5160-16-03 Rural health clinics (RHCs): limitations and noncovered services.

RHC services are reimbursable only if:

(A) Furnished by a physician as defined in accordance with rule 5101:3-4-01 of the Administrative Code.;

(B) Furnished by a nurse practitioner, or nurse -midwife, defined in accordance with rule 5101:3-8-21 of the Administrative Code, who is:

(1) Under the medical supervision of a physician as defined in paragraph (L) of rule 5101:3-16-01 of the Administrative Code;

(2) Performing such services in accordance with Chapter 4723. of the Revised Code; and

(3) Employed by, or receives compensation from, the RHC.

(C) Furnished by a physician assistant, defined in accordance with rule 5101:3-4-03 of the Administrative Code, who is:

(1) Under the medical supervision of a physician as defined in paragraph (L) of rule 5101:3-16-01 of the Administrative Code;

(2) Performing such services in accordance with Chapter 4730. of the Revised Code; and,

(3) Employed by, or receives compensation from, the RHC.

(D) Furnished by a clinical psychologist, in accordance with rule 5101:3-8-05 of the Administrative Code.

(E) Furnished by a clinical social worker, in accordance with rule 5101:3-4-29 of the Administrative Code.

(F) Relative to visiting nurse services, such services are covered if: provided in accordance with rule 5101:3-16-02 of the Administrative Code.

(G) Coverage limitations in RHCs.

(1) Coverage limitations set forth in Chapter 5101:3-4 of the Administrative Code apply to RHC services provided by physicians and physician assistants.

(2) Coverage limitations set forth in rule 5101:3-8-23 of the Administrative Code also apply to advanced practice nurse services provided under the auspices of an RHC.

(3) Coverage limitations set forth in rules 5101:3-8-05 and 5101:3-4-29 of the Administrative Code also apply to mental health services provided under the auspices of an RHC.

(H) RHC billable services.

(1) RHC services shall be billed on an encounter basis, in accordance with rule 5101:3-4-02 of the Administrative Code.

(2) All billable encounters shall be documented in the patient health record in accordance with rule 5101:3-1-27 of the Administrative Code.

(3) For consumers in the medicaid managed care program, claims submission requirements, including prior authorization requests for RHC services as defined in Chapter 5101:3-16 of the Administrative Code, are specified in rules 5101:3-26-03.1 and 5101:3-26-05.1 of the Administrative Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/30/2006 and 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, 8/1/01