notice will be deemed received by the provider on the date that ODJFS receives a certificate of mailing. In requesting a reconsideration, the provider, owner or owners shall submit written information and documents to ODJFS. The information and documents may pertain to any of the following issues:

(1) Whether the determination to suspend the provider agreement was based on a mistake of fact, other than the validity of the indictment;

(2) Whether any offense charged in the indictment resulted from an offense specified in paragraphs (B) and (C) of this rule.

(3) Whether the provider, owner or owners can demonstrate that the provider, owner or owners did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee that resulted in the indictment.

(J) ODJFS shall not suspend a provider agreement or terminate medicaid reimbursement if the provider, owner or owners can demonstrate that the provider, owner or owners did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee that resulted in the indictment.

(1) If ODJFS has knowledge at the time of indictment that the alleged criminal activity is limited to the individual(s) indicted, and that the provider, owner or owners did not directly or indirectly sanction the action of the individual(s) indicted, ODJFS may use that knowledge in determining that the non-institutional provider will not be suspended.

(2) If ODJFS does not have sufficient knowledge at the time of indictment to determine whether the criminal activity is limited to the individual(s) indicted, ODJFS shall notify the provider, owner or owners of the opportunity to present documentation sufficient to establish that the criminal activity is limited to the individual(s) indicted and that the provider, owner or owners did not directly or indirectly sanction this activity.

(a) The provider, owner or owners shall submit such documentation to ODJFS within thirty days after receipt of the notice provided in accordance with paragraph (G) of this rule.

(b) ODJFS shall have discretion not to impose a suspension during the period specified in paragraph (J)(2)(a) of this rule. During this period, ODJFS may place the provider on prepayment review in accordance with rule 5101:3-1-27 of the Administrative Code.

(K) ODJFS shall review the information and documents submitted in the request for reconsideration. After the review, the suspension may be affirmed, reversed, or modified, in whole or in part. ODJFS shall notify the affected provider, owner or owners of the results of the review. The review and notification of its results shall be completed not later than forty-five days after receiving the information and documents submitted in a request for reconsideration. The review shall be conducted by the ODJFS deputy director in the office where the contestation arose. The deputy director may designate a third party to hear the reconsideration provided that the designee was not involved in the original decision. Decisions made by the deputy director of ODJFS are not appealable or subject to further reconsideration.

Effective: 01/01/2008
R.C. 119.032 review dates: 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.031
Rule Amplifies: 5111.01 , 5111.02 , 5111.031

5160-1-17.6 Termination and denial of provider agreement [except long-term care nursing facilities (NFs) intermediate care facilities for the mentally retarded (ICFs-MR) and medicaid contracting managed care plans (MCPs)].

(A) For purposes of this rule, the following definitions apply:

(1) "Owner" means any person who has at least five per cent ownership, or interest, either directly, indirectly, or in any combination, as a medicaid provider or person who must be disclosed in accordance with rule 5101:3-1-17.3 of the Administrative Code.

(2) "Provider" means any individual, group practice, other corporation, or health care institution as defined in rule 5101:3-1-17 of the Administrative Code or any rule contained in division 5101:3 of the Administrative Code.

(3) "Provider Agreement" means an agreement as defined in rule 5101:3-1-17.2 of the Administrative Code or any rule contained in division 5101:3 of the Administrative Code.

(B) A provider may voluntarily terminate a provider agreement upon notice thirty days before the termination date. The Ohio department of job and family services (ODJFS) may waive the thirty day requirement if appropriate.

(C) ODJFS may terminate a provider agreement upon thirty days written notice prior to the termination date. When the termination of a provider agreement is based upon a denial, suspension, revocation, limitation, or failure to renew any license, permit, certificate or certification, the provider is ineligible for reimbursement for services provided after the effective date of the denial, suspension, revocation, failure to renew or imposition of limitation imposed by an official, board, commission, department, division, bureau, or other agency of state of federal government.

(D) ODJFS may propose termination or denial of a provider agreement at any time it is determined that continuation or assumption of provider status is not in the best interest of consumers or the state of Ohio. The phrase "not in the best interest" shall include, but not be limited to, the following circumstances or occurrences:

(1) The provider has not billed or otherwise submitted a medicaid claim to ODJFS for two years or longer.

(2) The provider, or any person having an ownership or controlling interest in the provider, or who is an agent or employee of the provider, has been indicted or granted immunity from prosecution for, or has pled guilty to, or has been convicted of, any criminal offense against the state of Ohio or any other state or territory.

(3) The provider has made false representations, by omission or commission, on the provider enrollment application or does not fully and accurately disclose to ODJFS information as required by the provider agreement or any rule contained in division 5101:3 of the Administrative Code.

(4) The provider has been determined liable for negligent performance of professional services to its clientele or patients.

(5) As determined by ODJFS, the provider has departed from or failed to conform to accepted standards of care of similar practitioners under the same or similar circumstances, whether or not actual injury to a patient is established.

(6) The provider has been formally reprimanded or censured, placed on probation, suspended or placed on practice limitations for unethical conduct or improper practices by a state licensure board or by an association of its peers.

(7) The provider fails to file cost reports as required.

(8) The provider makes false statements, provides false information, or alters records, documents, charts, or prescriptions, or fails to cooperate or provide records or documentation upon request during an audit or review of provider activity by staff or contracting entity of ODJFS, any county department of job and family services, the attorney general's office, the auditor of state, the department of health and human services, or any other state or federal agency which, by law, has authorized access to records or documents. An alteration of provider records does not include records for which there is a properly documented correction.

(9) The provider has not corrected deficiencies after receiving a written notice of operational deficiencies from ODJFS.

(10) The provider fails to abide by or have the capacity to comply with the terms and conditions of the provider agreement, and/or rules and regulations promulgated by ODJFS.

(11) The provider has been suspended or terminated from participation in another government medical program other than a program that requires automatic termination.

(12) The provider is found in violation of section 504 of the Rehabilitation Act of 1973, as amended, or the Civil Rights Act of 1964, as amended, in relation to the employment of individuals, the provision of services or in the purchase of goods and services.

(13) The provider, by any act or omission, has negatively affected the health, safety, or welfare of the medicaid consumers or the fiscal or programmatic integrity of the medicaid program.

(14) The office of the attorney general, auditor of state, or any board, bureau, commission, or department has recommended that ODJFS terminate the provider agreement where the reason for the request bears a reasonable relationship to the administration of the medicaid program, or the integrity of state and/or federal funds.

(15) As determined by ODJFS, the provider fails to use reasonable care or discretion in the storage, administration, dispensing, or prescribing of drugs, or fails to employ acceptable scientific methods in the selection of drugs or other modalities of treatment of disease.

(16) As determined by ODJFS, the provider sells, gives away, personally furnishes, prescribes, or administers drugs for other than legal and legitimate therapeutic purposes.

(17) The United States drug enforcement agency has suspended or revoked the provider's registration for any act or acts which would constitute a violation of paragraph (D)(5), (D)(15), or (D)(16) of this rule.

(18) After ODJFS has provided written billing instructions, the provider or the provider's staff misrepresents the type and/or units of service, inflates billing codes to increase payments, or bills for, or receives payments for services not rendered, or any other practice that is a violation of any rule contained in the division 5101:3 of the Administrative Code.

(19) As determined by ODJFS, the provider, or the provider's staff prescribes, authorizes, bills for, or receives payments for, services that are not medically necessary as defined in rule 5101:3-1-01 of the Administrative Code.

(20) The provider or the provider's staff lack the ability or legal authority to provide services for which the provider has billed, because of lack of equipment or material, or a failure to comply with minimal requirements under state and federal law.

(21) The provider consistently violates the prohibition against billing medicaid consumers or assigning provider claims to a factor, as found in rule 5101:3-1-13.1 or 5101:3-1-23 of the Administrative Code.

(22) The provider fails to notify ODJFS within thirty days of any changes in licensure, certification, accreditation, or registration status, ownership, closure, specialty, additions, deletions, or replacements in group memberships, and address, as referenced in paragraph (F) of rule 5101:3-1-17.2 of the Administrative Code.

(23) The provider fails to repay an overpayment or recovery amount assessed as a result of a final adjudication order.

(24) The provider has a previous or current exclusion, suspension, termination or involuntary withdrawal from participation in any medicaid program, or any other public or private health insurance program.

(25) The provider has been convicted under federal or state law of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.

(26) The provider has not responded to two certified mail correspondences and the provider's business cannot otherwise be located.

(27) The provider signed a time-limited provider agreement and failed to notify ODJFS of the intent to renew the provider agreement in accordance with rule 5101:3-1-17.4 of the Administrative Code.

(28) The provider fails to meet all applicable provider requirements set forth in division 5101:3 of the Administrative Code.

(29) Any reason permitted or required by federal law.

(E) For any reason permitted or required by federal law, ODJFS may deny or exclude from participation in the medicaid program any individual, provider of services or goods, or other entity that does not possess a medicaid provider agreement.

(F) ODJFS shall terminate or deny a provider agreement when any of the following apply:

(1) Any license, permit, or certification that is required in the provider agreement or department rule has been denied, suspended, revoked, not renewed or is otherwise limited and the provider has been afforded the opportunity for a hearing in accordance with the hearing process established by the official, board, commission, department, division, bureau, or other agency of state or federal government.

(2) The terms of a provider agreement require the provider to hold a license, permit, or certificate, or maintain certification, issued by an official, board, commission, department, division, bureau, or other agency of state or federal government, other than ODJFS, and the provider has not obtained the license, permit, certificate, or maintained the certification.

(3) An official, board, commission, department, division, bureau, or other agency of this state, other than ODJFS, has denied, terminated, or not renewed a license, permit, certificate or certification that is required for participation, notwithstanding the fact that the provider may hold a license, permit, certificate or certification from an official, board, commission, department, division, bureau, or other agency of another state.

(4) A judgment has been entered in either a criminal or civil action against a medicaid provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code, except if the provider or owner can demonstrate to ODJFS that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee which resulted in the conviction or entry of judgment.

(5) The provider is terminated, suspended, or excluded by the medicare program and/or by the federal department of health and human services and that action is binding on the provider's participation in the medicaid program or renders federal financial participation unavailable for that provider's participation in the medicaid program.

(6) The provider has been convicted of, or pled guilty to any criminal activity materially related to either the medicare or medicaid program.

(7) The provider has been convicted of one of the offenses that caused the provider agreement to be suspended in accordance with rule 5101:3-1-17.5 of the Administrative Code.

(8) The provider has failed to apply for re-enrollment within the time and in the manner specified for re-enrollment pursuant to section 5111.028 of the Revised Code.

(9) The provider fails to timely submit a required background check or when the background check reveals that the provider has been convicted of, or pled guilty to a disqualifying offense unless the provider meets specific circumstances provided in division 5101:3 of the Administrative Code.

(10) ODJFS has determined that the provider facility has closed or is not providing medicaid covered services.

(G) Appeal rights for the termination or denial of a provider agreement provided in this rule are found in rule 5101:3-1-57 of the Administrative Code.

(H) In determining the length of termination, ODJFS shall consider the following:

(1) The number and nature of program violations and other related offenses and the degree to which the provider participated in the offense;

(2) The nature and extent of any adverse impact the violations have had on consumers, including but not limited to the health and safety of those consumers who are aged and/or at greater physical, mental and emotional risk;

(3) The amount of any damages incurred by the medicaid program;

(4) Whether there are any mitigating circumstances;

(5) Any other facts bearing on the nature and seriousness of the violations or related offenses;

(6) The current, pending and previous sanction record of the provider under the medicare, medicaid, or other health-related programs; and

(7) Whether the provider is pending any future state or federal litigation relating to the current or any similar offense.

(I) ODJFS reserves the right to deny twelve months retroactivity for the submission of claims to providers whose agreement is reinstated after termination for cause in accordance with this rule.

Effective: 01/01/2008
R.C. 119.032 review dates: 08/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.028 , 5111.031 , 5111.032
Rule Amplifies: 5111.01 , 5111.02 , 5111.028 , 5111.031 , 5111.032
Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 6/16/88, 7/1/90, 1/1/95, 8/1/96, 5/30/02, 8/11/05

5160-1-17.7 Application by a former participating medicaid provider to resume participation in the Ohio medicaid program [except for medicaid contracting managed care plans (MCPs)].

(A) An individual or entity that at one time was a participating provider in the Ohio medicaid program and whose provider agreement was terminated either voluntarily or involuntarily in accordance with rule 5101:3-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program.

(B) In considering an application for participation in the Ohio medicaid program by a former medicaid provider described in paragraph (A) of this rule, and except as provided by paragraphs (C) and (D) of this rule, the Ohio department of job and family services (ODJFS) may grant the application only if it is reasonably certain that the types of actions that formed the basis for termination or exclusion have not recurred and will not recur. In making this determination, ODJFS will consider, in addition to any factors set forth in state law:

(1) The conduct of the former medicaid provider from the date the provider's previous provider agreement was terminated;

(2) Whether all fines, and all debts due and owing, including overpayments, to any federal, state or local government that relate to any of the state health care programs, have been paid, or satisfactory arrangements have been made, that fulfill these obligations; and (3) Whether all requirements for participation are met at the time of the application filed pursuant to paragraph (A) of this rule, as evidenced by all appropriate and required documentation submitted with the application by the former medicaid provider.

(C) Notwithstanding paragraph (B) of this rule, ODFJS shall deny the application of a former medicaid provider whose provider agreement was terminated under paragraph (F)(4) or (F)(6) of rule 5101:3-1-17.6 of the Administrative Code.

(D) In the case of a former medicaid provider that allowed its provider agreement to lapse by failing to timely renew its provider agreement, and whose provider agreement has been inactive for at least sixty days, ODJFS may, without regard to the criteria set forth in paragraph (B) of this rule and at its discretion, grant an application that demonstrates through all appropriate and required documentation that the requirements to participate as a medicaid provider are met at the time the application is filed.

(E) If ODJFS approves an application filed under paragraph (A) of this rule, it must give written notice to the applicant specifying the date on which participation in the Ohio medicaid program may resume. The notice shall specify whether the applicant is assigned its former provider number or a new provider number, the determination of which shall be in the sole discretion of ODJFS.

(F) If ODJFS does not approve an application filed under paragraph (A) of this rule, it must give the applicant written notice of that decision. The notice will provide review rights in accordance with rule 5101:3-1-57 of the Administrative Code.

Effective: 12/19/2009
R.C. 119.032 review dates: 12/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02

5160-1-17.8 Provider screening and application fee.

(A) To become an eligible provider as described in rule 5101:3-1-17 of the Administrative Code, a provider must meet the screening requirements described in this rule and pay an applicable application fee if required in the appendix to this rule. Provider screening and application fees are required at the time of enrollment and re-enrollment as defined in rule 5101:3- 17.4 of the Administrative Code.

(1) Exemptions from this rule.

(a) If a provider is required to participate in the medicare program as a condition of enrollment in medicaid or elects to participate in the medicare program and has met the provider screening requirements and paid an applicable application fee to the centers for medicare and medicaid services (CMS) or its designee, the provider is exempt from this rule.

(b) If a provider has met the provider screening requirements and paid an applicable application fee to another state medicaid agency or its designee, the provider is exempt from this rule.

(c) A provider must provide documentation to support it meets the criteria for an exemption described in paragraphs (A)(1)(a) and (A)(1)(b) of this rule.

(2) The appendix to this rule sets forth:

(a) The screening risk level assigned to each provider type in accordance with paragraph (B) of this rule; and

(b) The provider types that must pay an application fee in accordance with paragraph (C) of this rule.

(B) Screening requirements differ by risk level. If more than one risk level could apply to a provider, the highest level of screening is required.

(1) Limited.

(a) Providers are subject to verification that they meet any applicable medicaid requirements as stated in division 5101:3 of the Administrative Code for their provider type; and

(b) Providers are subject to license verifications, including state licensure verification in states other than Ohio; and

(c) Providers are subject to database checks on a pre- and post-enrollment basis to ensure that providers continue to meet the enrollment criteria for their provider type.

(i) Database checks must confirm the identity and exclusion status of providers and any person with a five per cent or greater ownership or control interest; or any person who is an agent or an individual (including a general manager, business manager, administrator, director, or consultant) who directly or indirectly manages, advises, or supervises any element of the practices, finances, or operations of the provider entity.

(ii) Databases to be checked include, but are not limited to, the social security administration's death master file, the national plan and provider enumeration systems (NPPES), the list of excluded individuals/entities (LEIE), and the excluded parties list system (EPLS).

(2) Moderate.

(a) Providers are subject to the requirements in paragraph (B)(1) of this rule; and

(b) Providers are subject to on-site visits.

(i) Pre- and post-enrollment site visits by the Ohio department of job and family serivces (ODJFS) or its designee will verify that information provided to ODJFS or its designee is accurate and to determine compliance with medicaid enrollment requirements.

(ii) Once enrolled, providers must allow CMS or its agents or contractors, or ODJFS or its agents or contractors to conduct unannounced on-site inspections of any and all provider locations.

(3) High.

(a) Providers are subject to the requirements in paragraphs (B)(1) and (B)(2)(b) of this rule; and

(b) Each person with a five per cent or greater ownership or control interest with the provider is subject to a criminal background check and is required to submit his or her fingerprints within thirty days of submission of the application in a form and manner determined by ODJFS, or its designee.

(C) Application fee.

(1) Provider types identified as subject to an application fee in the appendix to this rule must submit the fee in a form and manner determined by ODJFS at the time of application for enrollment or re-enrollment as a medicaid provider. If proof of fee payment is not submitted with the provider's application, the application will be denied.

(2) Individual physicians and non-physician practitioners are exempt from paying an application fee in accordance with 42 C.F.R. 455.460 , effective February 2, 2011.

(3) ODJFS may waive an application fee if:

(a) ODJFS determines that imposing the fee would have an adverse impact on beneficiary access to services; and

(b) ODJFS has requested and CMS has approved a waiver of the fee.

(4) If ODJFS receives approval from CMS to waive a medicaid application fee, providers are still subject to the screening requirements set forth in this rule.

(5) The application fee is equal to the amount established by CMS and includes an annual adjustment for inflation in accordance with paragraph (a)(2)(C)(i) of 42 U.S.C. 1395cc(j) .

(6) The application fee will not be refunded if:

(a) Enrollment is denied as a result of failure to meet the provider screening requirements described in this rule; or

(b) If enrollment is denied based on the results of the provider screening.

(D) If enrollment is denied as a result of failure to meet the provider screening requirements or failure to pay any associated application fee, the provider may request a hearing pursuant to Chapter 119. of the Revised Code.

Click to view Appendix

Effective: 03/31/2012
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.063
Rule Amplifies: 5111.02 , 5111.063

5160-1-17.9 Ordering or referring providers.

(A) Definitions for purposes of this rule only:

(1) A "participating provider" is an active provider who bills the medicaid program for rendered services, or who is an active provider who orders, prescribes, refers, or certifies but does not bill the medicaid program.

(2) An "ordering or referring only provider" is a provider who orders, prescribes, refers, or certifies an item or service reported on a claim, and is not a billing provider in the medicaid program. For example: a provider orders items or services for the medicaid consumer, such as prescription drugs, durable medical equipment, prosthetics, orthotics, and supplies, clinical laboratory services, or imaging services, and may certify home health services for a medicaid consumer.

(3) "Physician" or "supervising physician" means an individual authorized to practice medicine in Ohio or another state.

(4) "Other professional" means those providers, other than physicians, who order, prescribe, refer, or certify an item or service reported on a claim. Examples include but are not limited to: physician assistant, clinical nurse specialist, nurse practitioner, clinical psychologist, certified nurse midwife, clinical social worker, and interns, residents, and fellows.

(B) A physician or other professional who is an ordering or referring only provider of medicaid services must be enrolled as a participating provider with the medicaid program.

(C) An ordering or referring only provider shall be considered limited risk for purposes of screening, as defined in rule 5101:3-1-17.8 of the Administrative Code.

(D) Ordering and referring only providers who are enrolled with the office shall revalidate in accordance with rule 5101:3-1-17.4 of the Administrative Code.

(E) Claims for services that require an order, prescription, referral, or certification will be denied if they do not include the following:

(1) A valid national provider identifier (NPI) and the legal name of the ordering, prescribing, referring, or certifying provider; or,

(2) If the ordering, prescribing, referring, or certifying provider is not a provider type eligible to participate in Ohio medicaid, a valid NPI and the legal name of the physician or other professional supervising the ordering or referring provider.

(F) This rule does not apply to services delivered through medicaid managed care plans.

Effective: 01/01/2014
R.C. 119.032 review dates: 07/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02

5160-1-19 Claim submission.

(A) The following claims for services rendered to medicaid consumers are exempt from this rule:

(1) Claims for services provided through medicaid managed care plans must be submitted in accordance with Chapter 5101:3-26 of the Administrative Code; and

(2) Claims submitted by nursing facility providers must be submitted in accordance with rules 5101:3-1-05, 5101:3-1-08, and 5101:3-3-39.1 of the Administrative Code.

(3) Claims submitted by a provider or type of provider required by the office of medical assistance to submit claims in a format other than the electronic claims submission formats provided in paragraph (B) of this rule.

(B) All other claims, except for a state agency that has an interagency agreement with the office of medical assistance (OMA) to submit claims in a different format, must be submitted to the OMA through one of the following formats:

(1) Electronic data interchange (EDI) in accordance with standards established under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. EDI formats for claims submission include:

(a) The "837 Health Care Claim Professional" (837P) electronic format;

(b) The "837 Health Care Claim Institutional" (837I) electronic format; or

(c) The "837 Health Care Claim Dental" (837D) electronic format.

(2) The medicaid information technology system (MITS) web portal; or

(3) Pharmacy point-of-sale .

(C) Claims must be submitted pursuant to the national correct coding initiative and coding standards set forth in the following guides and described in 45 CFR 162.1000 and 45 CFR 162.1002 :

(1) The healthcare common procedure coding system;

(2) The current procedure terminology codebook;

(3) The current dental terminology codebook; or

(4) The international classification of diseases codebook.

(D) Timely filing limitations.

(1) Original claim submissions.

(a) Claims other than inpatient hospital claims must be received by OMA within three hundred sixty-five days of the actual date the service was provided.

(b) Inpatient hospital claims must be received within three hundred sixty-five days from the date of discharge.

(c) Claims received beyond three hundred sixty-five days from the actual date of service or hospital discharge will be denied except when the provisions of paragraph (E) of this rule apply.

(d) For purposes of this rule, the date of receipt is the date OMA assigns an internal control number.

(2) Re-submission of denied claims.

(a) Claims denied by the OMA may be re-submitted for payment and must be received by the later of the following dates:

(i) Three hundred sixty-five days from the actual date or service; or

(ii) One hundred eighty days from the date the claim denied, even if this date is beyond three hundred sixty five days from the original date of service.

(b) Resubmitted claims received beyond seven hundred thirty days from the actual date of service or hospital discharge will be denied.

(3) Claims with prior payment by medicare or another insurance plan must be received within one hundred eighty days from the date medicare or the insurance plan paid the claim.

(E) Exceptions to timely filing requirements.

(1) When submission of a claim is delayed due to the pendency of an administrative hearing decision by the Ohio department of job and family services (ODJFS) or an eligibility determination by a county department of job and family services (CDJFS), the claim must be received within one hundred eighty days from the date of the administrative hearing decision by ODJFS or the eligibility determination by the CDJFS. Documentation showing the date of service and the administrative hearing decision or eligibility determination must be submitted with the claim. In no case shall a delay in processing eligibility information at the CDJFS (as required in rule 5101:1-38-01.2 of the Administrative Code) be a basis for denial of payment under this provision.

(2) When a claim can not be submitted to OMA within three hundred sixty five days of the actual date of service due to coordination of benefits delays with medicare and/or other third party payers, the claim must be received by OMA within one hundred eighty days from the date medicare or the other insurance plan paid the claim.

(3) When a claim has been submitted and denied and is later found to meet the provisions in paragraph (E)(1) or (E)(2) of this rule, the claim may be resubmitted with documentation attached to support the delay in submission.

(F) Adjustments to claims.

(1) Adjustments to underpaid claims must be submitted within one hundred eighty days from the date medicaid paid the claim.

(2) Adjustments to overpaid claims must be submitted, and overpayments refunded, to OMA, within sixty days of discovery.

(a) Overpayments are recoverable by OMA at the time of discovery. Appeal rights under Chapter 119. of the Revised Code may be exercised to the extent provided in accordance with rule 5101:3-1-57 of the Administrative Code. All recoverable amounts are subject to the application of interest in accordance with rule 5101:3-1-25 of the Administrative Code.

(b) OMA will pursue collections by invoice for overpayments that result in a credit balance due to the OMA and remain outstanding for more than sixty days.

(3) Adjustments may be submitted through the EDI format or through the MITS web portal.

(4) OMA will no longer accept paper adjustment forms, except in cases where OMA determines a paper adjustment must be used for a claim to be adjusted.

(5) OMA will no longer process refund checks from providers for claim overpayments, except when an invoice or letter for collection of an outstanding overpayment has been sent to the provider for an OMA audit or review.

(G) Claims that require a specific OMA form to accompany the claim (for example, a claim for a hysterectomy service must have a hysterectomy consent form accompany the claim) may be submitted through the web portal, regular mail, or EDI format.

(1) Claims submitted via EDI shall be consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant format.

(2) All supporting documentation shall be submitted with the designated electronic data management system (EDMS) cover sheet.

(H) Trading partners submitting EDI transactions.

(1) Trading partners must enroll and receive an OMA defined trading partner number in order to submit EDI transactions.

(2) To become an active trading partner with OMA, all trading partners must abide by all OMA testing requirements, including the completing of a ninety per cent pass rate for each transaction type tested.

(3) Only authorized trading partners that are actively submitting and receiving 837 health care claim transaction sets may submit and receive the 270/271 and the 276/277 transaction sets.

Effective: 01/01/2013
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.052
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5111.052
Prior Effective Dates: 6/1/78, 6/3/83, 8/1/83 (Emer), 10/1/83, 2/1/84, 10/1/84, 7/1/85 (Emer), 7/11/85 (Emer), 9/30/85, 8/1/86, 10/1/87, 2/1/88, 5/1/89, 7/1/90, 7/1/02, 7/1/03, 10/16/03 (Emer), 1/1/04, 11/15/04, 12/30/04 (Emer), 4/1/05, 3/28/05, 7/1/05, 12/30/05 (Emer), 3/27/06, 12/29/06 (Emer), 3/29/07, 5/23/07, 12/31/07 (Emer), 3/30/08, 12/31/08 (Emer), 3/31/09, 12/31/09 (Emer), 2/1/10, 3/31/10, 8/2/11

5160-1-19.9 Inquiries regarding the status of claims [except for services provided through a medicaid managed care program].

(A) Prior to the submission of inquiries regarding the status of claims, the provider should assure that:

(1) The provider's accounts receivable have been properly reconciled using the department's remittance advice statements, including adjusting any billed amounts which exceed the department's maximum reimbursement limit. Remittance advice statements are defined as an electronic "835 Health Care Claim Payment/Advice", a cartridge tape remittance advice, or a paper remittance.

(2) The claim meets claim submission requirements defined in rule 5101:3-1-19.3 of the Administrative Code.

(3) The services provided were medicaid covered services.

(4) Eligibility of the consumer is verified using the interactive voice response unit (IVRU) or the "270/271 Health Care Eligibility Benefit Inquiry and Response", if the claim was previously rejected as "consumer ineligible for medicaid."

(B) Written inquiries about the status of claims must include a copy of the remittance advice (if the claim has been denied), the ODJFS problem claim form JFS 06653 (Rev. 07/2003), and an original invoice and be sent to the Ohio department of job and family services, provider network management section. Telephone inquiries may also be made to voice response unit in the provider network management section.

(C) EDI inquiries must be submitted as "276/277 Health Care Claim Status Request and Response" transaction formats.

R.C. 119.032 review dates: 02/04/2005 and 02/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 10/1/87, 5/1/89, 7/1/02, 10/16/03 (Emer.), 1/1/04

5160-1-20 Electronic data interchange (EDI) trading partner enrollment and testing.

(A) For purposes of this rule, the following definitions apply:

(1) "Covered entity," as defined by 45 C.F.R. 160.103 (rev. 1/2013), is a health plan, a health care clearinghouse, or a health care provider that transmits health care information in an electronic format in connection with a transaction covered by this rule. The following definitions apply:

(a) "Health plan" is an individual or group health plan that provides, or pays the cost of medical care.

(b) "Health care clearinghouse" is a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and value-added networks and switches, that does either of the following functions:

(i) Processes or facilitates the processing of health information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction; or

(ii) Receives a standard transaction from another entity and processes or facilitates the processing of health information into a nonstandard format or nonstandard data content for the receiving entity.

(c) "Health care provider" is a provider of medical or health services, and any person or organization who furnishes, bills for, or is paid for health care services in the normal course of business.

(2) "Electronic data interchange (EDI) transactions" are transactions developed by standards development organizations recognized by the federal centers for medicare and medicaid services (CMS) and adopted by the Ohio department of medicaid (ODM). The different EDI transactions are defined as follows:

(a) "ANSI X12 820 premium payment" is a transaction used to make a payment and/or send a remittance advice.

(b) "ANSI X12 834 monthly member roster or enrollment/disenrollment in a health plan" is a transaction used to establish communication between the sponsor of the insurance product and the payer.

(c) "ANSI X12 835 health care claims payment/remittance advice" is a transaction used to make a payment and/or send an explanation of benefits remittance advice.

(d) "ANSI X12 837 health care claim" is a transaction used to submit health care claim billing/encounter information, or both, from providers (institutional, professional, or dental) of health care services to payers, either directly or via clearinghouses.

(e) "ANSI X12 270 eligibility, coverage, or benefit inquiry" is a transaction used to inquire about the eligibility, benefits or coverage under a subscriber's health care policy.

(f) "ANSI X12 271 eligibility, coverage, or benefit information response" is a transaction used to communicate information about, or changes to, eligibility, benefits, and/or coverage.

(g) "ANSI X12 276 health care claim status request" is a transaction used to request the status of a health care claim.

(h) "ANSI X12 277 health care claim status notification" is a transaction used to respond to a request regarding the status of a health care claim.

(i) "ANSI X12 278 health care services review information request and response" is a transaction used to transmit health care service information for the purpose of referral, certification/authorization, notification, or reporting the outcome of a health care services review.

(3) "Eligibility verification services (EVS) vendor" means an entity with which a state contracts for the purpose of providing medicaid recipient eligibility verification data to state-approved medicaid providers that provide medical services to persons who are eligible for medicaid assistance.

(4) "Trading partner" is a covered entity or EVS vendor that submits, receives, routes, and/or translates EDI transactions directly related to the administration or provision of medical assistance provided under a public assistance program.

(B) Trading partners submitting EDI transactions.

(1) Trading partners must meet the definition of a covered entity as defined in paragraph (A)(1) of this rule or be an EVS vendor.

(2) To enroll as a medicaid EDI trading partner with ODM under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and be issued a trading partner number, a covered entity must complete the following:

(a) Complete and submit the medicaid "Trading Partner Profile" by completing the trading partner enrollment process.

(b) The JFS 06306 "Designation of an 835 or 834-820 Trading Partner" form (rev. 12/2006). This form is required only if the trading partner will be receiving the 835 remittance advice on behalf of its clients.

(c) A trading partner agreement. Two original trading partner agreements must be signed by an authorized representative of the trading partner and submitted to ODM. A countersigned original will be returned to the trading partner and must be kept on file.

(3) Once the medicaid trading partner number is assigned, the trading partner is eligible to submit claims, claim status inquiries, or eligibility inquiries for the testing process in accordance with paragraph (C) of this rule.

(C) Testing requirements.

(1) To become an active trading partner with ODM, all trading partners must abide by all ODM testing requirements as outlined in this paragraph and in the "Electronic Data Interchange Trading Partner Information Guide." The "Electronic Data Interchange Trading Partner Information Guide" is available at http:// medicaid.ohio.gov.

(a) Trading partners are required to submit three files per the following transaction types that must pass testing: 837 (professional, institutional and dental), 270 (eligibility) and 276 (claim status inquiry).

(b) Trading partners are only required to test the transaction types that they will be submitting in production.

(c) Each file must contain a minimum of fifty claims, claim status inquiries, or eligibility inquiries.

(d) All EDI files must completely pass X12 integrity testing, HIPAA syntax, and HIPAA situation testing. Trading partners are required to modify their EDI files in accordance with any new federally mandated HIPAA standards.

(e) During testing, trading partners may submit one claim file per day, per 837 transaction (one professional, one institutional, and one dental) and/or one eligibility inquiry and/or one claim status inquiry per day.

(f) Test files are considered passing when ninety per cent of the claims submitted pass the test adjudication process. A ninety per cent pass rate must be reached for each transaction type tested.

(D) Trading partners that are not actively submitting and receiving 837 health care claim transaction sets but who are actively submitting and receiving 270/271 and 276/277 transaction sets are subject to the following requirements:

(1) Trading partners must provide, in a manner specified by ODM, a report of all providers by national provider identifier (NPI) that the trading partner represents. The first report is due at the time of initiating a trading partner agreement with ODM. Subsequent reports are due quarterly based on the calendar year, no later than January first, April first, July first and October first.

(2) Trading partners shall be responsible for any breach of information and be held fully liable for any and all costs relating to such a breach.

Effective: 07/03/2014
R.C. 119.032 review dates: 11/01/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03 , 5164.02
Prior Effective Dates: 10/16/03 (Emer.), 1/1/04, 11/15/04, 5/23/07, 12/11/11

5160-1-23 Assignment of provider claims.

Payment for medicaid covered services rendered to medicaid consumers may be made only to a medicaid provider except as provided in this rule.

(A) Payment for medicaid covered services may be made in accordance with paragraphs (A)(1) to (A)(3) of this rule:

(1) Payment may be made to or through a billing agency or accounting firm that prepares invoices or receives payments in the name of the medicaid provider if the compensation meets the following requirements:

(a) It is related to the cost of processing the billing;

(b) It is not related on a percentage or other basis to the amount that is billed or collected; and

(c) It is not dependent upon the collection of the payment.

(2) For individual practitioners, payment may be made as follows:

(a) To the employer of the practitioner, if the practitioner requires as a condition of employment to turn over his or her fees to the employer;

(b) To the facility in which the service is provided, if the practitioner has a contract under which the facility submits the claim; or

(c) To a foundation, plan, or similar organization operating an organized health care delivery system, such as a managed care organization, if the practitioner has a contract under which the organization submits the claim.

(3) Payment may be made by reassignment from the medicaid provider to a government agency or reassignment by a court order.

(B) Medicaid providers are responsible for any payment received under their provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code. The assignment of provider claims must be in accordance with services rendered by valid providers under Chapter 5101:3-1 of the Administrative Code. Medicaid providers that receive payment for any assignment of provider claims that is false or misleading may be prosecuted under federal and state law.

(C) Payment for any covered service rendered to a medicaid consumer may not be made to or through a factor. A "factor" is defined as an individual or an organization such as a collection agency or service bureau that advances money to a provider for accounts receivable that have been assigned, sold, or otherwise transferred to such an organization or an individual for an added fee or a deduction of a portion of such accounts receivable.

Replaces: 5101:3-1-23

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 6/3/83, 2/1/84, 10/1/84, 7/1/85 (Emer), 9/30/85, 10/1/87, 5/30/02

5160-1-25 Interest on overpayments made to medicaid providers.

(A) Except for medicaid contracting managed care plans (MCPs), and nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICF/IID) rate recalculations performed in accordance with sections 5165.41 and 5124.41 of the Revised Code, any provider of services or goods contracting with the Ohio department of medicaid (ODM) pursuant to Title XIX of the Social Security Act who, without intent, obtains payment from the medicaid program in excess of the amount to which the provider is entitled becomes liable for payment of interest charged in accordance with this rule on the amount of the overpayment. The interest rate charged is the average bank prime rate in effect on the first day of the calendar quarter during which the provider receives notice of the excess payment,as determined in accordance with section 5164.60 of the Revised Code. Interest payments shall be calculated on the basis of simple interest.

(B) Interest payments shall be charged on a daily basis for the period from the date the payment was made to the date upon which repayment is received by the state.

(C) The "date payment was made" shall mean the following:

(1) For any reasonable cost basis, prospective payment basis, or other cost-related rate final settlement issued by ODM, the "date payment was made" shall be ten days from the date the final settlement is received by the provider as shown by the U.S. postal service return receipt slip, with a notice of rights to appeal pursuant to Chapter 119. of the Revised Code.

(2) For audits conducted in accordance with rule 5160-1-27 of the Administrative Code, the "date payment was made" shall be the latest date a warrant or electronic funds transfer (EFT) was issued to pay an item included in the random sample.

(3) For post-payment reviews conducted in accordance with rule 5160-1-27 of the Administrative Code, the "date payment was made" shall be the latest date a warrant or EFT was issued in payment of a claim that is included in the review.

(D) The "date upon which repayment is received by the state" shall mean the following:

(1) In the case of repayment by check or EFT, the "date upon which repayment is received by the state" shall be the date the repayment is date-stamped by ODM, the date the repayment is deposited as certified mail with the U.S. postal service, or the date the EFT is deposited in the state's account.

(2) In the case of repayment by one or more offsets implemented by the ODM claims adjustment unit against future claims payments owed to the provider, the "date upon which repayment is received by the state" shall be the date on which the total amount of the overpayment is fully recovered.

(E) ODM may waive interest when voluntary repayment is made by a provider before any notification by ODM that an overpayment has occurred.

Effective: 09/04/2014
R.C. 119.032 review dates: 06/13/2014 and 09/04/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.60
Prior Effective Dates: 8/1/82 (Temp), 11/1/82, 2/1/84, 10/1/87, 5/30/02, 09/01/2007

5160-1-27 Review of provider records.

(A) As specified in division 5101:3 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish medical necessity, and to fully disclose the basis for the type, extent, and level of the services provided to medicaid consumers, and to document significant business transactions. Medicaid providers are required to provide such records and documentation to the Ohio department of job and family services (ODJFS), the secretary of the federal department of health and human services, or the state medicaid fraud control unit upon request.

(B) For purposes of this rule, the following definitions apply:

(1) "Audit" means a formal postpayment examination, made in accordance with generally accepted auditing standards, of a medicaid provider's records and documentation to determine program compliance, the extent and validity of services paid for under the medicaid program and to identify any inappropriate payments. The department shall have the authority to use statistical methods to conduct audits and to determine the amount of overpayment. An audit may result in a final adjudication order by the department.

(2) "Hold and Review" means a process of prepayment review of a medicaid provider's claims, including client records, medical records, or other supporting documentation, for determination of appropriate claims payment or reimbursement.

(a) Hold and review administered by ODJFS will be done in accordance with rule 5101:3-1-27.1 of the Administrative Code.

(b) Hold and review administered by state agencies other than ODJFS will be done in accordance with rule 5101:3-1-27.2 of the Administrative Code.

(3) "Review" means a postpayment limited scope investigation, special project and/or special analysis, examination or monitoring of a medicaid provider's records, claims and/or supporting documentation to determine quality of care, compliance with accepted standards of care, program compliance and/or validity of services rendered, billed, or paid for under the medicaid program. A review may result in an educational letter, the denial of invalid services or claims, a corrective action plan subject to department approval, and/or the collection of overpayments under rule 5101:3-1-19.8 of the Administrative Code.

(4) "Notice of operational deficiency" means a written notice issued by the department that identifies provider conduct, treatment or practices that are determined by the department not to be in the best interests of the consumer or the medicaid program and/or are noncompliant with the regulations governing the medicaid program and that must be corrected. The notice states the nature of the deficiency, the time period that the provider has to correct the deficiency and the person within the department the provider is to contact to verify that the deficiency has been corrected.

(C) Records, documentation and information must be available regarding any services for which payment has been or will be claimed to determine that payment has been or will be made in accordance with applicable federal and state requirements. For the purposes of this rule, an invoice constitutes a business transaction but does not constitute a record which is documentation of a medical service.

(D) Various methods of audit and review will be utilized in all cases of suspected waste and abuse, in accordance with rule 5101:3-1-29 of the Administrative Code. If waste and abuse are apparent, the department will take action to gain compliance and recoup inappropriate payments.

(E) The provider must maintain all records as stipulated in this rule and rule 5101:3-1-17.2 or Chapter 5101:3-3 of the Administrative Code, as applicable.

(F) All records, documentation and/or information requested in accordance with paragraph (B) of this rule shall be submitted to the department or its' designee, in an appropriate manner as determined by the department. Records subject to audit and review must be produced at no cost to the department.

(1) Records subject to audit and review must be made available for examination in the time period described in rule 5101:3-1-17.2 of the Administrative Code, or as determined by the department or its' designee. Failure to supply requested records, documentation and/or information as indicated in this rule will result in no payment for outstanding services.

(2) In all situations the department has the authority to conduct an on-site visit with the provider at the provider's location for the examination or collection of records, and/or for compliance verification. Upon such occasions, as deemed necessary by the department or its' designee, a member of the provider's staff is to be assigned to assist in collecting the information. Upon request from the department, the provider will photocopy or make the applicable records available for photocopying.

(3) Services billed to and reimbursed by the department, which are not validated in the consumers record, are subject to recoupment through the audit and review process described in this rule.

Effective: 09/01/2007
R.C. 119.032 review dates: 02/12/2007 and 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.10 , 5111.85
Rule Amplifies: 5111.10 , 5111.02 , 5111.85
Prior Effective Dates: 4/7/77, 7/1/80, 10/1/84, 10/1/87, 7/1/90, 8/1/96, 5/30/02

5160-1-27.1 Hold and review process.

(A) "Hold and Review" is defined in accordance with rule 5101:3-1-27 of the Administrative Code.

(1) Hold and review without prior notification.

(a) The Ohio department of job and family services (ODJFS) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons:

(i) In response to allegations of fraud or other willful misrepresentation of claims submission; or

(ii) When a provider has been indicted for a criminal offense.

(b) ODJFS shall notify the provider in writing within ten business days that the provider's claims have been, and will continue to be, subject to hold and review. The notice shall describe the documentation needed to review the claims placed on hold and review along with the items stated in paragraphs (E)(1) to (E)(6) of this rule.

(2) Hold and review with prior notification.

(a) ODJFS may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, with prior notice to the provider under the following circumstances:

(i) When the information is used to complement or follow up a provider certification or other quality review process;

(ii) Upon request from the office of the attorney general, the office of inspector general or the auditor of state;

(iii) A medicaid provider's agreement has been proposed for termination for reasons other than those stated in paragraph (A) of this rule; or

(iv) For reasons otherwise necessary to assure the basic integrity of claims submission and payment.

(b) ODJFS will notify the provider in writing within ten business days before the effective start date of the hold and review.

(B) Review of the medicaid provider's claims and documentation for the hold and review process is subject to the provisions of rule 5101:3-1-27 of the Administrative Code.

(C) The hold and review may be applied without regard to date of service. Claims subject to the hold and review process include any claims for payment received by ODJFS after the effective date of the hold and review even if such claims are for dates of service that occurred prior to the effective date of the hold and review.

(D) Failure by ODJFS to notify a provider of a hold and review shall not impede the agency from taking actions under this rule.

(E) The notice from ODJFS shall:

(1) State the general reasons for the withholding of the medicaid provider's claims payments, but need not disclose any specific information concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation;

(2) State the effective date ODJFS implements the hold and review process;

(3) State the types of services and claims, in whole or in part, that will be subject to the hold and review process. Any claims received by ODJFS on or after the date of written notification may be subject to hold and review even if such claims are for dates of service that occurred prior to the effective date of the hold and review;

(4) State the documentation required to be submitted to ODJFS by the provider:

(a) Except for medicaid providers required to submit medical claims to ODJFS electronically, all claims from providers placed on hold and review must be submitted in non-electronic (paper) format.

(b) Providers who must submit medical claims electronically must submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by ODJFS.

(5) Inform the provider of the right to submit evidence for consideration to ODJFS;

(6) State the contact at ODJFS for questions regarding the hold and review process.

(F) ODJFS may, if appropriate, send copies of the notice to local, state and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment.

(G) No later than one hundred twenty days from the date ODJFS holds a claim for review, ODJFS shall forward the claim for adjudication if it is determined that the documentation supports the validity of the claim, or for denial processing if the documentation submitted does not support that paying the claim would be in compliance with law or if the provider fails to submit the requested supporting documentation to ODJFS. If the review results in ODJFS concluding that the provider has a pattern of submitting claims that are not in compliance with law, ODJFS may issue a "Notice of Operation Deficiency" to the provider and continue to hold and review the provider's claims until the operational deficiency is eliminated.

(H) Medicaid providers are not entitled to a hearing under Chapter 119. or section 5111.06 of the Revised Code for any action taken by ODJFS under this rule.

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.10 , 5111.85
Rule Amplifies: 5111.10 , 5111.02 , 5111.85

5160-1-27.2 Medicaid hold and review process for medicaid claims paid through state agencies other than the Ohio department of job and family services.

(A) "Medicaid administrative agency" means a state agency other than the Ohio department of job and family services (ODJFS) that:

(1) Administers a component of the medicaid program under the terms of a contract with ODJFS under section 5111.91 of the Revised Code; and

(2) Pays claims for medicaid services or reimburses local entities for claims paid for medicaid services.

(B) "Hold and Review" is defined in accordance with rule 5101:3-1-27 of the Administrative Code.

(C) Hold and review may be initiated by ODJFS or a medicaid administrative agency for the following reasons:

(1) When the information is used to complement or follow-up a provider or certification or other quality review process;

(2) In response to allegations of fraud or willful misrepresentation of claims submission;

(3) Upon the request of the office of the attorney general, the office of inspector general, or the auditor of state;

(4) When a provider's medicaid provider agreement is subject to termination;

(5) When a provider has been indicted for a criminal offense; or

(6) For reasons otherwise necessary to assure the basic integrity of claims submission and payment.

(D) The hold and review may be applied without regard to date of service. Claims subject to the hold and review process, may include any claims for payment received by ODJFS, the medicaid administrative agency, or a local entity that pays medicaid providers directly, after the effective date of the hold and review even if such claims are for dates of service that occurred prior to the effective date of the hold and review.

(E) Hold and review initiated by medicaid administrative agencies.

(1) The medicaid administrative agency shall have formal written approval from ODJFS to initiate a hold and review process.

(2) The medicaid administrative agency may recruit the assistance of local governmental entities to review records subject to hold and review.

(3) The medicaid administrative agency may initiate hold and review without prior notification to the provider when the medicaid administrative agency receives a request to initiate hold and review from the office of the attorney general, the office of inspector general, the auditor of state, or ODJFS.

(4) When the medicaid administrative agency initiates hold and review without prior notification to the provider, the medicaid administrative agency shall provide written notice to the provider, including a copy of ODJFS written approval within ten business days of initiating a hold and review.

(5) The medicaid administrative agency may initiate hold and review with prior notification to the provider for any purpose contained in paragraph (C) of this rule. The medicaid administrative agency shall notify the provider at least ten business days prior to subjecting the provider's claims to hold and review.

(6) For claims payment that the medicaid administrative agency pays directly to the medicaid provider, the medicaid administrative agency may subject the medicaid provider's claim(s) payment, in part or in whole, to hold and review.

(7) For reimbursements the medicaid administrative agency makes to local entities for claims that the local entity pays to the medicaid provider directly, the medicaid administrative agency:

(a) May require the local entity to hold the medicaid provider's claim(s) payment for claims subject to hold and review;

(b) May deny reimbursement to the local entity for the claims on which the hold and review was requested after allowing the local entity a reasonable time to comply; and

(c) Shall not deny reimbursement to the local entity for claims that the local entity paid prior to the request.

(8) A failure by the medicaid administrative agency to notify a provider of a hold and review process shall not impede the agency from taking actions under this rule.

(9) Review of the medicaid provider's claims and documentation for hold and review is subject to the provisions of rule 5101:3-1-27 of the Administrative Code.

(10) The notice from the medicaid administrative agency shall:

(a) State the general reasons for subjecting the medicaid provider's claims to hold and review, but need not disclose any specific information 5101:3-1- 27.2 2 concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation;

(b) State the date the medicaid administrative agency implements the hold and review;

(c) State the types of services and claims that are subject to hold and review;

(d) State the documentation required to submit to the medicaid administrative agency;

(e) Inform the provider of the right to submit evidence for consideration to the medicaid administrative agency; and

(f) State the contact at the medicaid administrative agency for questions regarding the hold and review and where to send the requested documentation.

(11) The medicaid administrative agency shall send copies of the notice to all local, state, and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment.

(12) Providers who submit medical claims electronically may be required under this rule to submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by the medicaid administrative agency.

(13) No later than one hundred twenty days from the date the medicaid administrative agency holds a claim for review, the medicaid administrative agency shall forward the claim for adjudication if it is determined that the documentation submitted supports the validity of the claim, or for denial if the documentation submitted does not support that the claim would be in compliance with the law or if a provider fails to submit the requested supporting documentation. If a review results in the medicaid administrative agency concluding that the provider has a pattern of submitting claims that are not in compliance with the law, the medicaid administrative agency may request ODJFS to issue a 'notice of operational deficiency' to the provider and may continue to hold and review the providers claims until the ODJFS determines that the operational deficiency is eliminated.

(F) Hold and review process initiated by ODJFS.

(1) ODJFS may require a medicaid administrative agency to initiate a hold and review described in this rule or to cooperate in a hold and review initiated by ODJFS under rule 5101:3-1-27.1 of the Administrative Code. 5101:3-1-27.23

(2) In cooperating with a request from ODJFS to initiate a hold and review, medicaid administrative agencies shall:

(a) Comply with the provider notification requirements of this rule; and

(b) Suspend payment or reimbursement of the claims that are subject to hold and review; and

(c) Require local entities to suspend payment for the claims subject to hold and review; and

(d) Obtain provider records, including client records, medical records, and other supporting documentation that ODJFS requests as part of the review from local entities and providers; and

(e) Participate in the review of records and other supporting documentation when requested by ODJFS; and

(f) Provide any other information requested by ODJFS in order to assure accurate tracking and timely resolution of the claims subject to hold and review.

(3) For claims associated with alcohol and drug addiction services, ODJFS shall rely on the Ohio department of alcohol and drug addiction services to obtain and review provider records, including client records and medical records, as necessary to assure the special confidentiality of these records required by 42 C.F.R., part 2 as amended through October 1, 2006.

(4) After requesting a hold and review and allowing the medicaid administrative agency a reasonable time to comply, ODJFS may stop drawing from the centers for medicare and medicaid services, and passing to the other agency, the federal match associated with the claims that are subject to the review. ODJFS will not withhold federal match for claims that other agencies or local entities paid prior to the ODJFS request.

(G) For purposes of determining whether time limits for the submission of claims have been met for claims subjected to hold and review, the date of claims submission shall be the date that the medicaid administrative agency received the original claim from the provider.

(H) A provider is not entitled to a hearing under Chapter 119. or section 5111.06 of the Revised Code for any action taken by ODJFS or a medicaid administrative agency under this rule.

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.02 , 5111.10
Rule Amplifies: 5111.02 , 5111.10 , 5111.85

5160-1-29 Medicaid fraud, waste, and abuse.

For purposes of this rule, the following definitions apply:

(1) "Fraud" is defined as an intentional deception, false statement, or misrepresentation made by a person with the knowledge that the deception, false statement, or misrepresentation could result in some unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law. If fraud is suspected or apparent, referral of the case to the attorney general's medicaid fraud control unit and/or the appropriate enforcement officials will be made by the Ohio department of job and family services (ODJFS).

(2) "Waste and abuse" are defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices; and that constitute an overutilization of medicaid covered services and result in an unnecessary cost to the medicaid program.

(B) ODJFS shall have in effect a program to prevent and detect fraud, waste, and abuse in the medicaid program. Where cases of suspected fraud to obtain payment from the medicaid program are detected, providers will be subject to a review or an audit by ODJFS. If waste and abuse are suspected or apparent, ODJFS will take action to gain compliance and recoup inappropriate payments through audit and review in accordance with rule 5101:3-1-27 or 5101:3-26-06 of the Administrative Code.

In all instances of fraud, waste, and abuse, any payment amount in excess of that legitimately due to the provider will be recouped by ODJFS through the office of fiscal and monitoring services, the state auditor, or the office of the attorney general.

(C) Cases of provider fraud, waste, and abuse may include, but are not limited to, the following:

(1) A pattern of duplicate billing by a provider to obtain reimbursement to which the provider is not entitled.

(2) Misrepresentation as to services provided, quantity provided, date of service, or to whom provided.

(3) Billing for services not provided.

(4) A pattern of billing, certifying, prescribing, or ordering services that are not medically necessary or reimbursable in accordance with rule 5101:3-1-01 of the Administrative Code, not clinically proven and effective, and not consistent with medicaid program rules and regulations.

(5) Differing charges for the same services to medicaid and non-medicaid consumers. For inpatient hospital services billed by hospitals reimbursed on a prospective payment basis, ODJFS will not pay, in the aggregate, more than the provider's customary and prevailing charges for comparable services.

(6) Violation of a provider agreement by requesting or obtaining additional payment for covered medicaid services from either the consumer or consumer's family, other than medicaid co-payments as designated in rule 5101:3-1-09 of the Administrative Code.

(7) Collusive activities, involving the medicaid program, between a medicaid provider and any person or business entity.

(8) Misrepresentation of cost report data so as to maximize reimbursement and/or misrepresent gains or losses.

(9) Billing for services that are outside the current license limitations or specific practice parameters of the person supplying the service.

(10) Misrepresenting by commission or omission any information on the provider enrollment form or included in the provider enrollment packet.

(11) Ordering excessive quantities of medical supplies, drugs and biologicals, or other services.

(D) ODJFS will not pay for services prescribed, ordered, or rendered by a provider, when those services were prescribed, ordered, or rendered by that provider after the date the provider was terminated under the medicaid program in accordance with rule 5101:3-1-17.6 of the Administrative Code.

(E) In instances when a provider suspects that there may be fraud, waste, or abuse by a consumer, the provider should contact the local county department of job and family services. Cases of consumer fraud, waste, and abuse may include, but are not limited to:

(1) Alteration, sale, or lending of the medicaid card to others for securing medical services, or other related criminal activities.

(2) Receiving excessive medical visits and services.

(3) Obtaining services outside of those personally needed and used by the consumer.

(F) Providers must assume responsibility for the business practices of employees. ODJFS presumes that providers will take the necessary time to thoroughly acquaint themselves and their employees with all rules relative to their participation in the medicaid program. Ignorance of medicaid program rules will not be an acceptable justification for violation of department rules.

Effective: 10/08/2009
R.C. 119.032 review dates: 07/22/2009 and 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 7/1/80, 10/1/84, 10/1/87, 8/1/96, 5/30/02, 1/1/04, 12/30/05 (Emer), 3/27/06

5160-1-31 Prior authorization [except for services provided through medicaid contracting managed care plans (MCPs)].

(A) Reimbursement for some items and/or services covered under the medicaid program is available only upon obtaining prior authorization from the Ohio department of job and family services (ODJFS). Prior authorization must be obtained from ODJFS or its designee by the provider before the services are rendered or the items delivered,unless the services meet the provisions in paragraph (F) of this rule. .

(B) Services, supplies or prescription drugs that require prior authorization by the department are identified in Chapters 5101:3-2 to 5101:3-56 of the Administrative Code.

(C) All prior authorization requests must be submitted through the medicaid information technology system (MITS) web portal. Paper prior authorization requests will be returned to the provider unprocessed.

(D) When the prior authorization request has been processed by ODJFS or its designee, the provider will receive notification indicating the decision for each service, supply or prescription drug. Only those services, supplies or prescription drugs approved in the prior authorization notice will be reimbursed.

(E) When a request for prior authorization has been approved, the notification will include a prior authorization (PA) number. In order for the provider to be reimbursed, the provider must use the assigned PA number when submitting the claim for payment.

(F) In situations where the provider considers a delay in providing services, supplies or prescription drugs requiring prior authorization to be detrimental to the health of the consumer, the services, supplies or prescription drugs may be rendered or delivered and approval for reimbursement sought after the fact.

(G) When a request for prior authorization is denied, ODJFS or its designee will issue a notice of medical determination and a right to a state hearing to the consumer. A copy of this denial notice will be sent to the county department of job and family services to be filed in the consumer's case record. Providers will also be notified of the denial.

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
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 7/1/91 (Emer), 9/30/91, 5/30/02, 8/11/05

5160-1-39 Verification of home care service provision to home care dependent adults.

(A) Home care service providers, as defined in this paragraph, must have a system as follows.

(1) Definitions.

(a) "Home care dependent adult" means a consumer who:

(i) Resides in a private home or other non-institutional, unlicensed living arrangement without a parent or guardian present;

(ii) Requires, due to health and safety needs, regularly scheduled home care services to remain in the home or other living arrangement; and,

(iii) Is sixty years of age or older, or is at least twenty-one years of age but less than sixty years of age, and has a physical disability or mental impairment.

(b) "Home care service provider" is:

(i) A medicare certified home health agency or other accredited agency in accordance with Chapter 5101:3-12 of the Administrative Code that provides service in the home to the home care dependent adult; or

(ii) A medicare certified hospice provider in accordance with Chapter 5101:3-56 of the Administrative Code that provides services to the terminally ill.

(c) "Life-threatening condition" means a health condition that will place the consumer at risk of permanent impairment if the home care service is not provided.

(d) "Mental impairment" means a consumer has a diminished capacity of judgment such that if the consumer were left alone, it would place the consumer at risk of permanent impairment.

(e) "Physical disability" means a consumer's physical condition of severe functional limitations.

(2) A home care service provider, who provides home care services to a home care dependent adult, must have a system which effectively monitors the delivery of services by its employee(s). The system must include:

(a) A mechanism to verify whether their employees are present (e.g., at the beginning and end of a visit) at the location and time where services are to be provided for home care dependent adults who have a mental impairment or life-threatening condition;

(b) Verification of whether the provider's employees have provided the services at the proper location and time at the end of each working day for all other home care dependent adults not addressed in paragraph (A)(2)(a) of this rule. (e.g., adults age sixty or older, or adults that are at least twenty-one years of age but less than sixty years of age and have a physical disability); and,

(c) Implementation of a protocol for scheduling substitute employees when the monitoring system identifies that an employee has failed to provide home care services at the proper location and time. The protocol must include a standard for determining the length of time that may elapse without jeopardizing the health and safety of the home care dependent adult.

(3) For the information obtained through the monitoring system in accordance with paragraph (A)(2) of this rule, the home care service provider must have procedures in place to:

(a) Maintain records;

(b) Compile annual reports which must include the rate at which home care services were provided at the proper location and time;

(c) Conduct random checks of the accuracy of the monitoring system. For purposes of conducting these checks, a random check is considered to be a check of not more than five per cent or less than one per cent of the home care visits the provider's employees make to different home care dependent adults within a particular work shift; and,

(d) Retain records in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(B) Home care service providers, as defined in paragraph (A) of this rule and as defined by the department of mental retardation/developmental disability or department of aging, shall demonstrate their verification system of home care service provision in accordance with section 121.36 of the Revised Code and paragraph (A) of this rule by:

(1) Participating in periodic compliance reviews; and/or,

(2) Furnishing upon request to ODJFS, its designee or the medicaid fraud control unit any records related to the provisions outlined in section 121.36 of the Revised Code.

Eff. 9-26-04; 4-1-05
Promulgated Under: 119.03
Statutory Authority: 121.36 , 5111.02
Rule Amplifies: 121.36 , 5111.01 , 5111.02
R.C. 119.032 review dates: 11/16/2004 and 04/01/2010

5160-1-57 Process for provider appeals from proposed departmental actions.

(A) The appeals process is designed to provide a hearing under Chapter 119. of the Revised Code (Administrative Procedures Act) whereby a provider may appeal the proposed decision of the Ohio department of job and family services (ODJFS) to deny, terminate, or not renew a "Provider Agreement," or to implement a final fiscal audit.

(1) The appeals process does not apply in the following circumstances:

(a) Whenever the terms of a provider agreement require the provider to hold a valid and current license, permit, certificate or maintain a certification issued by an official, board, commission, department, division or bureau, or other agency of state or federal government other than ODJFS, and the license, permit, or certificate, or certification has been denied, suspended, revoked, not renewed, or is otherwise limited and the provider has been afforded the opportunity for a hearing in accordance with the hearing process established by the official, board, commission, department, division, bureau, or other agency of state or federal government.

(b) Whenever the terms of a provider agreement require the provider to hold a license, permit, or certificate or maintain certification issued by an official, board, commission, department, division, bureau, or other agency of state or federal government other than ODJFS, and the provider has not obtained the license, permit, certificate, or certification.

(c) Whenever the provider agreement is denied, terminated, or not renewed due to the termination, refusal to renew, or denial of a license, permit, certificate, or certification by an official, board, commission, department, division, bureau, or other agency of this state other than ODJFS, notwithstanding the fact that the provider may hold a license, permit, certificate, or certification from an official, board, commission, department, division, bureau, or other agency of another state.

(d) Whenever a judgment has been entered in either a criminal or civil action against a medicaid provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code, except if the provider or owner can demonstrate to the department that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee which resulted in the entry of judgment.

(e) The attorney general on behalf of the state has commenced proceedings in any court of competent jurisdiction and settled or compromised any such case brought under section 5111.03 of the Revised Code.

(f) Whenever the "Provider Agreement" is denied, terminated, or not renewed due to provider termination, suspension, or exclusion by the medicare program and/or by the federal department of health and human services and that action is binding on the provider's participation in the medicaid program or renders federal financial participation unavailable for the provider's participation in the medicaid program.

(g) Whenever the "Provider Agreement" is denied, terminated, or not renewed due to the provider's pleading guilty to, or being convicted of, a criminal activity materially related to either the medicare or medicaid program.

(h) Whenever the provider agreement is suspended pursuant to rule 5101:3-1-17.5 of the Administrative Code pending indictment of the provider.

(i) Whenever the provider agreement is denied, terminated, or not renewed because the provider has been convicted of one of the offenses that caused the provider agreement to be suspended pursuant to rule 5101:3-1-17.5 of the Administrative Code.

(j) Whenever the provider agreement is converted under section 5111.028 of the Revised Code from a provider agreement that is not time-limited to a provider agreement that is time-limited.

(k) Whenever the provider agreement is terminated or an application for re-enrollment is denied because the provider has failed to apply for re-enrollment within the time or in the manner specified for re-enrollment pursuant to section 5111.028 of the Revised Code.

(l) Whenever the provider agreement is terminated or not renewed because the provider has not billed or otherwise submitted a medicaid claim to ODJFS for two years or longer, and ODJFS has determined that the provider has moved from the address on record with ODJFS without leaving an active forwarding address with ODJFS.

(2) If a provider objects to a proposed adjudication order of the department which would result in the denial, termination, suspension, or nonrenewal of a provider agreement not otherwise excluded from the process by paragraph (A)(1) of this rule or if the provider wishes to contest a final fiscal audit, the provider may request a formal hearing which shall be governed by Chapter 119. of the Revised Code. Such requests must be submitted in writing to the ODJFS office of legal services. In any medicaid hospital final settlement in which Title V monies are offset against medicaid monies, the department will offer a right of appeal pursuant to Chapter 119. of the Revised Code for both program areas.

(3) During the appeal of an ODJFS-proposed termination or nonrenewal of a "Provider Agreement," payment will occur as follows:

(a) Payments under department rules and regulations will continue unless the provisions of paragraphs (A)(3)(b)(i) to (A)(3)(b)(iii) of this rule apply.

(b) Payments under department rules and regulations may be withheld if each of the following conditions has been met by the department:

(i) Compliance with the provisions of section 119.07 of the Revised Code;

(ii) A hearing continuance has not been requested; and

(iii) A decision has been issued within thirty days after the hearing is completed.

(c) If the appeal is to be a final fiscal audit and the department complies with paragraph (A)(3)(b) of this rule, the department may withhold payments only to the extent that they do not exceed the amounts determined in that final fiscal audit.

(d) The provisions of paragraphs (A)(3) to (A)(3)(c) of this rule do not apply to long-term care facilities (LTCFs). Payment made to LTCFs during an appeal to ODJFS will occur as described in Chapter 5101:3-3 of the Administrative Code.

(B) Actions taken that meet the exceptions of paragraph (A)(1) of this rule and other administrative actions affecting the provider's medicaid program status that are not subject to hearings under Chapter 119. of the Revised Code, and those individuals or providers who do not have medicaid provider agreements and are proposed for exclusion from participation may be reconsidered by the deputy director in the office where the contestation arose. The deputy director may designate a third party to hear the reconsideration provided that the designee was not involved in the original decision or contestation. Decisions made by the ODJFS deputy director are not appealable or subject to further reconsideration.

(C) See Chapter 5101:3-2 of the Administrative Code for additional information concerning the applicability of the appeals process to hospital services.

(D) See Chapter 5101:3-3 of the Administrative Code for additional provisions specific to LTCFs.

(E) See Chapter 5101:3-26 of the Administrative Code for additional provisions specific to managed care plans (MCPs).

Effective: 01/01/2008
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.028 , 5111.031
Rule Amplifies: 5111.01 , 5111.02 , 5111.028 , 5111.031 , 5111.06
Prior Effective Dates: 4/7/77, 8/31/79, 7/1/80, 8/8/81, 10/1/84, 3/18/88 (Emer), 6/16/88, 5/30/02, 7/1/05

5160-1-60 Medicaid reimbursement.

(A) The medicaid payment for a covered service constitutes payment in full and may not be construed as a partial payment when the reimbursement amount is less than the provider's submitted charge. A provider may not collect from a consumer nor bill a consumer for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a consumer to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments as defined in rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the Administrative Code, however, precludes a provider from requesting payment, collecting, or waiving the collection of medicare copayments from medicaid consumers for medicare part D services. Medicaid consumer liability provisions set forth in rule 5160-1-13.1 of the Administrative Code do not apply to medicare part D services.

(1) For dental, vision, and non-emergent emergency department services and prescription services that are subject to a copayment in accordance with rule 5160-1-09 of the Administrative Code, the total medicaid maximum fee is reduced by the total medicaid copayment amount. The provider may collect from the consumer or bill the consumer for the total medicaid copayment amount, which is determined in accordance with the relevant rule of the Administrative Code:

(a) For dental services, rule 5160-5-01;

(b) For vision services, rule 5160-6-01;

(c) For pharmacy services, rule 5160-9-09; and

(d) For non-emergent emergency department services, rule 5160-2-21.1.

(2) In accordance with rule 5160-1-08 of the Administrative Code, providers are expected to take reasonable measures to determine any third-party resource available to a consumer and to file a claim with that third party when required to do so under rule 5160-1-08 of the Administrative Code. For a reimbursable claim involving a third-party payer, the Ohio department of medicaid (the department) will reimburse a provider the lesser of two amounts:

(a) The provider's submitted charge; or

(b) The medicaid maximum fee less the sum of the third-party payment and any applicable medicaid copayment (unless the difference is zero or less, in which case medicaid will make no further payment).

(B) Medicaid reimbursement is not available for non-covered services nor for covered services that are denied by the department as a result of a prepayment review, utilization review, or prior authorization process. (Chapter 5160-2 of the Administrative Code describes how these provisions are applied to inpatient and outpatient hospital services.)

(C) Reimbursement is made only for those covered services that are medically necessary and received by eligible medicaid consumers. The amount of payment is determined in accordance with federal and state laws and regulations. In establishing medicaid maximum fees, the department must ensure that reimbursement is consistent with efficiency, economy, and quality of care.

(D) The state's appropriation determines the total amount of funding that may be expended for services under medicaid. Providers are expected to report their usual and customary charge (the amount charged to the general public) on all claims. Except as otherwise permitted by federal statute or regulation, the medicaid maximum fees described in this rule must not exceed the established maximum medicare allowed amounts for the same services.

(E) Except as otherwise provided, the department reimburses the lesser of the submitted charge or the medicaid maximum fee for services or supplies furnished by advanced practice nurses, ambulance providers, ambulatory health care clinics, ambulatory surgery centers, chiropractors, dentists, home health agencies, independent diagnostic testing facilities, independent laboratories, mammography suppliers, medical suppliers, occupational therapists, optometrists, physical therapists, physicians, physician assistants, podiatrists, portable x-ray suppliers, private duty nurses, psychologists, wheelchair van or ambulette providers, and other providers of limited practitioner services.

(F) The department reimburses pharmacies for drugs at the lesser of the submitted charge or the maximum fee allowed in accordance with rule 5160-9-05 of the Administrative Code.

(G) Rural health clinics and federally qualified health centers are reimbursed through a prospective payment system established in accordance with federal law. Provisions governing reimbursement for rural health clinic services are set forth in Chapter 5160-16 of the Administrative Code and for federally qualified health center services in Chapter 5160-28 of the Administrative Code.

(H) Outpatient health facilities are reimbursed through a prospective system based on reasonable costs derived from submitted cost reports. Provisions governing reimbursement for outpatient health facility services are set forth in Chapter 5160-29 of the Administrative Code.

(I) Reimbursement for hospital services provided on an inpatient or outpatient basis is described in Chapter 5160-2 of the Administrative Code. Reimbursement for services provided in long-term care facilities is described in Chapter 5160-3 of the Administrative Code.

(J) The medicaid maximum fees for many professional or facility services are set forth in the text of or appendices to rules of the Administrative Code.

(1) For an ambulance service, ambulatory health care clinic service, clinical laboratory service, dental service, independent diagnostic testing facility service, mammography service, pathology (anatomical laboratory) service (total procedure), physician service, portable x-ray service, radiology service, vision service, or wheelchair van or ambulette service, the medicaid maximum fee is one hundred per cent of the amount specified in the relevant chapter of agency 5160 of the Administrative Code; if no amount is specified in that chapter, then the medicaid maximum fee is one hundred per cent of the amount listed in the appendix to this rule. Chapter 5160-13 of the Administrative Code delineates dialysis procedures that must be reported on a claim with appropriate revenue center codes.

(2) For the professional or technical component of a pathology service, the medicaid maximum fee is determined in accordance with paragraph (K) of this rule.

(3) For most medical supplier services, the medicaid maximum fee is one hundred per cent of the amount listed in the appendix to this rule; additional provisions governing reimbursement are set forth in Chapter 5160-10 of the Administrative Code.

(4) For a facility service provided by an ambulatory surgery center (ASC), the medicaid maximum fee is the surgical group rate indicated by numeric code in the 'current ASC group' column of the appendix to this rule. Nine surgical group rates have been established for dates of service January 1, 2010, and thereafter:

(a) Group 1: Two hundred forty-six dollars and seventy-eight cents;

(b) Group 2: Three hundred thirty-one dollars and seventy cents;

(c) Group 3: Three hundred eighty dollars and sixty-six cents;

(d) Group 4: Four hundred sixty-eight dollars and fifty-eight cents;

(e) Group 5: Five hundred thirty-four dollars and fifty-two cents;

(f) Group 6: Seven hundred four dollars and thirty-seven cents;

(g) Group 7: Seven hundred forty-two dollars and thirty-three cents;

(h) Group 8: Eight hundred thirteen dollars and twenty-seven cents; and

(i) Group 9: One thousand thirty-two dollars and seven cents.

(5) The reimbursement methodology for professional anesthesia services is set forth in rules 5160-4-21, 5160-4-21.1, and 5160-4- 21.2 of the Administrative Code.

(6) Medicaid maximum fees for home health services are described in rule 5160-12-05 of the Administrative Code and for private duty nursing services in rule 5160-12-06.

(K) Additional factors may affect reimbursement for a procedure, service, or supply.

(1) An entry in the 'prof/tech split' column of the appendix to this rule indicates either that the procedure is composed of both a professional and a technical component for the time period shown or that professional interpretation of the procedure is separately reimbursable. The indicator E (which is not in current use) specifies the maximum fee for professional interpretation as a given percentage of the maximum fee for the procedure itself; the other indicators denote the relative proportions of the medicaid maximum fee allocated to the professional and technical components. For example, the indicator C means that the medicaid maximum fees for the professional component and for the technical component are, respectively, forty per cent and sixty per cent of the medicaid maximum fee for the total procedure. Fourteen indicators appear in the appendix to this rule:

(a) C: Forty per cent / sixty per cent;

(b) D: Eighty per cent / twenty per cent;

(c) E: Four hundred per cent (for professional interpretation) / not applicable;

(d) F: Ten per cent / ninety per cent;

(e) G: Twenty per cent / eighty per cent;

(f) H: Twenty-five per cent / seventy-five per cent;

(g) I: Thirty per cent / seventy per cent;

(h) J: Thirty-five per cent / sixty-five per cent;

(i) K: Fifty per cent / fifty per cent;

(j) L: Sixty per cent / forty per cent;

(k) M: Seventy per cent / thirty per cent;

(l) O: One hundred per cent / zero per cent;

(m) P: Seventy-five per cent / twenty-five per cent; and

(n) Q: Ninety per cent / ten per cent.

(2) In the 'PC/TC indicator' column of the appendix to this rule, a numeric entry shows the degree to which a procedure is professional or technical in nature or has a professional or technical component, which affects reimbursement; these numeric values are defined by the centers for medicare and medicaid services (CMS). A lowercase alphabetic entry indicates a medicaid reimbursement restriction based on the location in which the procedure or service is performed (a place-of-service restriction). Meanings of these numeric and alphabetic indicators are explained in rule 5160-4-11 of the Administrative Code.

(3) The department may set reimbursement limits based on the characteristics of an individual procedure, service, or supply or the relationships between procedures, services, or supplies. For example, reimbursement may be disallowed for a procedure if it is incompatible with another procedure or another procedure makes it redundant. In configuring its claim-processing system, the department may define its own limits, adopt limits established by an authoritative source, or modify limits established by an authoritative source.

(L) "Healthcare common procedure coding system (HCPCS)" is a numeric and alphanumeric code set maintained and distributed by CMS, www.cms.gov [File Link Not Available], for the uniform designation of certain medical procedures and services. The update of HCPCS at the beginning of each calendar year involves the addition, deletion, and revision of procedure codes. The department updates the appendix to this rule accordingly and implements corresponding changes in the medicaid claim-processing system, which take effect on January first.

Click to view Appendix

Effective: 03/27/2014
R.C. 119.032 review dates: 12/01/2018
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03 , 5162.20 , 5164.02 , 5164.70
Prior Effective Dates: 07/10/1983, 10/01/1983 (Emer), 12/29/1983, 10/01/1984 (Emer), 12/30/1984, 02/15/1985 (Emer), 05/01/1985, 08/01/1985, 11/27/1985 (Emer), 01/16/1986, 05/09/1986 (Emer), 07/30/1986 (Emer), 10/25/1986, 05/01/1987, 10/01/1987, 01/04/1988, 06/23/1988, 10/01/1988, 01/13/1989 (Emer), 04/13/1989, 09/01/1989 (Emer), 12/01/1989, 05/01/1990, 06/20/1990 (Emer), 09/05/1990, 11/23/1990, 02/17/1991, 05/25/1991, 12/30/1991, 04/01/1992 (Emer), 07/01/1992, 07/31/1992 (Emer), 10/30/1992, 12/31/1992 (Emer), 04/01/1993, 07/01/1993, 11/15/1993, 12/30/1993 (Emer), 03/31/1994, 05/02/1994 (Emer), 07/01/1994, 09/30/1994 (Emer), 12/30/1994 (Emer), 03/30/1995, 08/01/1995, 12/29/1995 (Emer), 02/01/1996 (Emer), 04/04/1996, 12/31/1996 (Emer), 03/31/1997, 08/01/1997, 10/02/1997, 12/31/1997 (Emer), 03/19/1998, 07/01/1998, 12/31/1998 (Emer), 03/31/1999, 12/31/1999 (Emer), 03/20/2000, 12/31/2000 (Emer), 03/30/2001, 12/31/2001 (Emer), 03/29/2002, 07/01/2002, 11/14/2002, 03/24/2003, 07/01/2003, 09/25/2003, 12/08/2003, 01/02/2004 (Emer), 04/01/2004, 10/01/2004, 11/01/2004 (Emer), 01/16/2005, 09/01/2005, 11/17/2005, 12/30/2005 (Emer), 03/27/2006, 07/15/2006, 10/15/2006, 12/29/2006 (Emer), 03/29/2007, 07/26/2007, 12/31/2007 (Emer), 03/30/2008, 07/01/2008 (Emer), 08/21/2008, 11/13/2008, 12/31/2008 (Emer), 03/31/2009, 07/01/2009, 12/24/2009, 12/31/2009 (Emer), 02/01/2010 (Emer), 03/31/2010, 12/06/2010, 12/30/2010 (Emer), 03/30/2011, 09/01/2011, 12/22/2011, 12/30/2011 (Emer), 03/29/2012, 01/01/2013 (Emer), 03/29/2013, 09/01/2013, 12/31/2013, 12/18/2013 (Emer)

5160-1-60.1 Special provisions for reimbursement for physician groups acting as outpatient hospital clinics.

(A) For physician services rendered on and after the effective date of this rule by physician group practices that meet the criteria described in paragraphs (B) and (C) of this rule, the reimbursement amounts in appendix DD to rule 5101:3-1-60 of the Administrative Code, except for CPT codes 80002 to 89399, will be multiplied by 1.4. Pregnancy related services will be reimbursed according to appendix A to rule 5101:3-4-081 of the Administrative Code from March 3, 1992 through March 31, 1992. Pregnancy services will be reimbursed in accordance with appendix DD to rule 5101:3-1-60 of the Administrative Code from April 1, 1992. For dates of service May 1, 1994 and thereafter, the following evaluation and management codes will be reimbursed in accordance with appendix DD to rule 5101:3-1-60 of the Administrative Code: 99211, 99212, 99213, 99214, and 99215."CPT" as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.

(B) The physician group practice is physically attached to a hospital that does not provide physician clinic outpatient services and the hospital and physician group practice have signed a letter of agreement indicating that the physician group practice provides the outpatient hospital clinic service for that hospital.

(C) The Ohio department of job and family services provider utilization summary for calendar year 1990 establishes that the physician group practice provides at least forty per cent of the total number of medicaid physician visits provided in the county in which the physician group practice is located and an aggregate total of at least ten per cent of the physician visits provided in the contiguous counties.

Effective: 02/01/2007
R.C. 119.032 review dates: 10/03/2006 and 02/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 3/3/92 (Emer), 6/1/92, 5/2/94 (Emer), 7/24/94

5160-1-60.2 Direct reimbursement to medicaid recipients for out-of-pocket payments for medicaid covered services.

(A) In the case of erroneous determinations as specified in paragraph (A)(2) of this rule, ODHS will work with providers who received payment from recipients to facilitate the timely reimbursement of full payment to those recipients by their provider. If the provider does not reimburse the recipient in a timely manner, the department will directly reimburse the recipient of the medicaid covered service as specified in paragraph (B) of this rule as expeditiously as possible, not to exceed ninety days following completion of all the requirements of this rule. In order for a recipient to obtain direct reimbursement, all of the following requirements must be met.

(1)

(a) The service was a medicaid covered service, which is defined only for the purposes of this rule as a medically necessary service that is covered by the Ohio medicaid. Program and is delivered by a medical provider that qualifies for a medicaid provider agreement; and

(b) The service received by the medicaid recipient was not a nursing facility service.

(2)

(a) The individual was incorrectly determined to be ineligible for medicaid and the date on which the individual received the medicaid service was within the period of coverage for which the individual should have been eligible for medicaid; or

(b) The individual was found to be eligible for medicaid but the determination of eligibility was incorrectly delayed and the date on which the individual received the medicaid service was within the period of coverage for which the individual should have been eligible for medicaid.

(3) The individual has requested a state hearing or judicial action to dispute the finding of ineligibility or incorrect delay in eligibility determination pursuant to paragraph (A)(2)(a) or (A)(2)(b) of this rule for the period of coverage which includes the date of service.

(4) For errors pursuant to paragraph (A)(2)(a) of this rule, there is a documented CDHS determination of a CDHS error, or a hearing, administrative appeal or judicial decision that the individual was incorrectly determined to be ineligible for medicaid for a period of coverage which includes the date of service. For delays pursuant to paragraph (A)(2)(b) of this rule, there is a determination in a hearing, administrative appeal or judicial decision that the individual was incorrectly delayed an eligibility determination for a period of coverage which includes the date of service.

(5) The individual requests reimbursement from ODHS for the medically necessary medicaid covered service within ninety days of receiving documentation specified in paragraph (A)(4) of this rule issued by a CDHS, ODHS or a court of law pertaining to the finding of an erroneous determination of eligibility or the finding of an incorrect delay in eligibility determination made pursuant to paragraph (A)(4) of this rule.

(6) Within ninety days of the individual's request for reimbursement as described in paragraph (A)(5) of this rule, the individual provides all of the following:

(a) Written verification of a bill from the provider which specifies the medicaid covered services provided;

(b) Written verification that he or she paid the provider; and

(c) Documentation requested by the department.

(7) The individual contacts the provider, requests reimbursement, and accepts full reimbursement if offered by the provider.

(8) The provider does not reimburse the individual within a reasonable period of time, not to exceed ninety days from the date the individual provides documentation pursuant to paragraph (A)(6) of this rule.

(B) ODHS will reimburse recipients who meet the conditions specified in paragraph (A) of this rule in the following manner:

(1) If the recipient obtained the service from a medicaid contracting provider, ODHS will reimburse the recipient's full documented payment.

(2) If the recipient obtained the service from a provider who does not contract with medicaid, ODHS will reimburse the lesser of the recipient's payment or an amount equal to the rate medicaid pays medicaid contracting providers for the same service.

(C) All the provisions set forth in the chapters of agency-level designation 5101:3 of the Administrative Code remain in effect, except that direct reimbursement by ODHS to individual recipients of medicaid covered services is permitted under the circumstances set forth in this rule. All notice and hearing provisions set forth in agency-level designation 5101:6 of the Administrative Code apply to determinations made under this rule, and hearing officers have authority to direct ODHS to make payments in accordance with this rule.

R.C. 119.032 review dates: 04/20/2004 and 04/20/2009

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/22/99

5160-1-60.3 Primary care physician rate increase.

(A) For dates of service on or after January 1, 2013 through December 31, 2014, medicaid providers with the following specialty designations may receive increased reimbursement for rendering certain primary care services to medicaid-eligible individuals in both the fee for service and managed care populations:

(1) Family practice,

(2) General internal medicine,

(3) Pediatric medicine, or

(4) A subspecialty recognized by the American board of medical specialties within family practice, general internal medicine, or pediatric medicine.

(B) The primary care services subject to the increased payment are represented by current procedural terminology (CPT) evaluation and management procedure codes 99201 to 99499; CPT vaccine adminsitration codes 90460, 90461, and 90471 to 90474; and their successor codes.

(C) Except for circumstances described in paragraph (D) of this rule, the reimbursement to be paid to a qualified provider specified in paragraph (A) of this rule for rendering a service specified in paragraph (B) of this rule shall be the greater of two amounts:

(1) The allowed amount applicable to the site of service that is derived from the "Medicare Part B Physician Fee Schedule" for the calendar year in which the service was rendered (www.cms.gov) ; or

(2) The same allowed amount calculated with the conversion factor (CF) for calendar year 2009 in place of the CF for the calendar year in which the service was rendered.

(D) If the provider's billed charge is less than the amount described in paragraph (C) of this rule, the reimbursement to be paid to a qualified provider shall be the billed charge.

Effective: 01/01/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021