Lawriter - OAC - 5160-12-07 Reimbursement: exceptions.

5160-12-07 Reimbursement: exceptions.

Home health, RN assessment, RN consultation, and private duty nursing (PDN) service providers may be reimbursed when any of the exceptions set forth in this rule apply through no fault of the provider:

(A) Requirements of paragraphs (D)(2) of rule 5160-12-01 and ( E)(2) of rule 5160-12-02 of the Administrative Code are not met due to any of the following :

(1) Services are not identified on the all services plan when the individual is enrolled on an Ohio department of medicaid (ODM)-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 service plan or individual service plan when the individual is enrolled on an Ohio department of aging (ODA) or department of developmental disabilities (DODD)-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 service plan. Documentation shall include written proof of the provider's attempts to obtain the service 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 service plan.

(3) The provider verified and documented before providing services that either:

(a) The individual was not enrolled on 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 individual had become enrolled on an HCBS waiver; or

(b) The individual was not enrolled on a HCBS waiver and subsequently, at any point during the delivery of services, the provider became aware of the individual'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 individual had become enrolled on a HCBS waiver.

(B) Requirements of paragraphs ( H) of rule 5160-12-05 and ( H) of rule 5160-12-06 of the Administrative Code are not met due to either of the following:

(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, or other facility) stating that the facility/home is not responsible for providing the same or similar home health or PDN services to the individual; or

(2) Home health and/or PDN services provided to the individual enrolled on the assisted living HCBS waiver in accordance with rule 5160-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

(C) For services to be reimbursed by Ohio medicaid or its designee, the provider shall document all efforts to meet the requirements set forth in Chapter 5160-12 of the Administrative Code which includes maintaining a written record of the provider's effort to obtain missing information from case managers and other service related professionals. Provider documentation must include the date and time of each contact and attempted contact, contact's information (i.e., contact's title, telephone number, fax number, email address, and/or mailing address), and the nature of the provider's communication with the contact.


Effective: 7/1/2015
Five Year Review (FYR) Dates: 04/14/2015 and 07/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162..03, 5164.02 , 5164.77
Prior Effective Dates: 08/02/2007