Lawriter - OAC - 5160-1-02 General reimbursement principles.

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