5160-26-05.1 Managed health care programs: provider services.

(A) MCPs must provide the following written information to their contracting providers:

(1) The MCP's grievance, appeal and state fair hearing procedures and time frames, including:

(a) The member's right to file grievances and appeals and the requirements and time frames for filing;

(b) The MCP's toll-free telephone number to file oral grievances and appeals;

(c) The member's right to a state fair hearing, the requirements and time frames for requesting a hearing, and representation rules at a hearing;

(d) The availability of assistance from the MCP in filing any of these actions;

(e) The member's right to request continuation of benefits during an appeal or a state hearing and specification that at the discretion of ODM the member may be liable for the cost of any such continued benefits; and

(f) The provider's rights to participate in these processes on behalf of the provider's patients and to challenge the failure of the MCP to cover a specific service.

(2) The MCP's requirements regarding the submission and processing of prior authorization requests including:

(a) A list of the benefits, if any, that require prior authorization approval from the MCP;

(b) The process and format to be used in submitting such requests;

(c) The time frames in which the MCP must respond to such requests;

(d) Pursuant to the provisions of paragraph (A)(1) of this rule, how the provider will be notified of the MCP's decision regarding such requests; and

(e) Pursuant to the provisions of paragraph (A)(1) of this rule, the procedures to be followed in appealing the MCP's denial of a prior authorization request.

(3) The MCP's requirements regarding the submission and processing of requests for specialist referrals including:

(a) A list of the provider types, if any, that require prior authorization approval from the MCP;

(b) The process and format to be used in submitting such requests;

(c) How the provider will be notified of the MCP's decision regarding such requests; and

(d) The procedures to be followed in appealing the MCP's denial of such requests.

(4) The MCP's documentation, legibility, confidentiality, maintenance and access standards for member medical records; including a member's right to amend or correct his or her medical record as specified in 45 C.F.R. .164.526 (May 1, 2013).

(5) The MCP's process and requirements for the submission of claims and the appeal of denied claims.

(6) The MCP's process and standards for the recredentialing of providers.

(7) The MCP's policies and procedures regarding what action the MCP may take in response to occurrences of undelivered, inappropriate or substandard health care services, including the reporting of serious deficiencies to the appropriate authorities.

(8) A description of the MCP's care coordination and care management programs, and the role of the provider in those programs, including:

(a) The MCP's criteria for determining which members might benefit from care management;

(b) The provider's responsibility in identifying members who may meet the MCP's care management criteria; and

(c) The process for the provider to follow in notifying the MCP when such members are identified.

(9) The MCP's requirements and expectations for PCPs, including triage requirements.

(10) The mutually agreed upon policies and procedures between the MCP and provider that explain the provider's obligation to provide oral translation, oral interpretation, and sign language services to the MCP's members including:

(a) The provider's responsibility to identify those members who may require such assistance;

(b) The process the provider is to follow in arranging for such services to be provided;

(c) Information that members will not be liable for the costs of such services; and

(d) Specification of whether the MCP or the provider will be financially responsible for the costs of providing these services.

(11) The procedures that providers are to follow in notifying the MCP of changes in their practice, including at a minimum:

(a) Address and phone numbers;

(b) Providers included in the practice;

(c) Acceptance of new patients; and

(d) Standard office hours.

(12) Specification of what service utilization and provider performance data the MCP will make available to providers.

(13) Specification of the healthchek components to be provided to eligible members as specified in Chapter 5101:3-14 of the Administrative Code.

(B) MCPs must adopt practice guidelines and provide written copies to all affected providers. These guidelines must:

(1) Be based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field;

(2) Consider the needs of the MCP's members;

(3) Be adopted in consultation with contracting health care professionals; and

(4) Be reviewed and updated periodically, as appropriate.

(C) MCPs must have staff specifically responsible for resolving individual provider issues, including, but not limited to, problems with claims payment, prior authorizations and referrals. MCPs must provide written information to their contracting providers detailing how to contact these designated staff.

Effective: 07/01/2013
R.C. 119.032 review dates: 04/16/2013 and 07/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.16 , 5111.162 , 5111.17
Rule Amplifies: 5111.01 , 5111.02 , 5111.16 , 5111.162 , 5111.17
Prior Effective Dates: 4/1/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 12/10/99, 7/1/00, 10/27/00, 7/20/01, 7/1/02, 7/1/03, 1/1/06, 6/1/06, 1/1/07, 7/1/07, 1/1/08, 9/15/08