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