(A) A "by-report" service is any service requiring manual review by the Ohio department of job and family services (ODJFS) or its designee to determine one or all of the following: if the service rendered was medically necessary and is reimbursable; the reimbursement rate on an unpriced procedure; or if special conditions or requirements were met. By-report services are set forth in appendix DD to rule 5101:3-1-60 of the Administrative Code.
(B) Claims for by-report services rendered must be submitted to ODJFS or its designee along with reports and documentation necessary to complete a coverage determination. Reports documenting the services or procedures performed, specific methodology or treatment programs, medical history and indications must be provided at a minimum. Coverage and reimbursement for by-report services rendered will be determined by ODJFS or its designee on a case-by-case basis.
(C) Unlisted (miscellaneous) healthcare common procedure coding system (HCPCS) codes are not covered. Unlisted HCPCS may be submitted by-report only when there is no other specific HCPCS code that adequately describes the procedure or service. If an unlisted code is submitted for review and ODJFS or its designee verifies that the unlisted code is appropriate, the claim and reports will be reviewed. If it is determined that an unlisted code was submitted in error because the procedure or service is described by one or more specific HCPCS codes, ODJFS or its designee shall deny the claim. If denied, the provider may submit a new claim using the specific current procedural terminology (CPT) code(s) or alphanumeric HCPCS code(s) for the procedure or service described in the reports. Codes that do not require by-report manual review shall be submitted directly to ODJFS by electronic data interchange (EDI) or though the ODJFS claims portal for adjudication and must not be submitted as a by-report claim for manual review.
Replaces: 5101:3-4- 02.1
Cite as Ohio Admin. Code 5160-4-02.1
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 5/19/86, 7/1/87, 4/1/88, 9/1/89, 1/1/01