Chapter 5160-12 Ohio Home Care Program

5160-12-01 Home health services: provision requirements, coverage and service specification.

(A) "Home health services" includes home health nursing, home health aide and skilled therapies as defined in paragraph (G) of this rule.

(B) Home health services are covered only if the qualifying treating physician certifying the need for home health services documents that he or she had a face-to-face encounter with the consumer within the ninety days prior to the home health care start of care date, or within thirty days following the start of care date inclusive of the start of care date. To be a qualifying treating physician, the physician must be a doctor of medicine or osteopathy legally authorized to practice medicine and surgery as authorized under Chapter 4731. of the Revised Code in which he or she performs that function or action. Advanced practice nurses in accordance with rule 5101:3-8-21 of the Administrative Code and in collaboration with the qualifying treating physician, or a physician assistant in accordance with rule 5101:3-4-03 of the Administrative Code and under the supervision of the qualifying treating physician, have the authority to conduct the face-to-face encounter for the purposes of the supervising physician certifying the need for home health services. The face-to-face encounter with the consumer must occur independent of any provision of home health services to the consumer by the individual performing the face-to-face encounter. The face-to-face encounter must be documented:

(1) For home health services unrelated to an inpatient hospital stay, the face-to-face encounter must be documented by the qualifying treating physician using:

(a) The JFS 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services" (rev. 2/2011) or

(b) The consumer's plan of care may be used to certify medical necessity for home health services if all of the data elements specified for home health services unrelated to an inpatient hospital stay in the JFS 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services" (rev. 2/2011) are included and the plan of care contains the physician's signature, physician's credentials and the date of the physician's signature.

(2) For post hospital home health services, the face-to-face encounter must be documented by the qualifying treating physician using the JFS 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services" (rev. 2/2011).

(3) For a dual eligible consumer, if the face-to-face encounter date for medicare home health services falls within the ninety days prior to the medicaid home health services start of care date, or within thirty days following the medicaid start of care date inclusive of the medicaid start of care date, may be used on the JFS 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services" (rev. 2/2011) and the supporting documents attached to this form.

(C) Home health services are covered only if provided on a part-time and intermittent basis, which means:

(1) No more than a combined total of eight hours (thirty-two units) per day of home health nursing, home health aide, and skilled therapies except as specified in paragraph (H) of this rule;

(2) No more than a combined total of fourteen hours (fifty-six units) per week of home health nursing and home health aide services except as specified in paragraphs (D) and (H) of this rule; and

(3) Visits are not more than four hours (sixteen units). Most visits are usually less than two hours (eight units). Nursing visits over four hours (sixteen units) may qualify for coverage in accordance with rule 5101:3-12-02 of the Administrative Code.

(D) A combined total of twenty-eight hours (one hundred twelve units) per week of home health nursing and home health aide services is available to a consumer for up to sixty consecutive days from the date of discharge from an inpatient hospital stay of three or more covered days, if all of the following are met by the consumer as certified by the qualifying treating physician using the JFS 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services " (rev. 2/2011):

(1) Consumer has a discharge date from an inpatient hospital stay of three or more covered days. For the purposes of this rule, a covered inpatient hospital stay is defined in rule 5101:3-2-03 of the Administrative Code and is considered one hospital stay when a consumer is transferred from one hospital to another hospital, either within the same building or to another location. The sixty days will begin once the consumer is discharged to the consumer's place of residence or to a nursing facility as defined in paragraph (E)(4) of this rule, from the last inpatient stay whether or not the last inpatient stay was an inpatient hospital or inpatient rehabilitation unit of a hospital.

(2) Consumer has a comparable level of care as evidenced by either:

(a) Enrollment in a home and community based services (HCBS) waiver; or

(b) Has a medical condition that temporarily meets the criteria for an institutional level of care which are any of the following rules defined in rule 5101:3-3-05 of the Administrative Code for skilled level of care(SLOC), or defined in rule 5101:3-3-06 of the Administrative Code for intermediate level of care, or defined in rule 5101:3-3-07 of the Administrative Code for ICF/MR level of care. In no instance does this requirement constitute the determination of a level of care for waiver eligibility status, or admission into a medicaid covered long term care institution.

(3) Requires home health nursing or a combination of private duty nursing/home health nursing/waiver nursing/skilled therapy services at least once per week that is medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code.

(4) The consumer has had a covered inpatient hospital stay of three or more days, with the discharge date recorded on form JFS 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services" (rev. 2/2011).

(E) The only provider of home health services is the MCRHHA (medicare certified home health agency) that meets the requirements in accordance with rule 5101:3-12-03 of the Administrative Code. In order for home health services to be covered, MCRHHAs must:

(1) Provide home health services only if the qualifying treating physician has documented a face-to-face encounter with the consumer as specified in paragraph (B) of this rule.

(2) Provide home health services that are appropriate given the consumer's diagnosis, prognosis, functional limitations and medical conditions as ordered by the consumer's treating physician for the treatment of the consumer's illness or injury.

(3) Provide home health services as specified in the plan of care in accordance with rule 5101:3-12-03 of the Administrative Code. Home health services not specified in a plan of care are not reimbursable. Additionally the MCRHHA's plan of care must provide the amount, scope, duration, and type of home health service as:

(a) Identified on the all services plan as defined in rule 5101:3-45-01 of the Administrative Code that is prior approved by ODJFS or the case management agency when a consumer is enrolled in an ODJFS-administered home and community based services(HCBS) waiver. Home health services that are not identified on the all services plan are not reimbursable; or

(b) Documented on the services plan when a consumer is enrolled in an ODA- (Ohio department of aging) administered or a DODD- (Ohio department of developmental disabilities) administered HCBS waiver. Home health services that are not documented on the services plan are not reimbursable.

(4) Provide home health services in the consumer's place of residence, in a licensed child day-care center, or for a child three years and under in a setting where the child receives early intervention services (EI) as indicated in the individualized family service plan (IFSP).

(a) "Consumer's place of residence" is wherever the consumer lives, whether the home is the consumer's own dwelling, an apartment, an assisted living residence, a relative's home, or an other type of living arrangement. The place of residence does not include a hospital, nursing facility, or intermediate care facility for the mentally retarded (ICR/MR).

(b) For the purposes of this chapter, "licensed child day-care center" means a "child day-care center" as defined in section 5104.01 of the Revised Code that is licensed pursuant to section 5104.03 of the Revised Code but does not include a licensed child day-care center that is the permanent residence of the licensee or administrator.

(c) "Setting" is the natural environment in which the services will appropriately be provided.

(5) Not provide home health nursing and home health aide services for the provision of habilitative care, or respite care, and not provide skilled therapies for the provision of maintenance care, habilitative care or respite care.

(a) "Maintenance care" is the care given to a consumer for the prevention of deteriorating or worsening medical conditions or the management of stabilized chronic diseases or conditions. Services are considered maintenance care if the consumer is no longer making significant improvement in his or her medical condition.

(b) "Habilitative care" is in accordance with 42 U.S.C. 1396n(C)(5) (March 30, 2010).

(c) "Respite care" is the care provided to a consumer unable to care for himself or herself because of the absence or need for relief of those persons normally providing care.

(6) Bill for provided home health services in accordance with the visit policy in rule 5101:3-12-04 of the Administrative Code.

(7) Bill for provided home health services using the appropriate procedure code and applicable modifiers in accordance with rule 5101:3-12-05 of the Administrative Code.

(8) Bill after all documentation is completed for the services rendered during a visit in accordance with rule 5101:3-12-03 of the Administrative Code.

(F) Consumers who receive home health services must:

(1) Participate in a face-to-face encounter as specified in paragraph (B) of this rule for the purpose of certifying their medical need for home health services.

(2) Be under the supervision of a treating physician who is providing care and treatment to the consumer. The treating physician cannot be a physician whose sole purpose is to sign and authorize plans of care or who does not have direct involvement in the care or treatment of the consumer. A treating physician may be a physician who is substituting temporarily on behalf of a treating physician.

(3) Participate in the development of a plan of care along with the treating physician and the MCRHHA. An authorized representative may participate in the development of a plan of care in lieu of the consumer.

(4) Access home health services in accordance with the program for the all-inclusive care of the elderly (PACE) when the consumer participates in the PACE program.

(5) Access home health services in accordance with the consumer's provider of hospice services when the consumer has elected the hospice benefit.

(6) Access home health services in accordance with the consumer's managed care plan when the consumer is enrolled in a medicaid managed care plan.

(G) Covered home health services are:

(1) "Home health nursing" is a nursing service that requires the skills of and is performed by a registered nurse, or a licensed practical nurse at the direction of a registered nurse. The nurse performing the service must be employed or contracted by the MCRHHA providing the service. A service is not considered a nursing service merely because it is performed by a licensed nurse. Home health nursing services:

(a) Must be performed within the nurse's scope of practice as defined in Chapter 4723. of the Revised Code and rules adopted thereunder.

(b) Must be provided and documented in accordance with the consumer's plan of care in accordance with rule 5101:3-12-03 of the Administrative Code.

(c) Must be provided in a face-to-face encounter.

(d) Must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code to care for the consumer's illness or injury.

(e) Are not covered when the visit is solely for the supervision of the home health aide.

(f) May include home infusion therapy for the administration of medications, nutrients or other solutions intravenously, or enterally. A visit made for the purpose of home infusion therapy must be billed using the U1 modifier in accordance with rule 5101:3-12-05 of the Administrative Code.

(2) "Home health aide" is a service that requires the skills of and is performed by a home health aide employed or contracted by the MCRHHA providing the service. Home health aide services:

(a) Are performed within the home health aide's scope of practice as defined in 42 C.F.R. 484.36 (June 18, 2001). The home health aide cannot be the parent, step-parent, foster parent or legal guardian of a consumer who is under eighteen years of age, or the consumer's spouse.

(b) Are provided and documented in accordance with the consumer's plan of care in accordance with rule 5101:3-12-03 of the Administrative Code.

(c) Must be provided in a face-to-face encounter.

(d) Must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code to care for the consumer's illness or injury.

(e) Must be necessary to facilitate the nurse or therapist in the care of the consumer's illness or injury, or help the consumer maintain a certain level of health in order to remain in the home setting. Health related services can include:

(i) Bathing, dressing, grooming, hygiene, including shaving, skin care, foot care, ear care, hair, nail and oral care, that are needed to facilitate care or prevent deterioration of the consumer's health, and including changing bed linens of an incontinent or immobile consumer.

(ii) Feeding, assistance with elimination including administering enemas (unless the skills of a home health nurse are required), routine catheter care, routine colostomy care, assistance with ambulation, changing position in bed, and assistance with transfers.

(iii) Performing a selected nursing activity or task as delegated in accordance with Chapter 4723-13 of the Administrative Code, and performed as specified in the plan of care.

(iv) Assistance with activities such as routine maintenance exercises and passive range of motion as specified in the plan of care. These activities are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed. The plan of care is developed by either a licensed nurse or therapist within their scope of practice.

(v) Performing routine care of prosthetic and orthotic devices.

(f) May also include incidental services along with health related services as listed in paragraph (G)(2)(e) of this rule, as long as they do not substantially extend the time of the visit.

(i) Incidental services are necessary household tasks that must be performed by anyone to maintain a home and can include light chores, consumer's laundry, light house cleaning, preparation of meals, and/or taking out the trash.

(ii) The main purpose of a home health aide visit cannot be solely to provide these incidental services since they are not health related services.

(iii) Incidental services are to be performed only for the consumer and not for other people in the consumer's covered place of residence.

(3) "Skilled therapies" are defined as physical therapy, occupational therapy, and speech-language pathology services that require the skills of and are performed by skilled therapy providers to meet the consumer's medical needs, promote recovery, and ensure medical safety for the purpose of rehabilitation.

(a) "Skilled therapy providers" are licensed physical therapists, occupational therapists, speech-language pathologists, licensed physical therapy assistants (LPTA) under the direction of a physical therapist, or certified occupational therapy assistants (COTA) under the direction of a licensed occupational therapist who are contracted or employed by a MCRHHA.

(b) "Rehabilitation" is the care of a consumer with the intent of curing the consumer's disease or improving the consumer's condition by the treatment of the consumer's illness or injury, or the restoration of a function affected by illness or injury.

(c) Skilled therapies:

(i) Must be provided to the consumer within the therapist's or therapy assistant's scope of practice in accordance with sections 4755.44 , 4755.07 , and 4753.07 of the Revised Code.

(ii) Must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code to care for the consumer's illness or injury.

(iii) Must be provided and documented in the consumer's plan of care in accordance with rule 5101:3-12-03 of the Administrative Code.

(iv) Must be reasonable in their amount, frequency, and duration. Treatment must be considered according to the accepted standards of medical practice to be safe and effective treatment for the consumer's condition.

(v) Must be provided with the expectation of the consumer's rehabilitation potential according to the treating physician's prognosis of illness or injury. The expectation of the consumer's rehabilitation potential is that the condition of the consumer will measurably improve within a reasonable period of time or the services are necessary to the establishment of a safe and effective maintenance program.

(vi) May include treatments, assessments and/or therapeutic exercises but cannot include activities that are for the general welfare of the consumer, including motivational or general activities for the overall fitness of the consumer.

(H) A consumer who meets the requirements in this paragraph may qualify for increased services. The MCRHHA must assure and document the consumer meets all requirements in this paragraph prior to increasing services. The U5 modifier must be used when billing in accordance to rule 5101:3-12-05 of the Administrative Code. The use of the U5 modifier indicates that all conditions of this paragraph were met. The consumer who meets the following requirements may receive an increase of home health services if he or she:

(1) Is under age twenty-one and requires services for treatment in accordance with Chapter 5101:3-14 of the Administrative Code for the healthchek program.

(2) Requires more than, as ordered by the treating physician:

(a) Eight hours (thirty two units) per day of any home health service, or a combined total of fourteen hours (fifty six units) per week of home health aide and home health nursing as specified in paragraph (C) of this rule; or

(b) A combined total of twenty-eight hours (one hundred twelve units) per week of home health nursing and home health aide for sixty days as specified in paragraph (D) of this rule.

(3) Has a comparable level of care as evidenced by either:

(a) Enrollment in a HCBS waiver; or

(b) A level of care evaluated initially and annually by ODJFS or its designee for a consumer not enrolled in a HCBS waiver. The criteria for an institutional level of care are any of the rules regarding the skilled level of care (SLOC) as defined in rule 5101:3-3-05 of the Administrative Code, intermediate level of care(ILOC) as defined in rule 5101:3-3-06 of the Administrative Code, or ICF/MR level of care as defined in rule 5101:3-3-07 of the Administrative Code. In no instance does this constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long term care institution; and

(4) Requires home health nursing or a combination of PDN/home health nursing/waiver nursing/skilled therapy visits at least once per week that is medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code as ordered by the treating physician.

Effective: 02/01/2011
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/4/77, 4/7/77, 12/21/77, 6/1/80, 5/1/87, 4/1/88, 5/15/89, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/1/93 (Emer), 7/30/93, 9/1/93, 1/1/96, 5/1/98, 7/1/98, 9/29/00, 3/1/02 (Emer), 5/30/02, 1/31/05, 9/1/05, 7/1/06, 11/8/07

5160-12-02 Private duty nursing: services, provision requirements, coverage and service specification.

(A) "Private duty nursing (PDN)" is a continuous nursing service that requires the skills of and is performed by either a registered nurse or a licensed practical nurse at the direction of a registered nurse and is provided in one or more PDN visits. A continuous nursing visit (or PDN visit) is defined as a medically necessary visit that is more than four hours (more than sixteen units) but less than or equal to twelve hours (forty-eight units) in length. A service is not considered a nursing service merely because it was performed by a licensed nurse. For dates of service on or after 7/01/06, a covered PDN visit must meet the definition of paragraph (A) in rule 5101-3-12-04 of the Administrative Code and be more than four hours(more than sixteen units) in length but less than or equal to twelve hours (forty-eight units) in length, unless:

(1) An unusual, occasional circumstance requires a medically necessary visit of up to and including sixteen hours (sixty-four units); or

(2) Less than a two hour lapse between visits has occurred and the length of the PDN service requires an agency to provide a change in staff; or

(3) Less than a two hour lapse between visits has occurred and the PDN service is provided by more than one non-agency provider; or

(4) ODJFS or its designee has authorized PDN visits that are four hours or less length in accordance with rule 5101:3-12-02.3 of the Administrative Code.

(B) For PDN to be covered, the service:

(1) Must be performed within the nurse's scope of practice as defined in Chapter 4723. of the Revised Code and rules adopted thereunder.

(2) Must be provided and documented in accordance with the consumer's plan of care in accordance with rule 5101:3-12-03 of the Administrative Code.

(3) Must be provided in a face-to-face encounter.

(4) Must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code to care for the consumer's illness or injury.

(5) May include home infusion therapy for the administration of medications, nutrients or other solutions intravenously or enterally. A visit made for the purpose of home infusion therapy must be billed using the U1 modifier in accordance with rule 5101:3-12-06 of the Administrative Code.

(6) Must be provided in the consumer's place of residence unless it is medically necessary for a nurse to accompany the consumer in the community. The consumer's place of residence is wherever the consumer lives, whether the residence is the consumer's own dwelling, an apartment, assisted living facility, a relative's home, or other type of living arrangement. The place of residence cannot include a hospital, nursing facility, or intermediate care facility for the mentally retarded (ICF-MR). The place of service in the community cannot include the residence or business location of the provider of PDN.

(7) Must not be provided for the provision of habilitative care. "Habilitative care" is referenced in Chapter 5101:3-1 of the Administrative Code.

(8) Must meet the criteria in accordance with this paragraph and paragraphs (A), (C) and (D) of this rule.

(9) For "children" (consumers under the age of twenty-one), must also meet the criteria in accordance with either paragraph (E) or (F) of this rule.

(10) For "adults" (consumers age twenty-one and older), must also meet the criteria in accordance with either paragraph (E) or (G) of this rule.

(C) The providers of PDN are: MCRHHAs (medicare certified home health agencies) that meet the requirements in accordance with rule 5101:3-12-03 of the Administrative Code, an otherwise accredited agency that meets the requirements in accordance with rule 5101:3-12-03.1 of the Administrative Code, and a non-agency nurse that meets the requirements in accordance with rule 5101:3-12-03.1 of the Administrative Code. In order for PDN to be covered, these providers must:

(1) Provide PDN that is appropriate given the consumer's diagnosis, prognosis, functional limitations and medical conditions as documented by the consumer's treating physician.

(2) Provide PDN as specified in the plan of care in accordance with rule 5101:3-12-03 of the Administrative Code. PDN services not specified in a plan of care are not reimbursable. Additionally, for consumers enrolled on an HCBS waiver, the providers of PDN services must provide the amount, scope, duration, and type of PDN service within the plan of care as:

(a) Identified on the all services plan that is approved by ODJFS or the case management agency when a consumer is enrolled in an ODJFS administered home and community based services (HCBS) waiver. PDN services not identified on the all services plan are not reimbursable; or

(b) Documented on the services plan when a consumer is enrolled in an ODA (Ohio department of aging) administered or an ODMR/DD (Ohio department of mental retardation and developmental disabilities) administered HCBS waiver. PDN services not documented on the services plan are not reimbursable.

(3) Bill for provided PDN services using the appropriate procedure code and applicable modifiers in accordance with rule 5101:3-12-06 of the Administrative Code.

(4) Bill for provided PDN services in accordance with the visit policy in rule 5101:3-12-04 of the Administrative Code, except as provided for in paragraph (A) of this rule.

(5) Bill after all documentation is completed for services rendered during a visit in accordance with rule 5101:3-12-03 of the Administrative Code.

(D) Consumers who receive PDN must:

(1) Be under the supervision of a treating physician who is providing care and treatment to the consumer. The treating physician cannot be a physician whose sole purpose is to sign and authorize plans of care or who does not have direct involvement in the care or treatment of the consumer. A treating physician may be a physician who is substituting temporarily on behalf of a treating physician.

(2) Participate in the development of a plan of care with the treating physician and the MCRHHA or other accredited agencies or non-agency registered nurse. An authorized representative may participate in the development of the plan of care in lieu of the consumer.

(3) Access PDN in accordance with the program for the all-inclusive care of the elderly (PACE) if the consumer participates in the PACE program.

(4) Access PDN in accordance with the consumer's provider of hospice services if the consumer has elected hospice.

(5) Access PDN in accordance with the consumer's managed care plan if the consumer is enrolled in a medicaid managed care plan.

(E) Post hospital - PDN:

(1) Any medicaid consumer, whether adult or child, may receive PDN services up to fifty-six hours (two hundred twenty-four units) per week, and up to sixty consecutive days from the date of discharge from an inpatient hospital stay of three or more covered days in accordance with rule 5101:3-2-03 of the Administrative Code. For purposes of this rule, a covered inpatient hospital stay is considered one hospital stay when a consumer is transferred from one hospital to another hospital, either within the same building or to another location.

(a) The sixty days will begin once the consumer is discharged from the hospital to the consumer's place of residence as defined in paragraph (B)(6) of this rule, from the last inpatient stay whether or not the last inpatient stay was in an inpatient hospital or inpatient rehabilitation unit of a hospital.

(b) The sixty days will begin once the consumer is discharged from a hospital to a nursing facility. PDN is not available while residing in a nursing facility.

(2) The treating physician or a hospital discharge planner or a registered nurse acting under the orders of the treating physician certifies the medical necessity of PDN services using the JFS 07137 "Home Care Physician Certification Form" (rev. 7/2006). PDN is available to consumers only if they have a medical need comparable to a skilled level of care as evidenced by a medical condition that temporarily reflects the skilled level of care (SLOC) as defined in rule 5101:3-3-05 of the Administrative Code. In no instance do these requirements constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long-term care institution.

(3) The PDN service must not be for the provision of maintenance care. "Maintenance care" is the care given to a consumer for the prevention of deteriorating or worsening medical conditions or the management of stabilized chronic diseases or conditions. Services are considered maintenance care if the consumer is no longer making significant improvement in his or her medical condition.

(4) All requirements must be met in paragraph (E) of this rule as well as all the requirements in paragraphs (A), (B), (C) and (D) of this rule.

(5) Consumers who require additional PDN with or without a hospitalization may access PDN through either paragraph (F) or (G) of this rule.

(F) Child - PDN:

(1) A child may qualify for PDN services if he or she meets the requirements within paragraph (F) of this rule.

(a) Is under age twenty-one and requires services for treatment in accordance with Chapter 5101:3-14 of the Administrative Code for the healthchek program.

(b) Requires (as ordered by the treating physician) continuous nursing including the provision of on-going maintenance care. Services cannot be for habilitative care as defined in paragraph (B)(7) of this rule.

(c) Has a comparable level of care as evidenced by either:

(i) Enrollment in a HCBS waiver; or

(ii) A comparable institutional level of care as evaluated initially and annually by ODJFS or its designee for a consumer not enrolled in a HCBS waiver. The criteria for an institutional level of care are any of the rules regarding the skilled level of care (SLOC) as defined in rule 5101:3-3-05 of the Administrative Code, intermediate level of care(ILOC) as defined in rule 5101:3-3-06 of the Administrative Code, or ICF/MR level of care as defined in rule 5101:3-3-07 of the Administrative Code. In no instance do these criteria constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long-term care institution.

(2) The provider of PDN services must assure and document the consumer meets all requirements in paragraph (F) of this rule prior to requesting and billing for the PDN services.

(3) The U5 modifier must be used when billing in accordance with rule 5101:3-12-06 of the Administrative Code. The use of the U5 modifier indicates that all conditions of paragraph (F) of this rule were met, PDN authorization was obtained and the consumer continued to meet medical necessity criteria.

(4) The child must have a PDN authorization obtained in accordance with rule 5101:3-12-02.3 of the Administrative Code and approved by ODJFS or its designee to establish medical necessity and the consumer's comparable level of care. ODJFS or its designee will conduct a face-to-face encounter and/or review of documentation. In an emergency, PDN services may be delivered and PDN authorization obtained after the delivery of services when the services are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, and the services are required to protect the health and welfare of the consumer. A request for PDN authorization is made as follows:

(a) For a child not enrolled in a HCBS waiver, the provider of PDN must submit the request to ODJFS or its designee. Any documentation required by ODJFS or its designee for the review of medical necessity must be provided by the provider of PDN services. ODJFS or its designee will notify the provider of the amount, scope and duration of services authorized.

(b) For a child enrolled in an ODMR/DD or ODA-administered waiver, the provider of PDN must submit the request to the case manager of the HCBS waiver, who will be forwarded to ODJFS or its designee. Any documentation required by ODJFS or its designee for the review of medical necessity must be provided by the provider of PDN services. ODJFS or its designee will notify the provider and the case manager of the amount, scope and duration of services authorized.

(c) For a child enrolled in an ODJFS-administered waiver, the case manager will authorize PDN services through the all services plan.

(5) All requirements must be met in paragraph (F) of this rule as well as all the requirements in paragraphs (A), (B), (C) and (D) of this rule.

(G) Adult - PDN: The adult consumer who meets the following requirements may receive PDN services.

(1) The adult is age twenty-one or older.

(2) The adult requires (as ordered by the treating physician) continuous nursing including the provision of on-going maintenance care. Services cannot be for habilitative care as defined in paragraph (B)(7) of this rule.

(3) The adult has a comparable level of care as evidenced by either:

(a) Enrollment in a HCBS waiver; or

(b) A comparable institutional level of care as evaluated initially and annually by ODJFS or its designee for a consumer not enrolled in a HCBS waiver. The criteria for an institutional level of care are any of the rules regarding the skilled level of care (SLOC) as defined in rule 5101:3-3-05 of the Administrative Code, intermediate level of care(ILOC) as defined in rule 5101:3-3-06 of the Administrative Code, or ICF/MR level of care as defined in rule 5101:3-3-07 of the Administrative Code. In no instance does this constitute the determination of a level of care for waiver eligibility purposes, or admission into a medicaid covered long term care institution.

(4) The provider of PDN services must assure and document the consumer meets all requirements in paragraph (G) of this rule prior to providing PDN. Providers must bill using the U6 modifier in accordance with rule 5101:3-12-06 of the Administrative Code. The use of the U6 modifier indicates that all conditions of paragraph (G) of this rule were met, PDN authorization was obtained and the consumer continued to meet medical necessity criteria.

(5) The adult must have a PDN authorization obtained in accordance with rule 5101:3-12-02.3 of the Administrative Code and approved by ODJFS or its designee to establish medical necessity and the consumer's comparable level of care. ODJFS or its designee will conduct a face-to-face encounter and/or review of documentation. In an emergency, PDN services may be delivered and PDN authorization obtained after the delivery of services when the services are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, and the services are required to protect the health and welfare of the consumer. A request for PDN authorization is made as follows:

(a) For an adult not enrolled in a HCBS waiver, the provider of PDN must submit the request to ODJFS or its designee. Any documentation required by ODJFS or its designee for the review of medical necessity must be provided by the provider of PDN services. ODJFS or its designee will notify the provider of the amount, scope and duration of services authorized.

(b) For an adult enrolled in an ODMR/DD or ODA-administered waiver, the provider of PDN must submit the request to the case manager of the HCBS waiver, who will forward the request to ODJFS or its designee. Any documentation required by ODJFS or its designee for the review of medical necessity must be provided by the provider of PDN services. ODJFS or its designee will notify the provider and the case manager of the amount, scope and duration of services authorized.

(c) For an adult enrolled in an ODJFS-administered waiver, the case manager will authorize PDN services through the all services plan.

(6) All requirements must be met in paragraph (G) of this rule as well as all the requirements in paragraphs (A), (B), (C) and (D) of this rule.

(H) Consumers subject to medical determinations made by ODJFS or its designee pursuant to this rule will be afforded notice and hearing rights to the extent afforded in division 5101:6 of the Administrative Code.

Replaces: Part of 5101:3-12-01, 5101:3-12-02, 5101:3-12-03, 5101:3-12-04, 5101:3-12-05, 5101:3-12-06

Effective: 09/28/2006
R.C. 119.032 review dates: 09/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5111.85
Prior Effective Dates: 4/4/77, 4/7/77, 12/21/77, 6/1/80, 5/1/87, 4/1/88, 5/15/89, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/1/93 (Emer), 7/30/93, 9/1/93, 1/1/96, 5/1/98, 7/1/98, 9/29/00, 3/1/02 (Emer), 5/30/02, 1/31/05, 9/1/05, 6/30/06 (Emer)

5160-12-02.1 Provision for consumers enrolled in and providers who provide the core plus benefit package services.

(A) Core plus benefit package will no longer be available as of the effective date of this rule. The core plus benefit package was defined in Chapter 5101:3-12 of the Administrative Code prior to the effective date of this rule.

(B) Consumers who were enrolled in the core plus benefit package, for any time period during the one hundred twenty days preceding the effective date of this rule, will have an eligibility determination made by ODJFS or its designated case management agency (CMA) in accordance with rule 5101:3-45-15 of the Administrative Code to determine if the consumer is eligible for an ODJFS-administered waiver.

(C) If a consumer is determined ineligible for an ODJFS-administered waiver or the consumer chooses not to enroll in an ODJFS-administered waiver, the consumer will be afforded notice and hearing rights in accordance with division-level 5101:6 of the Administrative Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.85

5160-12-02.3 Private duty nursing: procedures for service authorization.

(A) As a prerequisite to receiving private duty nursing (PDN) services,

(1) A child must meet the requirements of rule 5101:3-12-02 of the Administrative Code, including paragraph (F)(4)(a) or (F)(4)(b), as applicable, which require the child receive PDN authorization from ODJFS or its designee; or

(2) An adult must meet the requirements of rule 5101:3-12-02 of the Administrative Code, including paragraph (G)(5)(a) or (G)(5)(b), as applicable, which require the adult receive PDN authorization from ODJFS or its designee.

(B) The procedures set forth in this paragraph must be followed when securing a PDN authorization for children and adults who are not enrolled on a home and community-based services (HCBS) waiver. ODJFS shall specify the amount, scope and duration of PDN services to be authorized. The period for which PDN authorization applies shall not exceed one hundred eighty days.

(1) The PDN provider shall submit a referral for PDN authorization to ODJFS on the JFS 02374, "Private Duty Nursing (PDN) Services Request" (9/06), and shall submit any additional supporting documentation requested by ODJFS.

(2) ODJFS shall conduct a face-to-face assessment and/or perform a desk review to determine if, in accordance with rule 5101:3-12-02 of the Administrative Code, the consumer has a medical condition that meets the criteria for an institutional level of care, and the services are medically necessary as set forth in rule 5101:3-1-01 of the Administrative Code.

(a) If ODJFS determines the consumer has a medical condition that meets the criteria for an institutional level of care, and PDN services are medically necessary as set forth in rule 5101:3-1-01 of the Administrative Code, ODJFS shall:

(i) Notify the PDN provider in writing of the authorized amount, scope and duration of PDN services and the PDN authorization number after conducting the face-to-face assessment and/or performing the desk review. The PDN provider shall begin furnishing PDN services to the consumer upon receipt of written PDN authorization and in accordance with all other requirements set forth in rule 5101:3-12-02 of the Administrative Code.

(ii) Inform the consumer and/or authorized representative of PDN authorization after conducting the face-to-face assessment and/or performing the desk review, and provide a written notice to the consumer and/or authorized representative specifying the authorized amount, scope and duration of PDN services.

(b) If the consumer and/or authorized representative disagrees with the authorized amount, scope and/or duration of PDN services, the consumer and/or authorized representative may request a hearing in accordance with division 5101:6 of the Administrative Code. PDN services shall be delivered according to the amount, scope and duration authorized pending the outcome of the hearing.

(c) If ODJFS determines the consumer does not have a medical condition that meets the criteria for an institutional level of care, and/or the services are not medically necessary as set forth in rule 5101:3-1-01 of the Administrative Code, ODJFS:

(i) Shall deny the PDN authorization request, and issue a denial notice and hearing rights to the consumer in accordance with division 5101:6 of the Administrative Code.

(ii) May conduct a review of the PDN authorization request that has been proposed for denial.

(iii) Shall notify the PDN provider in writing of the denial of the PDN authorization request.

(3) The provider shall notify ODJFS in writing on the JFS 02374, "Private Duty Nursing (PDN) Services Request," when there is any change in the consumer's condition that warrants a change in the amount, scope or duration of PDN services.

(C) The procedures set forth in this paragraph must be followed when securing a PDN authorization for children and adults enrolled on an HCBS waiver administered by the Ohio department of mental retardation and developmental disabilities (ODMR/DD) or the Ohio department of aging (ODA). ODJFS shall specify the amount, scope and duration of PDN services to be authorized. The period for which PDN authorization applies shall not exceed three hundred sixty-five days.

(1) The consumer and/or authorized representative, or PDN provider shall request that the ODMR/DD or ODA case manager submit a referral for PDN authorization to ODJFS on the JFS 02374, "Private Duty Nursing (PDN) Services Request," and shall submit any additional supporting documentation requested by ODJFS. The case manager shall assist the consumer and/or authorized representative in securing a potential PDN service provider.

(2) ODJFS shall conduct a face-to-face assessment and/or perform a desk review to confirm if, in accordance with rule 5101:3-12-02 of the Administrative Code, the consumer is enrolled in an ODMR/DD- or ODA-administered waiver, and has a medical condition that requires PDN services that are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code.

(a) If ODJFS confirms, in accordance with rule 5101:3-12-02 of the Administrative Code, the consumer is enrolled in an ODMR/DD- or ODA-administered waiver, and has a medical condition that requires PDN services that are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, ODJFS shall:

(i) Notify the ODMR/DD or ODA case manager, as applicable, in writing of the authorized amount, scope and duration of PDN services and the PDN authorization number after conducting the face-to-face assessment and/or performing the desk review. The ODMR/DD or ODA case manager shall notify the PDN provider of the authorized amount, scope and duration of PDN services and the PDN authorization number, and the PDN provider shall begin furnishing PDN services to the consumer upon receipt of written PDN authorization and in accordance with all other requirements set forth in rule 5101:3-12-02 of the Administrative Code.

(ii) Inform the consumer and/or authorized representative of PDN authorization after conducting the face-to-face assessment and/or performing the desk review, and provide a written notice to the consumer and/or authorized representative specifying the authorized amount, scope and duration of PDN services.

(b) If the consumer and/or authorized representative disagrees with the authorized amount, scope and/or duration of PDN services, the consumer and/or authorized representative may request a hearing in accordance with division 5101:6 of the Administrative Code. PDN services shall be delivered according to the amount, scope and duration authorized pending the outcome of the hearing.

(c) If ODJFS cannot confirm, in accordance with rule 5101:3-12-02 of the Administrative Code, the consumer is enrolled in an ODMR/DD- or ODA-administered waiver, and/or cannot confirm that the consumer has a medical condition that requires PDN services that are medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, ODJFS shall:

(i) Deny the PDN authorization request and issue a denial notice and hearing rights to the consumer and/or authorized representative in accordance with division 5101:6 of the Administrative Code.

(ii) Notify the ODMR/DD or ODA case manager in writing of the denial of the PDN authorization request. The ODMR/DD or ODA case manager shall notify the PDN provider in writing of the denial.

(3) The provider shall notify ODJFS and the ODMR/DD or ODA case manager in writing on the JFS 02374, "Private Duty Nursing (PDN) Services Request," when there is any change in the consumer's condition that warrants a change in the amount, scope or duration of PDN services.

(4) The ODMR/DD or ODA case manager shall notify ODJFS in writing on the JFS 02374, "Private Duty Nursing (PDN) Services Request," when there is a change in the consumer's level of care.

(D) PDN services shall be approved for ODJFS-administered waiver consumers as a result of the face-to-face assessment or reassessment conducted by ODJFS or its designated case management agency (CMA) in accordance with rule 5101:3-46-02 of the Administrative Code, or the reassessment conducted in accordance with rule 5101:3-47-02 or 5101:3-50-02 of the Administrative Code, as appropriate. As set forth in rule 5101:3-12-02 of the Administrative Code, PDN services must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code.

(1) The case manager shall assist the consumer and/or authorized representative in securing a PDN service provider.

(2) If PDN services are approved, ODJFS or its designated CMA shall:

(a) Record the amount, scope and duration of approved PDN services on the all services plan.

(b) Notify the provider, in writing, of the amount, scope and duration of approved PDN services.

(c) Inform the consumer and/or authorized representative of PDN service approval after conducting the assessment or reassessment, and provide a written notice to the consumer and/or authorized representative specifying the approved amount, scope and duration of PDN services.

(3) If the consumer and/or authorized representative disagrees with the authorized amount, scope and/or duration of PDN services, the consumer and/or authorized representative may request a hearing in accordance with division 5101:6 of the Administrative Code. PDN services shall be delivered according to the approved amount, scope and duration pending the outcome of the hearing.

(4) If PDN services are denied, ODJFS or its designated CMA shall issue a denial notice and hearing rights to the consumer and/or authorized representative in accordance with division 5101:6 of the Administrative Code.

(5) Requests for a change in the amount, scope and/or duration of authorized PDN services shall be submitted to ODJFS or its designated CMA. ODJFS or its designated CMA shall conduct a face-to-face reassessment and/or perform a desk review to evaluate the request.

(E) PDN services may be provided to a consumer in an emergency when the provider has an existing PDN authorization to provide PDN services to that consumer. For the purposes of this rule, emergency services are provided outside of normal state of Ohio office hours when prior authorization cannot be obtained.

(1) PDN services may be delivered in an emergency and a new PDN authorization obtained after the delivery of services. The PDN services must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, and the services must be necessary to protect the health and welfare of the consumer.

(2) The provider shall notify ODJFS, or the ODMR/DD or ODA case manager, as applicable, in writing on the JFS 02374, "Private Duty Nursing (PDN) Services Request," when emergency PDN services are furnished. Notification shall be immediate, or no later than the first business day following the emergency provision of PDN services.

(F) ODJFS may authorize the provision of PDN services by one or more provider(s) in visits of four hours or less during the authorized PDN service period in order to assure the health and welfare of the consumer. "PDN service period" means the length of time during which PDN services, which are more than four hours in length, are delivered without a two-hour lapse between visits.

(G) Utilization of authorized PDN services is subject to monitoring by ODJFS.

(H) ODJFS shall maintain all written records related to review of PDN service authorization for a period of six years following receipt of the request or until an initiated audit is resolved, whichever is longer.

Replaces: 5101:3-12- 02.3

Effective: 12/07/2006
R.C. 119.032 review dates: 12/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5111.85
Prior Effective Dates: 9/1/06 (Emer)

5160-12-03 Medicare certified home health agencies (MCRHHA): qualifications and requirements.

(A) A medicare certified home health agency (MCRHHA) that meets the requirements in accordance with this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(B) MCRHHAs are required:

(1) To be certified for medicare participation by the Ohio department of health (ODH) in accordance with Chapter 3701-60 of the Administrative Code.

(2) To meet the conditions of participation in accordance with 42 C.F.R. 484

(October 1, 2005).

(3) To implement policy components for home health and private duty nursing as specified in the "Medicare Benefit Policy Manual, Chapter Seven: Home Health Services" (August 12, 2005) for the following sections:

(a) "Determination of Coverage" section 20;

(b) "Content of the Plan of Care" section 30.2 to "Under the Care of a Physician" section 30.3 ; and

(c) "Covered Services Under a Qualifying Home Health Plan of Care" section 40 to "Medical Social Services" section 50.3.

(4) To comply with all applicable requirements for medicaid providers in Chapter 5101:3-1 of the Administrative Code.

(5) To comply with all federal, state and local laws and regulations.

(C) MCRHHAs are required:

(1) To have back up staff available to provide services when the agency's regularly scheduled staff cannot or do not meet their obligation to provide services.

(2) To submit written notification to the consumer at least thirty days prior to the last date of service when terminating a service unless:

(a) The consumer's treating physician has discontinued home health services;

(b) The treating physician has been notified that goals have been met;

(c) The consumer is no longer at the consumer's place of residence;

(d) The consumer or another person has harmed or threatened to harm the MCRHHAs staff;

(e) The consumer requested that services be terminated;

(f) The consumer has been enrolled in a medicaid managed care plan (MCP).

(3) To contact the consumer's medicaid MCP to request prior authorization for home health and PDN services.

(4) To maintain documentation on all aspects of services provided in accordance with this chapter. All documentation must be complete prior to billing for services provided in accordance with this chapter. This includes but is not limited to:

(a) Clinical records (including all signed orders) as specified in paragraph (B) of this rule.

(b) Time keeping records that indicate the date and time span of the services provided during a visit, and the type of service provided.

(c) To obtain the completed and signed JFS 07137 "Certificate of Medical Necessity Home Care Certification" (rev. 7/2006), which certifies the medical necessity for services in accordance with paragraph (C) of rule 5101:3-12-01 or paragraph (B) of rule 5101:3-12-02 of the Administrative Code.

Effective: 11/08/2007
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 5/1/87, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer) 10/30/92, 7/1/93 (Emer), 9/1/93, 1/1/96, 7/1/98, 9/29/00, 9/1/05, 7/1/06

5160-12-03.1 Non-agency nurses and otherwise-accredited agencies: qualifications and requirements.

"Non-agency nurses" and "otherwise-accredited agencies" who meet the qualifications and requirements of this rule can provide private duty nursing (PDN) in accordance with rule 5101:3-12-02 of the Administrative Code.

(A) A "non-agency nurse" that meets the requirements in accordance with this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code. A non-agency nurse is required:-

(1) To be a registered nurse or licensed practical nurse at the direction of a registered nurse practicing within the scope of his or her nursing license pursuant to Chapter 4723. of the Revised Code as an independent provider.

(2) To comply with the requirements of an MCRHHA in accordance to rule 5101:3-12-03 of the Administrative Code except for paragraphs (A), (B)(1) and (C)(1) of rule 5101:3-12-03 of the Administrative Code.

(3) To not be related to the consumer.

(4) To meet all conditions of participation in paragraphs (C) and (D) of rule 5101:3-45-10 of the Administrative Code.

(B) "Otherwise-accredited agency" means an agency that has and maintains accreditation by a national accreditation organization for the provision of home health services, private duty nursing, personal care services and support services, and that has executed a medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code. The accreditation shall be granted by a national accreditation organization approved by the centers for medicare and medicaid services(CMS), which may include, but is not limited to, one of the following: the accreditation commission for health care (ACHC), the community health accreditation program (CHAP) and the joint commission.

(C) Providers of PDN services who are also providers of waiver services to a waiver consumer enrolled in a home and community based services (HCBS) waiver must comply with all applicable requirements including those set forth by the HCBS waiver rule(s).

Effective: 10/26/2009
R.C. 119.032 review dates: 08/11/2009 and 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5111.85
Prior Effective Dates: 7/1/06

5160-12-04 Home health and private duty nursing: visit policy.

Reimbursement of home health services or private duty nursing (PDN) in accordance with this chapter is on a per visit basis.

(A) A "visit" is the duration of time that a covered home health service or private duty nursing service is provided in a face to face encounter to one or more medicaid consumer(s) at the same residence on the same date during the same time period; and

(1) Begins with the provision of a covered service and ends when the face to face encounter ends; and

(2) Must have a lapse of time of two or more hours between any previous or subsequent visit for the provision of the same covered service unless the length of a private duty nursing visit requires an agency to provide a change in staff; and

(3) Must have a lapse of two or more hours between the provision of home health nursing or private duty nursing service.

(B) When a consumer is enrolled in a home and community based services (HCBS) waiver and is receiving consecutive home health or PDN service(s) with waiver service(s) that have the same scope of service, there must be a lapse of time of two or more hours between the services. A "scope" of a service includes the definition of the service and the conditions that apply to its provision and the provider who renders the service(s).

(C) Each covered visit must be billed:

(1) As a separate line item. The number of lines/procedure codes must reflect the number of visits provided with one line equaling one visit.

(2) To reflect the length of the visit where one unit equals fifteen minutes. Units must be rounded down if the number of minutes is seven or less and rounded up if over seven minutes.

(D) A "group visit" is a visit where the service(s) is provided to more than one person. During a group visit:

(1) The ratio of an individual provider or an employee of a provider to the people being served may never exceed one to three.

(2) An entire visit is considered a group visit even if only a portion of the visit met the definition of a group visit.

(3) A modifier HQ must be used when billing for a group visit to identify each group setting in accordance with rule 5101:3-12-05 of the Administrative Code.

(E) A "multiple visit" is when the provision of the same home health service or PDN by the same provider occurs on the same date of service for the same consumer separated by a lapse of two hours. Multiple visits must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code due to the functional limitations and/or medical condition of the consumer as documented in the plan of care, and if the consumer is enrolled in HCBS waiver, the services plan or all services plan. Documentation must support the medical need for multiple visits. After the initial visit multiple visits must either be billed with a U2 modifier for the second visit or U3 for the third or any subsequent visit.

Replaces: Part of 5101:3-12-06, 5101:3-12-10

Effective: 07/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.85
Prior Effective Dates: 4/7/77, 5/1/87, 4/1/88, 5/15/89, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/1/93 (Emer), 7/30/93, 9/1/93, 1/1/96, 7/1/98, 9/29/00, 9/1/05

5160-12-05 Reimbursement: home health services.

(A) Definitions of terms used for billing home health services rates set forth in appendix A to this rule are:

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

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

(B) Home health services are delivered and billed in accordance with this chapter by medicare certified home health agencies (MCRHHA).

(C) The amount of reimbursement for a visit shall be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and unit rate found in appendix A to this rule using the number of units of service (one unit equals fifteen minutes) that were provided during a visit in accordance with this chapter as follows:

(1) Each visit must be less than or equal to four hours (sixteen units).

(2) For a visit that is less than one hour (four units) the medicaid maximum is the amount of the base rate.

(3) For a visit that is over one hour (four units) the medicaid maximum is the amount of the base rate plus the unit rate amount for each unit over one hour (four units), but not to exceed four hours (sixteen units).

(D) The amount of reimbursement for a visit shall be the lesser of the provider's billed charge or seventy-five per cent of the total medicaid maximum as specified in paragraph (B) of this rule when billing with the modifier HQ "group setting" for group visits conducted in accordance with rule 5101:3-12-04 of the Administrative Code.

(E) The modifiers set forth in appendix B to this rule must be used to provide additional information in accordance with this chapter.

(F) Reimbursement must be provided in accordance with paragraphs (A) to (D) of rule 5101:3-1-60 of the Administrative Code.

(G) A MCRHHA will not be reimbursed for home health services provided to a consumer that duplicates same or similar services already paid by medicaid or another funding source. For example, if the facility/home where a residential state supplemental recipient or medicaid consumer resides, such as an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility is paid to provide personal care or nursing services, then home health services are not reimbursable by medicaid.

(H) A MCRHHA will be reimbursed for home health services provided to a consumer if the provider has written documentation from a facility/home (i.e., an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility) stating that the facility/home is not responsible for providing the same or similar home health services to the consumer.

(I) Home health services provided to the consumer enrolled in the assisted living HCBS waiver in accordance with rule 5101:3-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

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Effective: 10/01/2011
R.C. 119.032 review dates: 07/14/2011 and 10/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0213
Rule Amplifies: 5111.02 , 5111.021 , 5111.0213
Prior Effective Dates: 5/1/87, 4/1/88, 5/15/89, 7/1/98, 7/1/06, 7/1/08, 1/1/10

5160-12-06 Reimbursement: private duty nursing services.

(A) Definitions of terms used for billing private duty nursing services (PDN) rates set forth in appendix A to this rule are:

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

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

(B) PDN services are delivered and billed as PDN visits in accordance with rules 5101:3-12-02, 5101:3-12-2.3 and 5101:3-12-04 of the Administrative Code. The services are provided by medicare certified home health agencies,"otherwise accredited agencies," or "non-agency nurses." PDN service rates are identified in appendix A to this rule.

(C) The amount of reimbursement for a visit shall be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and unit rate found in appendix A to this rule using the number of units of service (one unit equals fifteen minutes) that were provided during a visit in accordance with this chapter. The medicaid maximum rate for a private duty nursing visit is the amount of the base rate plus the unit rate amount for each unit over four units.

(D) The amount of reimbursement for a visit shall be the lesser of the provider's billed charge or seventy-five per cent of the total medicaid maximum as specified in paragraph (B) of this rule when billing with the modifier HQ "group setting" for group visits conducted in accordance with rule 5101:3-12-04 of the Administrative Code.

(E) The modifiers set forth in appendix B to this rule must be used to provide additional information in accordance with this chapter.

(F) Reimbursement must be provided in accordance with paragraphs (A) to (D) of rule 5101:3-1-60 of the Administrative Code.

(G) Providers of PDN will not be reimbursed for PDN services provided to a consumer that duplicate services already paid by medicaid or another funding source. For example, if the facility/home where a residential state supplemental recipient or medicaid consumer resides, such as an adult foster home, adult family home, adult group home, ICF/MR, residential care facility, community alternative home, or other facility is paid to provide nursing services, then PDN services are not reimbursable by medicaid.

(H) Providers of PDN will be reimbursed for PDN services provided to a consumer if the provider has written documentation from a facility/home (i.e., an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility) stating that the facility/home is not responsible for providing the same or similar PDN services to the consumer.

(I) PDN services provided to the consumer enrolled in the assisted living HCBS waiver in accordance with rule 5101:3-1-60 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

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Effective: 10/01/2011
R.C. 119.032 review dates: 07/14/2011 and 10/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0213
Rule Amplifies: 5111.02 , 5111.021 , 5111.0213
Prior Effective Dates: 5/1/87, 4/1/88, 5/15/89, 7/1/98, 6/30/06 (Emer), 9/28/06, 7/1/08, 1/1/10

5160-12-07 Reimbursement: exceptions.

Home health and private duty nursing (PDN) service providers may be reimbursed when circumstances outside the provider's control result in any of the exceptions set forth in this rule. The provider shall maintain written documentation that includes the date, the time (if available), the content of the communication, the contact name, and the contact information (e.g., telephone number, fax number, email address, or mailing address).

(A) Requirements of paragraphs (D)(2) of rule 5101:3-12-01 and (C)(2) of rule 5101:3-12-02 of the Administrative Code do not have to be met if either paragraph (A)(1), (A)(2), or (A)(3) of this rule applies:

(1) Services are not identified on the all services plan when the consumer is enrolled in an ODJFS-administered waiver, and the provider has documented attempts to work with the case manager and the case manager's supervisors to identify the services on the all services plan. Documentation shall include written proof of the provider's attempts to obtain the all services plan that identifies the services. This exception does not extend to instances in which the provider disagrees with the amounts of service identified on the all services plan.

(2) Services are not documented on the services plan when the consumer is enrolled in an ODA- or ODMR/DD-administered waiver, and the provider has documented attempts to work with the case manager and the case manager's supervisors to identify the services on the services plan. Documentation shall include written proof of the provider's attempts to obtain the services plan that identifies the services. This exception does not extend to instances in which the provider disagrees with the amounts of service identified on the services plan.

(3) The provider verified and documented before providing services that either paragraph (A)(3)(a) or (A)(3)(b) of this rule applies.

(a) The consumer was not enrolled in a home and community-based services (HCBS) waiver at the initiation of services and every six months thereafter. And the case manager cannot produce documentation that the provider was notified that the consumer had become enrolled in an HCBS waiver.

(b) The consumer was not enrolled in an HBCS waiver and subsequently, at any point during, the delivery of services, the provider became aware of the consumer's enrollment and the provider notified the case manager and requested that the services be identified on the plan. And the case manager cannot produce documentation that the provider was notified that the consumer had become enrolled in an HCBS waiver.

(B) Requirements of paragraphs (F) of rule 5101:3-12-05 and (F) of rule 5101:3-12-06 of the Administrative Code do not have to be met if either paragraph (B)(1) or (B)(2) of this rule applies.

(1) The provider has written documentation from a facility/home (i.e., an adult foster home, adult family home, adult group home, residential care facility, community alternative home, or other facility) stating that the facility/home is not responsible for providing the same or similar home health or PDN services to the consumer.

(2) Home health and/or PDN services provided to the consumer enrolled in the assisted living HCBS waiver in accordance with rule 5101:3-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

Effective: 08/02/2007
R.C. 119.032 review dates: 08/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.85