(1) "MCP" means a managed care plan as defined in rule 5101:3-26-01 of the Administrative Code that reimburses a rural health clinic(RHC) for services provided by the RHC to a medicaid recipient enrolled in the MCP.
(2) "Encounter" is defined in accordance with rule 5101:3-16-01 of the Administrative Code.
(3) "Enrollee," otherwise known as a member, means each eligible individual enrolled in an MCP as specified in rule 5101:3-26-01 of the Administrative Code.
(B) Effective for services furnished on or after January 1, 2001, RHCs that have received payment from an MCP for RHC services identified in rule 5101:3-16-02 of the Administrative Code are eligible to receive a supplemental payment from the department if the amount the RHC was paid by an MCP for services provided to an MCP enrollee is less than the amount the RHC would have received under the prospective payment system(PPS) reimbursement method described in rule 5101:3-16-06 of the Administrative Code.
(C) To receive the supplemental payment for an encounter provided to an MCP enrollee, an RHC must submit a claim to the department following the Ohio medicaid provider billing instructions utilized by RHCs for fee-for-service medicaid consumers with third party insurance.
(1) These billing instructions require an RHC to report the following on the claim:
(a) The encounter code and the appropriate modifier to signify the type of encounter provided by the RHC.
(i) RHCs that choose to submit a paper claim must submit the standard professional claim form.
(ii) RHCs that choose to submit a claim via an electronic transaction shall submit the transaction in an electronic format recognized by the department in accordance with the department's billing instructions.
(b) A detailed CPT code listing reflecting all services provided during the encounter.
(2) RHCs seeking supplemental payments must also report the following information on the claim:
(a) The third party indicator for the medicaid supplemental payment;
(b) The medicaid identification number of the MCP that paid the RHC in the referring physician field; and
(c) The sum of the dollar amount the RHC was paid by any MCP for the service(s) provided to the medicaid recipient listed on the claim, minus any incentive payments received from an MCP and any amount received by the RHC from any other third party insurance.
(3) The data elements submitted for a supplemental payment claim are dependent on whether the claim is a paper claim or an electronic transaction.
(a) RHCs that choose to submit a paper claim shall submit the data elements outlined in paragraphs (C)(1) and (C)(2) of this rule; and
(b) RHCs that choose to submit a claim via an electronic transaction shall use the "837" transaction and report the data elements unique for supplemental claims, including:
(i) The name of the MCP provider under the "other payer name" field;
(ii) The "identification code," as assigned by the Ohio department of job and family services (ODJFS), of the MCP payer that initially paid for the services; and
(iii) The sum of the dollar amount the MCP paid the RHC for services without regard to the effects of any financial incentive payments (positive or negative) received from the MCP plus any amount received from any other third party insurance, in "monetary amount" under the "other payer" field.
(D) Calculation of supplemental payments:
(1) Using the methodology described in paragraph (C) of this rule, the department will pay the RHC no less frequently than every four months.
(2) For dates of service on and after January 1, 2001, upon receipt of the claim the department will pay any difference between the amount paid by the MCP to the RHC and the amount due the RHC based on its PPS rate approved by the department for the specific claim submitted.
The department's supplemental payment obligation will be determined using the baseline payment that the RHC would have received under PPS reimbursement as described in rule 5101:3-16-06 of the Administrative Code, without regard to the effects of any financial incentives(positive or negative) received from the MCP that are linked to utilization outcomes or other reductions in patient costs.
(E) If a claim is not submitted by an RHC to the department within the standard time frames required for claims submission in accordance with rule 5101:3-1-19.3 of the Administrative Code, no supplemental payment(s) will be made by the department to the RHC.
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: 8/6/01