5160-16-02 Rural health clinics (RHCs): covered services.

RHCs are required to provide a core set of services. The scope of the services furnished by RHCs is comparable to services provided in a physician's office. Services furnished by RHCs may be provided by physicians and mid-level practitioners, including physician assistants, nurse practitioners, and certified nurse-midwives. Services also include outpatient mental health services furnished by clinical psychologists and clinical social workers.

(A) Covered RHC services are:

(1) Services furnished by a physician, physician assistant, nurse practitioner, or nurse-midwife:

(a) In accordance with Chapter 5101:3-4 of the Administrative Code; and

(b) Within the scope of practice of his or her profession under state law.

(2) Services furnished by a clinical psychologist and:

(a) Defined in accordance with paragraph (B)(8) of rule 5101:3-28-03 of the Administrative Code; and

(b) In accordance with the limitations specified in rule 5101:3-8-05 of the Administrative Code.

(3) Services by a clinical social worker for the diagnosis and treatment of mental illness and:

(a) Billable under physician supervision in accordance with rule 5101:3-4-29 of the Administrative Code;

(b) Defined in accordance with paragraph (B)(8) of rule 5101:3-28-03 of the Administrative Code; and

(c) In accordance with the limitations specified in rule 5101:3-16-03 of the Administrative Code.

(4) Services and supplies furnished as incident to professional services and services furnished by a physician and services and supplies furnished as incident to services provided by a physician assistant, nurse practitioner, nurse-midwife, clinical psychologist, or clinical social worker, as would otherwise be covered if furnished as incident to a physician service(s).

(5) Visiting nurse services if:

(a) The RHC is located in an area in which the United States secretary of health and human services has determined that there is a shortage of home health agencies;

(b) The services are furnished by a registered nurse or a licensed practical nurse employed by, or otherwise compensated for the services by, the RHC;

(c) The services are furnished to a homebound individual; and

(d) The services are furnished under a written plan of treatment that is established and reviewed at least every sixty days by a supervising physician of the RHC or that is established by a physician, physician assistant or nurse practitioner and reviewed at least every sixty days by a supervising physician of the RHC and signed by the physician, physician assistant, nurse practitioner, or supervising physician

(B) The following services are not billable under a provider's RHC provider number. These services should be billed by an RHC under a different medicaid provider number as a fee-for-service ambulatory clinic provider:

(1) Inpatient hospital surgery;

(2) Inpatient hospital visits or consultations;

(3) Medicare crossover claims that are not paid through the automatic medicare crossover process in accordance with rule 5101:3-1-05 of the Administrative Code;

(4) Disability assistance program claims;

(5) Take home drugs shall be billed through the pharmacy program as described in Chapter 5101:3-9 of the Administrative Code; and

(6) Durable medical equipment (DME) for take-home use shall be billed through the DME program in accordance with rule 5101:3-10 of the Administrative Code

(C) For dates of service on and after January 1, 2006, the Ohio department of job and family services (ODJFS) shall institute a co-payment program under medicaid in accordance with rule 5101:3-1-09 of the Administrative Code. This co-payment program shall also apply to services rendered by an RHC. Specific information regarding implementation of co-payments in managed care settings are located in Chapter 5101:3-26 of the Administrative Code

(D) Provisions regarding outpatient hospital services identified in rule 5101:3-2-03 of the Administrative Code also apply to RHCs.

Replaces: 5101:3-16-02

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 , 5111.021
Prior Effective Dates: 4/1/80, 6/1/91, 7/1/01