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