5160-4-01 Physicians and other eligible providers of physician services.

(A) The following definitions and clarifications apply to division 5101:3 of the Administrative Code:

(1) "Physician" is an individual currently licensed under the laws of Ohio or of another state to practice as a doctor of medicine and surgery or as a doctor of osteopathic medicine and surgery. An unlicensed individual who is authorized to practice under the laws of the state in which the services are performed is not a physician, even if the person holds a staff or faculty appointment.

(2) "Provider-based physician" is a physician who has entered into an employment agreement, contract, or other legally binding arrangement with a site-based provider entity such as a hospital, clinic (either fee-for-service or cost-based), or long-term care facility and is consequently under the fiscal, administrative, and professional control of that provider entity. Interns, residents, and fellows are not physicians. Services provided by interns, residents, and fellows are treated as hospital services.

(3) Physicians may form or enter into a professional medical group in accordance with the provisions set forth in rule 5101:3-1-17 of the Administrative Code. A professional medical group may submit claims for physician services performed by its member physicians.

(B) The following Ohio medicaid providers are eligible providers of physician services:

(1) A physician;

(2) A professional medical group;

(3) An ambulatory health care clinic, which is defined in Chapter 5101:3-13 of the Administrative Code;

(4) A federally qualified health center, which is defined in Chapter 5101:3-28 of the Administrative Code;

(5) An outpatient health facility, which is defined in Chapter 5101:3-29 of the Administrative Code;

(6) A rural health clinic, which is defined in Chapter 5101:3-16 of the Administrative Code; and,

(7) For the sole purpose of demonstrating eligibility for incentive payments made in accordance with Section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA, Pub. L. No. 111-5 ) and the regulations published at 42 C.F.R. Part 495 (July 28, 2010), an optometrist operating within the appropriate scope of practice defined in section 4725.01 of the Revised Code.

(C) Reimbursement for providers of physician services is subject to the following provisions:

(1) A provider of physician services may be reimbursed for providing covered services only if two conditions are met:

(a) The provider of physician services is currently enrolled as a medicaid provider; and

(b) The services are rendered to medicaid-eligible Ohio recipients in a state in which the provider is licensed or authorized to practice.

(2) Professional services rendered by a provider-based physician directly to or for the benefit of an individual patient are separately reimbursable only if the following requirements are met:

(a) The physician is separately enrolled as an Ohio medicaid provider;

(b) The physician personally rendered the services to the individual patient;

(c) The services contribute directly to the diagnosis or treatment of the individual patient;

(d) The services ordinarily require performance by a physician;

(e) In the case of anesthesiology, laboratory, or radiology services, the additional requirements set forth in rules 5101:3-4-21 and 5101:3-4-25 of the Administrative Code are met; and

(f) The expenses associated with the provision of the professional services are excluded from the cost report of the site-based provider entity.

(3) Facility-related services rendered by a provider-based physician that are of benefit to patients in general (e.g., teaching; research; administration; supervision of professional or technical personnel, residents, interns, or fellows; or service on provider committees) are reimbursable only to the employing or contracting provider.

Replaces: 5101:3-4-01

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Effective: 03/02/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02 , 5111.021
Prior Effective Dates: 04/07/1977, 10/01/1983 (Emer), 12/29/1983, 09/01/1989, 03/26/2001, 09/01/2005, 10/25/2008, 08/02/2011, 12/02/2011 (Emer)