This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and
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| Rule |
Rule 5160-1-01 | Medicaid medical necessity: definitions and principles.
Effective:
February 24, 2022
(A) Medical necessity for individuals covered by early and periodic screening, diagnosis and treatment (EPSDT) is criteria of coverage for procedures, items, or services that prevent, diagnose, evaluate, correct, ameliorate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability. (B) Medical necessity for individuals not covered by EPSDT is criteria of coverage for procedures, items, or services that prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without which the person can be expected to suffer prolonged, increased or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort. (C) Conditions of medical necessity for a procedure, item, or service are met if all the following apply: (1) It meets generally accepted standards of medical practice; (2) It is clinically appropriate in its type, frequency, extent, duration, and delivery setting; (3) It is appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome; (4) It is the lowest cost alternative that effectively addresses and treats the medical problem; (5) It provides unique, essential, and appropriate information if it is used for diagnostic purposes; and (6) It is not provided primarily for the economic benefit of the provider nor for the sole convenience of the provider or anyone else other than the recipient. (D) The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment. (E) The definition and conditions of medical necessity articulated in this rule apply throughout the entire medicaid program. More specific criteria regarding the conditions of medical necessity for particular categories of service may be set forth within the Ohio department of medicaid (ODM) coverage policies or rules.
Last updated February 24, 2022 at 8:25 AM
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Rule 5160-1-02 | General reimbursement principles.
Effective:
December 1, 2019
This rule describes general principles regarding
reimbursement of services by medicaid. Reimbursement may be subject to
additional administrative criteria as described in agency 5160 of the
Administrative Code. (A) A medical service is reimbursable
if: (1) The service is
determined medically necessary as defined in rule 5160-1-01 of the
Administrative Code. (2) The service is agreed
to by the medicaid-covered individual or the medicaid-covered individual's
authorized representative. (3) The service is
rendered to a medicaid-covered individual as defined in division 5160:1 of the
Administrative Code. (4) The service is
provided within the limits of the medicaid-covered individual's medicaid
benefit package. (5) The service is
provided within the scope of practice of the rendering provider as defined by
applicable federal, state, and local laws and regulations. (6) The service is
rendered by a provider assigned to or selected by the medicaid-covered
individual or medicaid-covered individual's authorized representative,
with the exception of medicaid-covered individuals enrolled in the coordinated
services program as defined in Chapter 5160-20 of the Administrative
Code. (7) The service is
rendered by an eligible provider or panel provider for managed care plan
participating provider. (B) Special conditions regarding medicaid
reimbursement. (1) If a service is
charged to medicaid at a rate greater than the provider's usual and
customary charge to other patients for comparable services, the provider will
be reimbursed at the provider's usual and customary charge or medicaid
permitted reimbursement rate, whichever is lower. (2) Inpatient and
outpatient hospital services billed by hospitals reimbursed on a prospective
payment basis, as defined in Chapter 5160-2 of the Administrative Code, will
not be paid, in the aggregate, more than the provider's customary and
prevailing charges for comparable services. (3) Medicaid will not provide
reimbursement for a provider-preventable condition as defined in 42 CFR 447.26
(as in effect on October 1, 2018). The prohibition on provider-preventable
conditions shall not result in a loss of access to care or services for
medicaid-covered individuals. (C) Additional reimbursement principles
are applicable to the following: (1) Services delivered
through the medicaid managed plans as described in Chapter 5160-26 of the
Administrative Code. (2) Habilitation services
as defined in 42 USC 1396n(c)(5) (as in effect on October 1, 2018) and
permitted in agency 5160 of the Administrative Code. (D) Commingling is prohibited. For the
purposes of this rule commingling occurs when the sharing of office space,
staff (employed or contracted), supplies, equipment, or other resources with an
on-site practice or provider organization owned or operated by the same
provider, physician, or non-physician practitioners results in one or both of
the following: (1) Duplicate medicaid
reimbursement for services performed; or (2) A provider
selectively choosing a higher reimbursement rate for the services
performed.
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Rule 5160-1-04 | Employee access to confidential personal information.
Effective:
August 1, 2016
(A) Definitions. For the purposes of rules promulgated by this
agency in accordance with section 1347.15 of the Revised Code effective April
9, 2009, the following definitions apply: (1) "Access" as
a noun means an instance of copying, viewing, or otherwise perceiving; whereas,
"access" as a verb means to copy, view, or otherwise
perceive. (2) "Acquisition of
a new computer system" means the purchase of a "computer
system," as defined in this rule, that is not a computer system currently
in place nor one for which the acquisition process has been initiated as of
April 7, 2009. (3) "Confidential personal
information" (CPI) has the meaning as defined by division (A)(1) of
section 1347.15 of the Revised Code. The appendix to this rule identifies, in
accordance with division (B)(3) of section 1347.15 of the Revised Code, the
federal statutes and regulations and state statutes and administrative rules
that make personal information maintained by the agency
confidential. (4) "Employee of the state
agency" means each employee of a state agency regardless of whether he or
she holds an elected or appointed office or position within the state agency.
"Employee of the state agency" is limited to the specific employing
state agency. (5) "Incidental contact" means
contact with the information that is secondary or tangential to the primary
purpose of the activity that resulted in the contact. (6) "Individual" means a
natural person and in the context used in division (C)(1)(b) of section 1347.15
of the Revised Code, and paragraph (E)(4)(b)(iv) of this rule, means the
subject of the confidential personal information or the subject of the
confidential personal information's authorized representative, legal
counsel, legal custodian or legal guardian, and anyone as otherwise permitted
under state or federal law acting on behalf of, or in furtherance of, the
interests of the subject of the confidential personal information.
"Individual" does not include an opposing party in litigation, or the
opposing party's legal counsel, or an investigator, auditor or any other
party who is not acting on behalf of, or in furtherance of the interests of,
the subject of the confidential personal information, even if such individual
has obtained a signed release from the subject of the confidential personal
information. (7) "Information owner" means
the individual appointed in accordance with division (A) of section 1347.05 of
the Revised Code to be directly responsible for a system. (8)
"Interconnection of Systems" Refers to a linking of systems that
belong to more than one agency, or to an agency, and other organization, which
linking of systems results in a system that permits each agency or organization
involved in the linking to have unrestricted access to the systems of the other
agencies and organizations. (9) "Person"
means a natural person. (10) "Personal
information" has the same meaning as defined in division (E) of section
1347.01 of the Revised Code. (11) "Personal
information system" means a "system" that "maintains"
"personal information" as those terms are defined in section 1347.01
of the Revised Code. "System" includes manual and computer
systems. (12) "Research"
means a methodical investigation into a subject. (13) "Routine"
means commonplace, regular, habitual, or ordinary. (14) "Routine
information that is maintained for the purpose of internal office
administration, the use of which would not adversely affect a person" as
that phrase is used in division (F) of section 1347.01 of the Revised Code
means personal information relating to employees and maintained by the agency
for internal administrative and human resource purposes. (15) "System or
Information System" As defined in section 1347.01 of the Revised Code,
"system" means any collection or group of related records that are
kept in an organized manner and that are maintained by a state or local agency,
and from which personal information is retrieved using the person's name
or by an identifying number, symbol, or other identifier assigned to the
person. "System" includes both records that are manually stored and
records that are stored using electronic data processing
equipment. (16) "Upgrade"
means a substantial redesign of an existing computer system for the purpose of
providing a substantial amount of new application functionality, or application
modifications that would involve substantial administrative or fiscal resources
to implement, but would not include maintenance, minor updates and patches, or
modifications that entail a limited addition of functionality due to changes in
business or legal requirements. (B) Procedures for accessing confidential
personal information. (1) Criteria for
accessing confidential personal information. Personal information systems of the Ohio
department of medicaid (ODM) are managed on a "need-to-know" basis
whereby the information owner determines the level of access required for an
employee of the agency to fulfill his or her job duties. The determination of
access to confidential personal information shall be approved by the
employee's supervisor, the information's owner, designee operating
under guidlines approved by the information's owner before providing the
employee with access to confidential personal information within a personal
information system. The agency shall establish procedures for determining a
revision to an employee's access to confidential personal information upon
a change to that employee's job duties including, but not limited to,
transfer or termination. Whenever an employee's job duties no longer
require access to confidential personal information in a personal information
system, the employee's access to confidential personal information shall
be removed. (2) Individual's
request for a list of confidential personal information. Based upon a request of any individual for a
list of confidential personal information about the individual maintained by
ODM, or its predecessor ODJFS, ODM shall do the following: (a) Verify the identity of the individual by a method that
provides safeguards commensurate with the risk associated with the confidential
personal information. (b) Provide to the individual the confidential personal
information that does not relate to an investigation about the individual or is
otherwise not excluded from being released under Chapter 1347. of the Revised
Code, or other federal/state laws or regulations. (c) If all information relates to an investigation about
that individual, inform the individual that the agency has no confidential
personal information about the individual that is responsive to the
individual's request. (d) Notifications made under this section shall be made in
compliance with all applicable state and federal regulations. (3) Notice of invalid
access. (a) Upon discovery or notification that confidential
personal information of a person has been accessed by an employee for an
invalid reason, the agency shall notify the person whose information was
invalidly accessed as soon as practical and to the extent known at the time.
However, the agency shall delay notification for a period of time necessary to
ensure that the notification would not delay or impede an investigation or
jeopardize homeland or national security. Additionally, the agency may delay
the notification consistent with any measures necessary to determine the scope
of the invalid access, including which individuals' confidential personal
information was invalidly accessed, and to restore the reasonable integrity of
the system. "Investigation" as used in this paragraph means the
investigation of the circumstances and involvement of an employee surrounding
the invalid access of the confidential personal information. Once the agency
determines that notification would not delay or impede an investigation, the
agency shall disclose the access to confidential personal information made for
an invalid reason to the person. (b) Notification provided by the agency shall inform the
person of the type of confidential personal information accessed and the date
or dates of the invalid access, if known. (c) Notification may be made by any method reasonably
designed to accurately inform the person of the invalid access, including
written, electronic, or telephone notice. (d) Notifications made under this section shall be made in
compliance with all applicable state and federal regulations. (4) Appointment of a data
privacy point of contact and completion of a risk of harm
assessment. (a) The ODM director shall designate an employee of ODM to
serve as the data privacy point of contact under the working title of "ODM
HIPAA privacy official." (b) The ODM HIPAA privacy official shall work with the
state of Ohio chief privacy officer and the state of Ohio chief information
security officer within the state of Ohio office of information technology to
assist ODM with both the implementation of privacy protections for the
confidential personal information that ODM maintains and compliance with
section 1347.15 of the Revised Code and the rules adopted
thereunder. (c) The ODM HIPAA privacy official shall ensure the timely
completion of the "privacy impact assessment" developed by the state
of Ohio office of information technology. (C) Valid reasons for accessing
confidential personal information. Pursuant to the requirements of division (B)(2)
of section 1347.15 of the Revised Code, this rule contains a list of valid
reasons, directly related to the ODM exercise of its powers or duties, for
which only employees of the agency may access confidential personal information
regardless of whether the personal information system is a manual system or
computer system. Except as prohibited by federal and state law,
performing the following functions constitute valid reasons for authorized
employees of the agency to access confidential personal information: (1) Responding to a
public records request, which would require all appropriate redaction of any
responsive records as required by law; (2) Responding to a
request from an individual for the list of the confidential personal
information the agency maintains on that individual; (3) Administering a
constitutional provision or duty; (4) Administering a
statutory provision or duty; (5) Administering an
administrative rule provision or duty; (6) Complying with any
state or federal program requirements; (7) Processing or payment
of claims or otherwise administering a program with individual participants or
beneficiaries; (8) Auditing
purposes; (9) Licensure (or permit,
eligibility, filing, etc.) processes; (10) Investigation or law
enforcement purposes; (11) Administrative
hearings; (12) Litigation,
complying with an order of the court, or subpoena; (13) Human resource
matters (for example, hiring, promotion, demotion, discharge,
salary/compensation issues, leave requests/issues, time card
approvals/issues); (14) Complying with an
executive order or policy; (15) Complying with an
agency policy or a state administrative policy issued by the department of
administrative services, the office of budget and management, or other similar
state agency; (16) Complying with a
collective bargaining agreement provision; or (17) Research in the
furtherance of agency specific programs in so far as allowed by
statute. (D) Confidentiality statutes and
administrative rules. The federal statutes and regulations and state
statutes and administrative rules listed in the appendix to this rule make
personal information maintained by the agency confidential and identify the
confidential personal information that are subject to rules promulgated by this
agency in accordance with section 1347.15 of the Revised Code. (E) Restricting and logging access to
confidential personal information systems. For personal information systems that are
computer systems and contain confidential personal information, ODM shall do
the following: (1) Access
restrictions. Access to confidential personal information
that is kept electronically shall require a password or other sufficient
authentication measure as determined by the ODM HIPAA privacy official in
conjunction with the chief information security official will determine what
constitutes sufficient authentitication measures. (2) Acquisition of a new
computer system. When the agency acquires a new computer system
that stores, manages, or contains confidential personal information, ODM shall
include a mechanism for recording specific access by employees of ODM to
confidential personal information in the system. (3) Upgrading existing
computer systems. When ODM modifies an existing computer system
that stores, manages, or contains confidential personal information, that
results in over half of the lines of code associated with that system being
modified, then that system must have an automated mechanism for recording
specific access by employees of ODM to any confidential personal information
that is accessed via that system. (4) Logging requirements
regarding confidential personal information in existing ODM computer
systems. (a) ODM shall require employees who access confidential
personal information within ODM computer systems to maintain a log that records
that access. (b) Access to confidential information is not required to
be entered into the log under the following circumstances: (i) The ODM employee is
accessing confidential personal information for official agency purposes
including research, and the access is not specifically directed toward a
specifically named individual or a group of specifically named
individuals. (ii) The ODM employee is
accessing confidential personal information for routine office procedures and
the access is not specifically directed toward a specifically named individual
or a group of specifically named individuals. (iii) The ODM employee
comes into incidental contact with confidential personal information and the
access of the information is not specifically directed toward a specifically
named individual or a group of specifically named individuals. (iv) The employee of the
agency accesses confidential personal information about an individual based
upon a request made under either of the following circumstances: (a) The individual requests confidential personal
information about himself or herself; or (b) The individual makes a request that ODM take some
action on that individual's behalf and accessing the confidential personal
information is required in order to consider or process that
request. (v) ODM shall use a
consistent electronic means for logging where reasonably possible. If the
logging requirements are already being met through existing means, then no
additional logging is required in those instances. (5) Log
management. Each office within ODM shall use the log
provided by the agency, currently identified as "CPI Log", or its
successor system. Nothing in this rule limits the agency from requiring logging
in any circumstance that it deems necessary.
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Rule 5160-1-05 | Medicaid coordination of benefits with the medicare program (Title XVIII).
Effective:
September 16, 2019
Paragraphs (A)(7) to (F)(4) of this rule do not
apply to pharmacy services covered under the medicare part D program. Pharmacy
services covered under the medicare part D program should be billed in
accordance with rule 5160-9-06 of the Administrative Code. (A) Definitions. (1) "Medicare"
is a federally financed program of hospital insurance (part A) and supplemental
medical insurance (also called SMI or part B) for aged and disabled
persons. (2) "Medicare
Benefits" means the health care services available to an individual
through the medicare program where payment for the services is either
completely the obligation of the medicare program or in part the obligation of
the medicare program with the remaining payment obligations belonging to the
individual, some other third party payer, or medicaid. (3) "Traditional
Medicare" is a health plan that pays for medicare benefits provided to
individuals on a fee-for-service basis. (4) "Medicare
Advantage Plan (also known as medicare part C plan)" is a managed care
delivery system that includes coverage for both hospital insurance and SMI, but
the delivery of health care services are contracted to and provided by an
approved medicare managed care plan, preferred provider organization, private
fee-for-service plans, or medicare specialty plans. (5) "Medicare Cost
Sharing" for the purpose of this rule means the portion of a medicare
crossover claim paid by medicaid. (6) "Dual Eligibles
or Dually Eligible Individuals" are individuals who are entitled to
medicare hospital insurance and SMI and are eligible for medicaid to pay some
form of medicare cost sharing. The following is a list of dual eligibles or
dually eligible individuals that qualify to have medicaid pay all or part of
the cost sharing portion of a paid medicare claim: (a) "Qualified Medicare Beneficiaries without Other Medicaid
(QMB Only)" are individuals entitled to medicare hospital insurance, have
income of one hundred per cent of the federal poverty level (FPL) or less and
resources that do not exceed the maximum amount of resources allowed under
section 1905(p)(1) of the Social Security Act (as in effect on October 1,
2018), as adjusted annually according to the change in the consumer price index
for urban areas (CPI-U), and are not otherwise eligible for full medicaid
benefits. (b) "QMBs with Full Medicaid (QMB Plus)" are
individuals entitled to medicare hospital insurance, have incomes of one
hundred per cent FPL or less and resources that do not exceed the maximum
amount of resources allowed under section 1905(p)(1) of the Social Security Act
(as in effect on October 1, 2018), as adjusted annually according to the change
in the consumer price index for urban areas (CPI-U), and are eligible for full
medicaid benefits. (c) "Specified Low-Income Medicare Beneficiaries with Full
Medicaid (SLMB Plus)" are individuals entitled to medicare hospital
insurance, have income of greater than one hundred per cent FPL, but less than
one hundred twenty per cent FPL and resources that do not exceed twice the
limit for SSI eligibility, and are eligible for full medicaid
benefits. (d) "Medicaid Only Dual Eligibles (for example Non
QMB)" are individuals entitled to medicare hospital insurance and SMI and
are eligible for full medicaid benefits. They are not eligible for medicaid in
any of the other dual eligible categories (for example QMB). (7) "Medicare
Crossover Claim" means any claim that has been submitted to the Ohio
department of medicaid (ODM) for medicare cost sharing payments after the claim
has been adjudicated and paid by the medicare central processor, medicare
carrier/intermediary or the medicare managed care plan. Claims denied by the
medicare carrier/intermediary or the medicare managed care plan are not
considered medicare crossover claims. See paragraphs (E) and (F) of this rule
for policy on services denied or not covered by medicare. (a) "Automatic Crossover Claim" is a medicare claim
submitted to ODM via the automatic medicare crossover process described in
paragraph (B)(2)(a) of this rule. (b) "Provider-Submitted Crossover Claim" means a
medicare crossover claim submitted to ODM as described in paragraph (B)(2)(b)
of this rule. (B) Medicare crossover
process. (1) Medicare crossover
claims must meet the claim submission guidelines in accordance with rule
5160-1-19 of the Administrative Code. (2) The medicare program determines the
portion of medicare cost sharing, if any, due to the provider based on
medicare's business rules and submits the claim for payment to ODM using
the automatic medicare crossover process. (a) The "Automatic Medicare Crossover Process" is the
coordination of benefit (COB) process whereby the provider bills medicare for
services provided to a dual eligible or a dually eligible individual described
in paragraph (A)(6) of this rule. Medicare adjudicates the claim, pays the
provider and electronically submits the claim to ODM for the medicare cost
sharing determination. Then, when appropriate, the provider is paid by medicaid
within ninety days from the date of payment by medicare. (b) When the automatic medicare crossover process does not work
(i.e., the provider has received payment by medicare, has not received a
payment from medicaid for the medicare cost sharing portion and at least ninety
days has elapsed from the date of the receipt of the medicare payment), the
provider must submit a medicare crossover claim directly to ODM. This is
considered the "Provider-Submitted Crossover Claim
Process." (3) For a provider to receive
reimbursement through the automatic medicare crossover process, all of the
following criteria must be met: (a) The provider must be recognized as both a medicare and
medicaid provider; (b) The provider must accept medicare assignment;
and (c) The individual must be receiving health care benefits under
the traditional medicare part A and part B program (i.e., the individual is not
enrolled in a medicare managed care plan). At this time ODM does not have
payer-to-payer COB arrangements with medicare managed care plans. (4) For medicare crossover claims, the
total sum of the payments made by ODM, medicare and all other third party
payers is considered payment in full and no additional payment may be requested
from the individual with the exception of medicare co-payments as specified in
paragraph (E)(5) of this rule. This is true whether or not the provider
normally accepts assignment under medicare. (a) When the provider's total reimbursement from medicare
and all other third party payers equals or exceeds the medicare approved
amount, no additional payment will be made by ODM. (b) If payment (other than the cost sharing amounts) is
inadvertently received from both medicare and medicaid for the same service,
the provider must notify the ODM claims adjustment unit in accordance with the
provisions set forth in rule 5160-1-19 of the Administrative Code. (5) Provider submitted crossover claims
must be submitted timely in accordance with rule 5160-1-19 of the
Administrative Code. (6) Crossover claims are not subject to
medicaid co-payments in accordance with rule 5160-1-09 of the Administrative
Code. (C) When the individual receiving
medicaid is covered by other third party payers, in addition to medicare,
medicaid is the payer of last resort. Whether or not medicare is the primary
payer, providers must bill all other third party payers prior to submitting a
crossover claim to ODM in accordance with rule 5160-1-08 of the Administrative
Code. (D) ODM will not pay for services denied
by medicare for lack of medical necessity, but may pay claims denied for
reasons other than lack of medical necessity in accordance with paragraph (F)
of this rule as long as the services are covered under the medicaid program.
ODM will not pay for any service payable by, but not billed to,
medicare. (E) Reimbursement for medicare cost
sharing on medicare crossover claims. Reimbursement for medicare crossover claims is
limited to the dual eligibles or dually eligible individuals listed in
paragraph (A)(6) of this rule. (1) The medicaid maximum
reimbursement for the medicare cost sharing of hospital inpatient, outpatient
or emergency room services is set forth in rule 5160-2-25 of the Administrative
Code for individuals that elected to receive medicare benefits under
traditional medicare. (2) The medicaid maximum
reimbursement for the medicare cost sharing of nursing facility services
included in the nursing facility per diem is set forth in Chapter 5160-3 of the
Administrative Code for individuals that elected to receive medicare benefits
under traditional medicare. (3) The medicaid maximum
reimbursement for the medicare cost sharing of all other part B services not
included in paragraph (E)(1) or paragraph (E)(2) of this rule is set forth in
rule 5160-1-05.3 of the Administrative Code for individuals that elected to
receive medicare benefits under traditional medicare. (4) The medicaid maximum
reimbursement for the medicare cost sharing of all advantage plan (part C)
services is set forth in rule 5160-1-05.1 of the Administrative Code for
individuals that elected to receive medicare benefits under a medicare
advantage plan. (5) Cost sharing for
medicare part D services is not reimbursable by ODM in accordance with rule
5160-9-06 of the Administrative Code. Dual eligibles or dually eligible
individuals may be required to pay medicare co-payments for prescription drugs
that are covered by medicare part D. (F) Services that are not covered by
medicare must be submitted to ODM as a regular medicaid claim and should never
be submitted as a medicare crossover claim. With the exception of long term care nursing
facilities, when the service is denied by medicare, and is also denied by
medicaid with an error message indicating that the service is covered under
medicare and the provider has documentation to support the service is not
covered under medicare, the provider must do all of the following when
requesting payment consideration from ODM: (1) Submit the
appropriate claim in accordance with rule 5160-1-19 of the Administrative
Code; (2) Attach the summary
notice of medicare benefits that shows the denied medicare services, and the
denial reason code with the denial reason code explanation from the medicare
summary of benefits, the provider is requesting ODM to consider for
payment; (3) Attach a completed
"ODM 06653 Medical Claim Review Request Form (rev. 7/2014 )" with
supporting documentation; and (4) Submit all forms
together to the address indicated on the instruction page accompanying the ODM
06653 form. (G) Long term care nursing facility
providers must submit the appropriate claim in accordance with Chapter 5160-3
of the Administrative Code.
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Rule 5160-1-05.1 | Payment for "Medicare Part C" cost sharing.
(A) For qualified medicare beneficiaries
and medicaid recipients enrolled in medicare part C managed health care plans
(medicare advantage plans) the department will pay as cost sharing the lesser
of the following amounts: (1) The provider's
billed charges for the service (except for hospital and nursing facility
services); or (2) The deductible,
coinsurance and co-payment amount as provided by the medicare part C plan;
or (3) The difference
between the medicare part C plan's payment to a provider for a service or
services identified and the medicaid maximum allowable reimbursement rate for
the same identified service or services; or (4) The medicaid
liability for the cost sharing if the service had been rendered under medicare
part A or part B (calculated as twenty-five per cent of the medicare maximum
allowed amount). (B) The department will not make any
additional payment to the provider, or will make a payment of zero dollars,
when payment for part C cost sharing is made using the method described in
paragraph (A)(3) of this rule, and the sum of the amounts paid by medicare and
all other third party insurers exceeds the medicare or medicaid maximum allowed
amount. (C) The medicaid provider is ultimately
responsible for accurate and valid reporting of medicaid claims and retention
of relevant documents to support claims submitted for payment and any other
business transactions in accordance with rule 5160-1-17.2 of the Administrative
Code. (D) Any costs beyond the medicare
advantage plan's maximum out-of-pocket (MOOP) limit are not subject to
cost sharing pursuant to 42 C.F.R. 422.100 (as in effect January 1,
2023).
Last updated July 27, 2023 at 8:36 AM
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Rule 5160-1-05.3 | Payment for "Medicare Part B" cost sharing.
Effective:
January 1, 2016
(A) The reimbursement methodology set forth in paragraph (B) of this rule is limited to medicare part B services that meet all of the following criteria: (1) Are not hospital services defined in accordance with Chapter 5160-2 of the Administrative Code; (2) Are not nursing facility services included in the nursing facility per diem as defined in accordance with Chapter 5160-3 of the Administrative Code; (3) Are covered as supplemental medical insurance benefits under the medicare program; and (4) Are provided to dual eligibles, defined in accordance with paragraph (A)(6) of rule 5160-1-05 of the Administrative Code, who elect to receive their medicare part B benefits through the original medicare program. (B) The Ohio department of medicaid (ODM) will pay the lesser of the following calculations for part B cost sharing described in this rule: (1) The sum of the deductible and coinsurance medicare specifies ODM is obligated to pay for crossover claims; or (2) The difference between the medicare approved amount and the sum of the amount medicare paid and all other third party (insurance other than medicare or medicaid) payments; or (3) The difference between the sum of the amount medicare paid and any third party payments, and the medicaid maximum allowable reimbursement rate for the same identified service or services. (C) When payment for part B cost sharing is made using the method described in paragraph (B)(2) or (B)(3) of this rule and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid approved amount, ODM will not make any additional payment to the provider, or will make a payment of zero dollars, and the service(s) are considered to be paid in full to the provider.
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Rule 5160-1-06.1 | Home and community-based service waivers: PASSPORT.
Effective:
October 1, 2024
(A) The Ohio department of aging (ODA) is responsible for the
daily administration of the preadmission screening system providing options and
resources today (PASSPORT) medicaid waiver program. ODA will administer the
waiver pursuant to an interagency agreement with the Ohio department of
medicaid in accordance with section 5162.35 of the Revised Code. (B) The PASSPORT waiver provides home and community based
services (HCBS) to individuals enrolled in the waiver in accordance with rule
5160-31-03 of the Administrative Code. (C) The PASSPORT HCBS waiver covered services and eligibility
requirements are set forth in Chapter 5160-31 of the Administrative Code.
(D) The maximum allowable payment rates for PASSPORT HCBS waiver
program services are listed in the appendix to this rule. (E) PASSPORT HCBS payment will be provided in accordance with
paragraphs (A) to (C) of rule 5160-1-60 of the Administrative
Code.
View Appendix
Last updated October 1, 2024 at 9:06 AM
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Rule 5160-1-06.5 | Home and community based services (HCBS)
waivers: assisted living.
(A) The Ohio department of aging (ODA) is responsible for the
daily administration of the assisted living HCBS waiver. ODA will administer
this waiver pursuant to an interagency agreement with the Ohio department of
medicaid (ODM), in accordance with section 5162.35 of the Revised
Code. (B) The assisted living HCBS waiver is an alternative to nursing
facility placement for persons age twenty-one and over who require an
intermediate level of care or a skilled level of care as set forth in rule
5160-3-08 of the Administrative Code and are enrolled in the
waiver. (1) The assisted living HCBS
waiver's services and program eligibility criteria are set forth in
Chapter 5160-33 of the Administrative Code. (2) The maximum allowable reimbursement
rates for assisted living HCBS waiver program services are listed in appendix A
to this rule. (3) Assisted living HCBS reimbursement
are provided in accordance with rule 5160-1-60 of the Administrative
Code. (4) The billing maximum for the community
transition service listed in appendix A to this rule represents the cumulative
maximum for the items purchased or deposits made through the community
transition service as set forth in rule 173-39-02.17 of the Administrative
Code.
View Appendix
Last updated July 1, 2024 at 4:38 PM
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Rule 5160-1-08 | Coordination of benefits.
Effective:
September 16, 2019
(A) Definitions. (1) "Coordination of
benefits" (COB) means the process of determining which health plan or
insurance policy will pay first or determining the payment obligations of each
health plan, medical insurance policy, or third party resource when two or more
health plans, insurance policies or third party resources cover the same
benefits for a medicaid covered individual. (2) "Coordination of
benefits claim" (COB claim) means any claim that meets either the
definition of third party claim as described in paragraph (A)(7) of this rule
or the definition of medicare crossover claim as described in rule 5160-1-05 of
the Administrative Code. (3) "Explanation of
benefits" (EOB) or "remittance advice" means the information
sent to providers or plan beneficiaries (covered individuals) by any other
third party payer, medicare, or medicaid to explain the adjudication of the
claim. (4) "Medicare
benefits" has the same meaning as in rule 5160-1-05 of the Administrative
Code. (5) "Third
party" (TP) has the same meaning as in section 5160.35 of the Revised
Code. (6) "Third party
benefit" means any health care service available to individuals through
any medical insurance policy or through some other resource that covers medical
benefits and the payment for those services is either completely the obligation
of the third party payer (TPP) or in part the obligation of the individual, the
third party payer, or medicaid (examples of a third party benefit include
private health or accidental insurance, medicare, CHAMPUS or worker's
compensation). (7) ) "Third party
claim" means any claim submitted to the Ohio department of medicaid (ODM)
for reimbursement after all TPPs have met their payment obligations. In
addition, the following will be considered third party claims by
ODM: (a) Any claim received by ODM that shows no prior payment
by a TPP, but, ODM's records indicate the medicaid covered individual has
third party benefits. (b) Any claim received by ODM that shows no prior payment
by a TPP but the provider's records indicate the medicaid covered
individual has third party benefits. (8) "Third party
liability" (TPL) means the payment obligations of the third party payer
for health care services rendered to eligible medicaid covered individuals when
the individual also has third party benefits as described in paragraph (A)(6)
of this rule. (9) "Third party
payer" (TPP) means an entity, other than the medicaid or medicare
programs, responsible for adjudicating and paying claims for third party
benefits rendered to an eligible medicaid covered individual. (B) If the existence of a third party
benefit is known to ODM, a code number that represents the name of the third
party payer covering the individual will be indicated on the individual's
medicaid card. The provider shall obtain from the medicaid covered individual
the name and address of the insurance company, and any other necessary
information, and bill the insurance company prior to billing ODM. (C) The provider must always review the
individual's Ohio medicaid card for evidence of third party benefits.
Whether there is or is not an indication of a TPP on the medicaid card, the
provider must always request from the medicaid covered individual, or the
individual's representative, information about any third party benefit(s).
If the medicaid covered individual specifies no TP coverage and the medicaid
card does not indicate TP coverage, the provider may submit a claim to medicaid
(and the claim for the service is not considered a TP claim). If, as a result
of this process, the provider or ODM determines that TP liability exists, the
provider may only submit a claim for reimbursement if it first takes reasonable
measures to obtain TP payments as set forth in paragraph (E) of this
rule. (D) The medicaid program must be the last
payer to receive and adjudicate the claim except for the following:
(1) Medicaid pays after
any TPL and medicare but before: (a) The children with medical handicaps program under
sections 3701.021 to 3701.0210 of the Revised Code. (b) The state sponsored program awarding reparations to
victims of crime under sections 2743.51 to 2743.72 of the Revised
Code. (2) Medicaid pays before
any TPL and medicare for preventive pediatric services identified in 42 C.F.R.
433.139 (as in effect October 1, 2018). (E) ODM reimburses for medically
necessary covered services only after the provider takes reasonable measures to
obtain all third party payments and file claims with all TPPs prior to billing
ODM. Providers who have gone through reasonable measures to obtain all third
party payments, but who have not received payment from a TPP, or have gone
through reasonable measures and received partial payment, may use an
appropriate code on the claim to obtain payment and submit a claim to ODM
requesting reimbursement for the rendered service. (1) Providers are
considered by ODM to have taken reasonable measures to obtain all third party
payments if they comply with one of the following requirements: (a) The provider submits a claim first to the TPP and
receives a remittance advice indicating that a valid reason for non-payment
applies for the service as described in paragraph (E)(2) of this
rule. (b) The provider submits a claim first to the TPP for the
rendered service no less than three times within a ninety-day period and does
not receive a remittance advice or other communication from the TPP within
ninety days of the last submission to the TPP. Providers must be able to
document each claim submission and the date of the submission. (c) The provider followed the process described in
paragraph (C) of this rule for the billed service and meets the following
requirements: (i) The provider did not
find a change in third party coverage; (ii) The billed service
was previously rendered to the medicaid covered individual by the provider
within the last three hundred sixty-five days; and (iii) The claim for the
previously rendered service met the requirements of paragraph (E)(1)(a) or
paragraph (E)(1)(d) of this rule. (d) The provider did not send a claim to the TPP, but has
received and retained at least one of the following types of documentation that
indicates a valid reason for non-payment for the service(s) as set forth in
paragraph (E)(2) of this rule: (i) Written documentation
from the TPP; (ii) Written
documentation from the TPP's automated eligibility and claim verification
system; (iii) Written
documentation from the TPP's member benefits reference guide or manual;
or (iv) Any other reliable
method for obtaining information or documentation from the TPP that there is no
third party benefit coverage for the rendered service(s). (e) The provider submits a claim first to the TPP and
receives a partial payment along with a remittance advice documenting the
allocation of the billed charges. (2) Valid reasons for
non-payment from a third party payer to the provider for a third party benefit
claim include, but are not limited to, the following: (a) The service is not covered under the medicaid covered
individual's third party benefits. (b) The medical expenses for the medicaid covered
individual were incurred prior to the third party benefit's coverage
dates. (c) The medical expenses for the medicaid covered
individual were incurred after the third party benefits coverage was
terminated. (d) The medicaid covered individual does not have third
party benefits through the TPP for the date of service. (e) All of the provider's billed charges or the
TPP's approved rate was applied to the medicaid covered individual's
third party benefit deductible amount. (f) All of the provider's billed charges or the
TPP's approved rate was applied in total across the medicaid covered
individual's deductible, coinsurance, or co-payment for the third party
benefit. (g) The medicaid covered individual has not met eligibility
requirements, out-of-pocket expenses, required waiting periods, or residency
requirements for the third party benefits. (h) The medicaid covered individual is a dependent of the
individual with third party benefits, but the benefits do not cover the
individual's dependents. (i) The medicaid covered individual has reached the
lifetime benefit maximum for the medical service being billed to the third
party payer. (j) The medicaid covered individual has reached the benefit
maximum of the third party benefits. (k) The TPP is disputing or contesting its liability to pay
the claim or cover the service. (l) The claim was submitted timely and with the correct
information to the TPP but the claim was rejected by the TPP. (F) Providers who have gone through
reasonable measures as described in paragraph (E) of this rule to obtain all
third party payments, but who have not received payment from a TPP, or received
a partial payment, may submit a claim to ODM requesting reimbursement for the
rendered service. If payment from the TPP is received after ODM has made
payment, the provider is required to repay ODM any overpaid amount. The
provider must not reimburse any overpaid amounts to the medicaid covered
individual. (G) Providers who have billed the TPP and
the TPP submits payment directly to the medicaid covered individual should
contact the individual to request the payment be remitted to the provider. If
the individual is uncooperative with the request, the provider should contact
the county department of job and family services (CDJFS). (H) Third party claims must meet the
claim submission guidelines in accordance with rule 5160-1-19 of the
Administrative Code. (I) Medicaid reimbursement for third
party claims will not exceed the medicaid maximum payment for the service,
determined in accordance with applicable rules for the service, less all third
party payments for the service. If the result is less than or equal to zero
dollars, there will be no further medicaid payment for the
service. (J) ODM will reject a TP claim when a
third party claim indicates coverage by a TPP, or when the existence of third
party benefits is known to ODM, and the submitted claim does not indicate
collection of the third party payment or does not indicate compliance with
paragraph (E) of this rule. Providers should complete their investigation of
available third party benefits before submitting a TP claim to ODM for
payment. (K) The provider is prohibited from billing the medicaid
covered individual any charges in accordance with rule 5160-1-60 of the
Administrative Code. (L) If the medicaid covered individual states his or her
private health insurance has changed or been terminated, the provider should
advise the individual to contact his or her county caseworker to correct the
case record. If the individual is not cooperative in pursuing third party
liability as required by rule 5160:1-2-10 of the Administrative Code, the
provider should contact the CDJFS. Once the case record has been corrected, the
provider may bill ODM directly. (M) ODM has right of recovery pursuant to section 5160.37
of the Revised Code (medicaid, or any federal or state funded public health
program) against the liability of a third party for the cost of medical
services paid by ODM, or billable to ODM for payment at a later date. Section
5160.37 of the Revised Code requires that a medicaid covered individual provide
notice to ODM prior to initiating any action against a liable third party. ODM
will take steps to protect its rights of recovery if that notice is not
provided. If any person, whether the medicaid covered individual or an
individual acting on the behalf of a medicaid covered individual requests a
financial statement from a medicaid provider for services paid by ODM or to be
billed to ODM on behalf of the medicaid covered individual, the provider shall
meet all of the following requirements: (1) Require that the
medicaid covered individual or the individual's representative make a
request for access to financial statements in writing. (2) Notify ODM
immediately upon receipt of the medicaid covered individual's written
request and forward a copy of the request to ODM, bureau of claims operations,
coordination of benefits section. (3) Release the financial
statement to the medicaid covered individual or the individual's
representative no later than thirty days after the date the request is
received. (4) Stamp or type on each
page of the financial statement in bold font "SUBJECT TO RIGHT OF RECOVERY
PURSUANT TO SECTION 5160.37 OF THE OHIO REVISED CODE. FAILURE TO COMPLY MAY
RESULT IN PERSONAL LIABILITY." (5) This rule applies to
financial statements whether or not the provider has received reimbursement
from ODM. This rule is not intended to prevent or restrict the provider from
furnishing records of medical treatment and condition to the medicaid covered
individual. (N) Except as otherwise provided in paragraph (D)(2) of
this rule, when the medicaid covered individual is covered by medicare, in
addition to other third party payers, medicaid is the payer of last resort.
Whether or not a TPP is the primary payer, providers must bill all other third
party payers and medicare prior to submitting a claim to ODM in accordance with
rule 5160-1-05 of the Administrative Code.
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Rule 5160-1-09 | Co-payments.
This rule sets forth requirements regarding co-payments by individuals for medicaid-covered services. (A) Certain medicaid services are subject to individual co-payments. Information regarding these services and co-payment amounts can be found in the following Administrative Code rules: (1) Co-payments for dental services are described in rule 5160-5-01 of the Administrative Code. (2) Co-payments for vision services are described in rule 5160-6-01 of the Administrative Code. (3) Co-payments for non-emergency emergency department services are described in rule 5160-2-21.1 of the Administrative Code. (4) Co-payments for pharmacy services are described in rule 5160-9-09 of the Administrative Code. (5) Co-payment requirements for services provided through a medicaid managed care plan are described in Chapter 5160-26-12 of the Administrative Code. (B) With regard to the application of individual payments, the following apply: (1) No provider may deny services to an individual who is eligible for the services on account of the individual's inability to pay the medicaid co-payment. Individuals who are not able to pay their medicaid co-payment may declare their inability to pay for services or medication and receive their services or medication without paying their medicaid co-payment amount. With regard to an individual who is unable to pay a required medicaid co-payment in accordance with this paragraph, this does not: (a) Relieve the individual from the obligation to pay a medicaid co-payment; or (b) Prohibit the provider from attempting to collect an unpaid medicaid co-payment. (2) No provider shall waive an individual's obligation to pay a provider a medicaid co-payment except when paragraph (A)(5) of this rule applies. (3) No provider or drug manufacturer, including the manufacturer's representative, employee, independent contractor, or agent, shall pay any co-payment on behalf of an individual. (4) If it is the routine business practice of the provider to refuse service to any individual who owes an outstanding debt to the provider, the provider may consider an unpaid medicaid co-payment as an outstanding debt and refuse service to an individual who owes the provider an outstanding debt. If the provider intends to refuse service to an individual who owes the provider an outstanding debt, the provider shall notify the individual of the provider's intent to refuse services. In determining outstanding debt of an individual, the following apply: (a) A provider's decision to continue rendering services to an individual who has an unpaid co-payment shall not be considered an outstanding debt of an individual. (b) Charges which are prohibited in accordance with paragraph (A) of rule 5160-1-60 of the Administrative Code may not be considered an outstanding debt of an individual. (C) The following individuals are excluded from the co-payment requirement for dental, vision, non-emergency emergency department services and pharmacy services: (1) Children and youth under the age of twenty-one. (a) The provider may use the individual's date of birth to identify if this exclusion applies; or (b) The provider may submit the claim to the Ohio department of medicaid (department). During adjudication of the claim, if the department identifies the individual as a child or youth under the age of twenty-one, the department will not reduce the medicaid payment by the co-payment amount. (2) Pregnant women during pregnancy and women with post-partum coverage as defined in rule 5160-4-04 of the Administrative Code. The following also apply: (a) Routine eye examinations and the dispensation of eyeglasses during an individual's pregnancy are subject to co-payment. (b) For all other claims, the provider may accept the individual's self-declaration of her pregnancy if the pregnancy/ post-partum co-payment exclusion applies. If the provider reports this exclusion applies, the medicaid payment will not be reduced by the co-payment amount. (3) Residents of a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID). (a) The provider may use the individual's address to validate whether the individual resides in a NF or ICF/IID; or (b) The provider may submit the claim to the department. During the adjudication of the claim, if the department identifies the individual as a resident of a NF or ICF/IID, the department will not reduce the medicaid payment by the co-payment amount. (4) Individuals receiving emergency services are excluded from co-payment when they are provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy; (5) Individuals receiving family planning services defined as pregnancy/contraception management services in rule 5160-21-02 of the Administrative Code are excluded from co-payment when these services are provided to an individual of child-bearing age. The provider may determine on the basis of his or her professional judgment that the individual is receiving pregnancy prevention/ contraceptive services and the co-payment exclusion applies. (6) Individuals receiving hospice services are excluded from co-payment obligations. The provider may accept the individual's self-declaration that he or she is enrolled in hospice. If the provider reports that the individual is enrolled in hospice, the medicaid payment will not be reduced by the co-payment amount. (7) Individuals receiving medicaid because of the state's election to provide coverage under the breast and cervical cancer option pursuant to 42 CFR 447.56(a)(1)(xi). (D) Medicare cross-over claims as defined in rule 5160-1-05 of the Administrative Code are not subject to medicaid co-payments.
Last updated September 12, 2022 at 8:13 AM
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Rule 5160-1-10 | Limitations on elective obstetric deliveries.
(A) Payment for any cesarean section, labor induction, or any delivery following labor induction is subject to the following criteria: (1) Gestational age of the fetus must be determined to be at least thirty-nine weeks; or (2) If a delivery occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions must indicate medical necessity for the delivery. (B) Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to thirty-nine weeks gestation that are not considered medically necessary are not eligible for payment.
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Rule 5160-1-11 | Out-of-state coverage.
(A) Out-of-state providers: (1) Should be licensed,
accredited, or certified by their respective states to be considered eligible
to receive reimbursement for services provided to Ohio medicaid covered
individuals. (2) Should meet any
standards applicable to the provision of the service in the state in which the
service is being furnished, as well as those standards set forth in the Ohio
medicaid program and in the Administrative Code. (3) Except as provided in
paragraph (A)(4) of this rule, need to enroll as Ohio medicaid providers in
order to obtain payment and follow appropriate billing procedures in accordance
with Chapter 5160-1 of the Administrative Code and Chapter 5160-3 of the
Administrative Code for long term care nursing facility services. (4) Who are rendering
services to medicaid covered individuals enrolled in a managed care plan (MCP)
are not required to enroll with the Ohio department of medicaid (ODM)
when: (a) The out-of-state provider is not in the MCP's
network and is providing services under a single case agreement;
or (b) The out-of-state provider is a pharmacy that is
in-network with the MCP under a national contract. (5) May have their out-of-state
provider's enrollment application denied by ODM based on the denial,
censure or revocation of their professional license by the applicable licensing
board of any other state, or if the applicable licensing board in Ohio denies,
censures or revokes a professional license even if another state's
licensing board approves the respective provider. (B) Ohio medicaid covered services will
be reimbursed when rendered by out-of-state providers only under the following
circumstances: (1) The medically
necessary services are not available within the state of Ohio, and the use of
out-of-state providers to perform the services is authorized by the department
or its designee, or authorized in accordance with rule 5160-1-31 of the
Administrative Code; or (2) The medical need
arose as a result of an emergency, an accident, or an illness which occurred
during a period of time the medicaid covered individual was temporarily absent
from Ohio; or (3) The individual's
health would have been endangered if care was postponed until the individual
returned to Ohio or attempted to return to Ohio; or (4) The provider location for the
medically necessary service is in a bordering state of Ohio, and it is the
usual practice of residents in that community to utilize out-of-state
providers, so long as the cost of the service does not exceed the cost of the
service if provided by in-state providers; or (5) The state determines on the basis of
medical advice, that the needed medical services or necessary supplementary
resources are more readily available in another state.
Last updated April 8, 2021 at 1:29 PM
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Rule 5160-1-13.1 | Medicaid recipient liability.
Effective:
January 1, 2020
(A) In accordance with 42 C.F.R. 447.15
(as in effect October 1, 2018), the medicaid payment for a covered service
constitutes payment-in-full. It shall not be construed as a partial payment
even when the payment amount is less than the provider's
charge. (1) The provider shall not collect nor bill a medicaid
recipient for any difference between the medicaid payment and the
provider's charge, nor shall the provider ask a medicaid recipient to
share in the cost through a deductible, coinsurance, co-payment, missed
appointment fee or other similar charge, other than medicaid co-payments as
defined in rule 5160-1-09 of the Administrative Code and patient liability as
described in Chapter 5160-3 and rule 5160:1-6-07 of the Administrative
Code. (2) The provider shall not charge a medicaid recipient a
down payment, refundable or otherwise. (3) Should the individual become eligible for medicaid
after the date of service and the eligibility span includes the date of
service, the individual may not be financially responsible. (B) A medicaid recipient cannot be billed
when a medicaid claim has been denied for any of the following
reasons: (1) Unacceptable or
untimely submission of a claim; (2) Failure to request a
prior authorization; or (3) A retroactive finding
by a peer review organization (PRO) that a rendered service was not medically
necessary. (C) A provider may bill a medicaid
recipient for a medicaid covered service in lieu of submitting a claim to the
Ohio department of medicaid (ODM) only if all of the following conditions are
met: (1) The provider explains
to the medicaid recipient that the service is a covered medicaid service and
other medicaid providers may render the service at no cost to the
individual; (2) Prior to each date of
service for the specific service rendered, the provider notifies the medicaid
recipient in writing that the provider will not submit a claim to ODM for the
service; (3) The medicaid
recipient agrees to be liable for payment of the service and signs a written
statement to that effect before the service is rendered; and (4) The medicaid covered
service is not a prescription for a controlled substance as defined in section
3719.01 of the Revised Code. (D) Services that are not covered by the
medicaid program, including services requiring prior authorization that have
been denied by ODM, may be billed to a medicaid recipient when the conditions
in paragraphs (C)(2) to (C)(4) of this rule are met. (E) Any individual not covered by
medicaid on the date of service is financially responsible for those services
unless the individual qualifies for the hospital care assurance program (HCAP)
in accordance with section 5168.14 of the Revised Code.
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Rule 5160-1-14 | Healthchek: early and periodic screening, diagnostic, and treatment (EPSDT) covered services.
Effective:
November 1, 2017
(A) Definitions. (1) "Healthchek" is Ohio's early
and periodic screening, diagnostic, and treatment (EPSDT) benefit for all
medicaid recipients younger than twenty-one years of age, described in 42
U.S.C. 1396d(r) (as in effect 10/2017). (2) "Bright futures guidelines" are the
American academy of pediatrics bright futures guidelines for preventive health
care (rev. 2/2017), available at http://www.aap.org. (3) "Medical necessity" and
"medically necessary" have the same meaning as in rule 5160-1-01 of
the Administrative Code. (4) "Prior authorization" is one of two
processes: (a) For members of a
medicaid managed care plan (MCP), it is the process established by the medicaid
MCP as required by rule 5160-26-05.1 of the Administrative Code. (b) For all other medicaid
recipients, it is the process outlined in rule 5160-1-31 of the Administrative
Code. (B) Providers. Healthchek screening, diagnostic, and treatment
services may be rendered by eligible providers in an appropriate discipline,
acting within the scope of practice authorized under state law and as set forth
in agency 5160 of the Administrative Code. (C) Coverage. For medicaid-eligible individuals younger than
twenty-one years of age, healthchek covers the following services and
items: (1) Screening services. (a) Healthchek screening
services include, but are not limited to, all of the following
procedures: (i) A comprehensive health and developmental
history, including assessment of both physical and mental health development,
as well as substance abuse disorders; (ii) A comprehensive unclothed physical exam,
when appropriate; (iii) Immunizations appropriate to age and health
history; (iv) Laboratory tests, including lead blood level
assessment appropriate to age and risk factors, as required by the centers for
medicare and medicaid services (CMS); (v) Nutritional status assessment;
and (vi) Health education, counseling, anticipatory
guidance, and risk factor reduction intervention provided to an individual
younger than twenty-one years of age and, as applicable, to another person
responsible for the individual younger than twenty-one years of
age. (b) Healthchek screening
services are covered at the following frequency: (i) For immunizations, in accordance with the
schedule regarding the appropriate periodicity, dosage, and contraindications
applicable to pediatric vaccines established by the advisory committee on
immunization practices of the centers for disease control and prevention, found
at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html; (ii) For other screening services, at ages and
intervals in accordance with the bright futures guidelines; and (iii) For all screening services, at such other
intervals indicated as medically necessary to determine the existence of
physical or mental illnesses or conditions. (2) Vision services. (a) Healthchek vision
services include but are not limited to diagnosis and treatment for defects in
vision, including eyeglasses. (b) Healthchek vision
services are covered at the following frequency: (i) At intervals that meet reasonable standards
of medical practice in accordance with the bright futures guidelines;
and (ii) At such other intervals indicated as
medically necessary to determine the existence of a suspected illness or
condition. (3) Dental services. (a) Healthchek dental
services include but are not limited to relief of pain and infections,
restoration of teeth, and maintenance of dental health. (b) Healthchek dental
services are covered at the following frequency: (i) For individuals six years of age or younger,
at intervals that meet reasonable standards of dental practice in accordance
with the bright futures guidelines; (ii) For individuals older than six and younger
than twenty-one years of age, at least once every one hundred eighty days;
and (iii) For all individuals younger than twenty-one
years of age, at such other intervals indicated as medically necessary to
determine the existence of a suspected illness or condition. (4) Hearing services. (a) Healthchek hearing
services include but are not limited to diagnosis and treatment for defects in
hearing, including hearing aids. (b) Healthchek hearing
services are covered at the following frequency: (i) At intervals that meet reasonable standards
of medical practice in accordance with the bright futures guidelines;
and (ii) At such other intervals indicated as
medically necessary to determine the existence of a suspected illness or
condition. (5) All medically necessary services and items
set forth in agency 5160 of the Administrative Code. (6) All medically necessary screenings, health
care, diagnostic services, treatment, and other measures described in 42 U.S.C.
1396d(a) (as in effect 10/2017) to correct or ameliorate defects and physical
and mental illnesses and conditions, regardless of whether such measures are
addressed in agency 5160 of the Administrative Code. (D) Additional provisions. (1) Coverage limits that have been established
may be exceeded, with prior authorization, for medically necessary services
rendered to medicaid-eligible individuals younger than twenty-one years of
age. (2) Separate payment may be made for additional
medically necessary services rendered during, as part of, or as a result of a
screening visit. Payment may be made to a provider for necessary follow-up
services rendered at the time of the screening visit if the provider is
qualified to perform them. (3) In accordance with guidance issued by CMS in
"EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children
and Adolescents" (June 2014, found at http://www.medicaid.gov), when a
screening examination indicates the need for further evaluation of a
child's health, the child must be appropriately referred without delay
for diagnosis, necessary treatment, and follow-up.
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Rule 5160-1-16 | Preventive services.
Effective:
October 1, 2017
(A) "Preventive service" is a procedure, treatment, or other measure that is included in either of two groups: (1) Services addressed in any of the following sources: (a) "USPSTF A and B Recommendations" (January 2017), published by the United States preventive services task force and available at http://www.uspreventiveservicestaskforce.org; (b) Immunization schedules for January 2017 published by the centers for disease control and prevention and available at http://www.cdc.gov; (c) "Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, 4th Edition" (2017), published by the American academy of pediatrics and available at http://www.aap.org; or (d) "Recommendations for Preventive Services for Women" (December 2016), published by the women's preventive services initiative and available at http://www.womenspreventivehealth.org; or (2) Medically necessary procedures that meet the definition of "early and periodic screening, diagnostic, and treatment services" set forth in 42 U.S.C. 1396d(r) (as in effect in January 2017). (B) Payment may be made for a preventive service and necessary related services (e.g., medications, procedures, devices, tests, education, and counseling) when both of the following conditions are met: (1) A practitioner in an appropriate discipline, acting within the scope of practice authorized under state law, has determined, on the basis of at least one risk factor, that the preventive service is indicated for a particular individual; and (2) The preventive service is provided in accordance with nationally recognized, evidence-based frequency schedules.
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Rule 5160-1-17 | Eligible providers.
Effective:
November 25, 2019
This rule sets forth eligibility requirements for
practitioners, group practices, or organizational providers enrolling with, and
seeking reimbursement from, the Ohio medicaid program. (A) Eligible provider means any
practitioner, group practice, or organization identified by the Ohio department
of medicaid (ODM) as a type of provider eligible to enroll in the medicaid
program that: (1) Meets the applicable
provider requirements and standards in agency 5160 of the Administrative Code
that address applicable service categories and provider types covered under the
Ohio medicaid program; (2) Meets additional
requirements and standards set forth in this rule; (3) Meets provider
screening requirements and, when applicable, pays the fee for enrollment as a
provider in the medicaid program in accordance with rule 5160-1-17.8 of the
Administrative Code; and (4) Is approved for
participation in the medicaid program by ODM as evidenced by the issuance of
both a signed "provider agreement" and an Ohio medicaid provider
number. (B) Eligible practitioners licensed by an Ohio licensing
board may enroll as a medicaid provider in accordance with their active
licensure and scope of practice as determined by the licensing
entity. (C) A provider can be assigned a professional group
provider type when organized for the purpose of providing professional services
under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755.,
4757., 4759., or 4762. of the Revised Code, and meets the requirements in
either paragraph (C)(1) or (C)(2) of this rule, and meets the additional
requirements set forth in paragraphs (C)(3) to (C)(5) of this
rule. (1) A professional
practice that is owned by an individual may be enrolled as a professional group
practice if the practice is formed as an organizational structure listed in
paragraph (C)(3) of this rule, and the owner or member of the practice
possesses a valid license, certificate, or other legal authorization issued
under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755.,
4757., 4759., or 4762. of the Revised Code, and also meets the requirements
found in paragraph (A)(1) of this rule. A provider enrolling with the medicaid program
that does not meet the provisions listed in paragraph (C) of this rule may only
be enrolled as an individual provider. (2) Any group of two or
more individuals may be enrolled as a professional group practice if the
practice is formed as an organizational structure listed in paragraph (C)(3) of
this rule. ODM recognizes two types of professional group practices, a
professional medical group and a professional dental group. (a) A professional medical group is a group that consists
of individual practitioners recognized by ODM as eligible members. These
eligible members include but are not limited to: physicians, osteopaths,
advanced practice nurses, physician assistants, psychologists, podiatrists,
optometrists, chiropractors, licensed independent social workers, licensed
professional clinical counselors, independent marriage and family counselors,
licensed independent chemical dependency counselors, occupational therapists,
physical therapists, speech therapists, acupuncturists, audiologists,
opticians, ocularists, licensed dietitians and registered dietitian
nutritionists. With the exception of an incorporated individual in accordance
with paragraph (C)(3)(b) of this rule, the professional medical practice must
consist of two or more members, of like or different scopes of practice or
licensure. (b) A professional dental group is a group that consists
only of dentists. With the exception of an incorporated individual in
accordance with paragraph (C)(3)(b) of this rule, the practice must consist of
two or more dentists. (c) An out of state professional medical group must abide
by the requirements stated in rule 5160-1-11 of the Administrative
Code. (3) For the purposes of
the Ohio medicaid program, a professional group practice may be organized in
accordance with one of the following organization structures: (a) A corporation formed under Chapter 1701. of the Revised
Code. (b) A limited liability company formed under Chapter 1705.
of the Revised Code. (c) A non-profit corporation formed under Chapter 1702. of
the Revised Code. (d) A professional association formed under Chapter 1785.
of the Revised Code. (e) A partnership formed under Chapters 1776. and 1782. of
the Revised Code. (4) With the exception of
hospitals, long term care facilities, home health agencies, hospice programs,
and intermediate care facilities, each practitioner employed by or under
contract with a group practice or an organization, including, but not limited
to professional group practices, clinics, federally qualified health centers,
and behavioral health facilities, who also meet the respective requirements in
paragraph (A) of the rule, must have an approved individual provider agreement
with ODM. (5) Each practitioner,
employed or under contract with a group practice or an organization that is
actively enrolled as a provider in the Ohio medicaid program, shall affiliate
themselves with their respective group practices or organizational providers
when applying for a provider agreement with ODM. (D) Requirements for obtaining and using national provider
identifiers (NPI). (1) For the purposes of
receiving reimbursement for services rendered to medicaid recipients, ODM shall
require providers and practitioners enrolling in the medicaid program to obtain
a NPI. (2) Providers, and
practitioners, whether practicing independently or employed or under contract
with a group practice or organization, who are identified by the american
medical association's national uniform claim committee with a provider
taxonomy number shall obtain a NPI and shall divulge the NPI to ODM upon
enrollment. (3) The name and NPI of
the practitioner who furnishes services to medicaid recipients shall be on
claims submitted to ODM for reimbursement. Claims submitted without a NPI will
be denied. (4) An organization with
components or subparts is responsible for determining if any components or
subpart of its organization require a separate NPI and, if so, shall obtain it
for that component or subpart. (E) As part of the initial medicaid provider application,
an applicant shall include a list of all geographical locations at which it
renders services under its NPI. An existing provider shall submit to ODM any
additions or deletions to the list of locations within thirty calendar days of
the change. An enrolled provider must also notify ODM of any provider
affiliation additions or deletions within thirty days of the change. Failure to
follow the requirements of this paragraph may prevent an applicant from being
enrolled as a medicaid provider or if enrolled, may result in the termination
of a provider agreement as provided for in rule 5160-1-17.6 of the
Administrative Code. (F) ODM does not enroll providers located outside of the
United States and its territories.
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Rule 5160-1-17.2 | Provider agreement for providers.
Effective:
September 19, 2019
Provisions of provider agreements for long term
care nursing facilities are defined in Chapter 5160-3 of the Administrative
Code. Provisions for provider agreements for medicaid contracting managed care
plans are defined in Chapter 5160-26 of the Administrative Code. A valid provider agreement with medicaid will act
as a provider agreement for participation in the medicaid program. All medicaid
provider applications must be submitted through the medicaid information
technology system (MITS) web portal. Provider applications submitted in paper
format will be returned to the provider unprocessed. If a provider application requires additional
supporting documentation by the department for the application process to be
completed, the supporting documentation may be sent through the MITS web portal
or sent to the department through regular mail service. A provider agreement is a contract between the Ohio
department of medicaid (ODM) and a provider of medicaid covered services. By
signing this agreement the provider agrees to comply with the terms of the
provider agreement, Revised Code, Administrative Code, and federal statutes and
rules; and the provider certifies and agrees: (A) To render medical services as
medically necessary for the patient and only in the amount required by the
patient without regard to race, creed, color, age, sex, national origin,
source(s) of payment, or disability; submit claims only for services actually
performed; and, bill ODM for no more than the usual and customary fee charged
other patients for the same service. (B) To ascertain and recoup any
third-party resource(s) available to the consumer prior to billing ODM. ODM
will then pay any unpaid balance up to the lesser of the provider's billed
charge or the maximum allowable reimbursement as set forth in agency 5160 of
the Administrative Code. (C) To accept the allowable reimbursement
for all covered services as payment-in-full, except as required in paragraph
(B) of this rule. The provider will not seek reimbursement for that service,
except as defined in rule 5160-1-09 of the Administrative Code, from the
patient, any member of the family, or any other person. (D) To maintain all records necessary and
in such form so as to fully disclose the extent of services provided and
significant business transactions. The provider will maintain such records for
a period of six years from the date of receipt of payment or until any audit
initiated within the required six year record maintenance period is
completed. (E) To furnish to ODM, the secretary of
the department of health and human services, or the Ohio medicaid fraud control
unit or their designees any information maintained under paragraph (D) of this
rule for audit and review purposes. Audits may use statistical sampling.
Failure to supply requested records within thirty days shall result in
withholding of medicaid payments and may result in termination from the
medicaid program. (F) To inform ODM within thirty days of
any changes including, but not limited to changes in licensure, certification,
or registration status; ownership; specialty; additions, deletions, or
replacements in group membership and hospital-based physician affiliations; and
address, including all locations where services are rendered. (G) To disclose ownership and control
information, and to disclose the identity of any person who has been convicted
of a criminal offense related to medicare, medicaid, or services provided under
Title XX of the Social Security Act as in effect on November 15, 2018 (Title
XX), as specified in rule 5160-1-17.3 of the Administrative Code. (H) That neither the individual
practitioner, nor the company, nor any owner, director, officer, or employee of
the company, nor any independent contractor retained by the company, is
currently subject to sanction under medicare, medicaid, or Title XX; or, is
otherwise prohibited from providing services to medicare, medicaid, or Title XX
beneficiaries. (I) To provide to ODM, through the court of jurisdiction, notice
of any bankruptcy action brought by the provider. Notice shall be mailed to:
office of legal services, Ohio department of medicaid. (J) To comply with the appropriate advance directives
requirements for hospitals, providers of home health care, personal care
services, and hospices as specified in Chapter 3701-83 of the Administrative
Code. (K) To comply with the confidentiality safeguards and the use and
release of information regarding public assistance recipients as described in
section 5101.27 of the Revised Code. (L) To comply with section 121.36 of the
Revised Code and rule 5160-1-39 of the Administrative Code when providing home
care services.
Last updated September 1, 2023 at 12:55 PM
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Rule 5160-1-17.3 | Provider disclosure requirements.
(A) For the purposes of this rule, the
following definitions apply: (1) "Affiliation" has the same meaning as in 42
C.F.R. 455.101 (as in effect on October 1, 2023). (2) "Agent" has
the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1,
2023). (3) "Disclosable
event" has the same meaning as in 42 C.F.R. 455.101 (as in effect on
October 1, 2023). (4) "Disclosing
provider" means a medicaid provider, managed care entity, or fiscal agent
under contract with the department of medicaid (department) in accordance with
42 C.F.R. 455.101 (as in effect on October 1, 2023). (5) "Indirect
ownership interest" means an ownership interest in an entity that has
direct or indirect ownership in the disclosing provider. (6) "Managing employee" has the
same meaning as in 42 C.F.R. 455.101 (as in effect on October 1,
2023). (7) "Person with an ownership or
control interest" means a person or corporation that meets any of the
following: (a) Has an ownership interest totaling five per cent or
more in the disclosing provider; (b) Has an indirect ownership interest equal to five per
cent or more in the disclosing provider; (c) Has a combination of direct and indirect ownership
interest equal to five per cent or more in the disclosing
provider; (d) Owns an interest of five per cent or more in any
mortgage, deed of trust, note, or other obligation secured by the disclosing
entity if that interest equals at least five per cent of the value of the
property or assets of the disclosing provider; (e) Is an officer or director of the disclosing provider
that is organized as a corporation or non-profit; or (f) Is a partner in the disclosing provider that is
organized as a partnership or limited liability company. (8) "Significant business
transaction" has the same meaning as in 42 C.F.R. 455.101 (as in effect on
October 1, 2023). (B) Disclosing providers will disclose
the following information to the department in accordance with 42 C.F.R.
455.104 to 42 C.F.R 455.106 (as in effect on October 1, 2023): (1) The name and address
of any person (individual or corporation) with an ownership or control interest
in the disclosing provider. (a) In the case of an individual, date of birth and social
security number. (b) In the case of a corporation, other tax identification
number with an ownership or control interest in the disclosing provider or in
any subcontractor in which the disclosing provider has a five per cent or more
interest. (2) Whether the person (individual or
corporation) with an ownership or control interest in the disclosing provider
is related to another person with ownership or control interest in the
disclosing provider as a spouse, parent, child, or sibling. (3) Whether the person (individual or
corporation) with an ownership or control interest in any subcontractor in
which the disclosing provider has a five per cent or more interest is related
to another person with ownership or control interest in the disclosing provider
as a spouse, parent, child, or sibling. (4) The name of any disclosing provider
in which an owner of the disclosing provider has an ownership or control
interest. (5) The name, address, date of birth, and
social security number of any managing employee of the disclosing
provider. (6) The identity of any person who has
ownership or control interest in the disclosing provider or is an agent or
managing employee of the disclosing provider, and has been convicted of a
criminal offense related to that person's involvement in any program under
medicare, medicaid, or the title XX services program since the inception of
those programs. (7) The ownership of any subcontractor
with whom the disclosing provider has had business transactions totaling more
than twenty-five thousand dollars during the preceding twelve-month period
ending on the date the disclosure is due. (8) Any significant business transaction
between the disclosing provider and any wholly owned supplier, or between the
disclosing provider and any subcontractor, during the preceding five-year
period ending on the date the disclosure is due. (C) Disclosing providers, prior to
initial enrollment or revalidation with the Ohio department of medicaid
(department), who are not enrolled in medicare, will at the request of the
department disclose when a managing employee, within the past five years, has
an affiliation with a currently or formerly enrolled medicare, medicaid, or
child health insurance program (CHIP) provider or supplier that has had a
disclosable event in accordance with 42 C.F.R. 455.107 (as in effect on October
1, 2023). (1) Applicable disclosing
providers will disclose the following information about each
affiliation: (a) General identifying information including: (i) Legal name of the
provider as reported to either the internal revenue service (IRS) or social
security administration (SSA); (ii) Legal name of any
managing employees as reported to either the IRS or SSA; (iii) Tax identification
number (TIN); and (iv) National provider
identifier (NPI); (b) Length of the relationship; (c) Type of affiliation; (d) Degree or extent of affiliation; and (e) If the affiliation has ended, the reason for the
termination. (2) The department, in
consultation with the center for medicare and medicaid services (CMS), will
decide, utilizing the factors found in 42 C.F.R 455.107 (as in effect on
October 1, 2023), whether the affiliation poses an undue risk of fraud, waste,
and abuse. (a) If the department determines the provider's
affiliation poses an undue risk, the provider's application will be denied
or if enrolled, will result in the termination of the provider
agreement. (b) If enrollment is denied or the provider agreement
terminated as a result of the department determining the provider's
affiliation poses an undue risk of fraud, waste, and abuse, the provider may
request a hearing pursuant to Chapter 119. of the Revised Code. (D) Disclosures will be due at any of the
following times in accordance with 42 C.F.R. 455.104 (as in effect on October
1, 2023): (1) Prior to entering
into a medicaid provider agreement or contract, during a procurement process or
as part of a request for proposal. (2) Prior to revalidating
a medicaid provider agreement, or the renewal or extension of the contract.
(3) Within thirty-five
days of any change in ownership. (4) At any time within
thirty-five days upon written request from the department. (E) Failure by the disclosing provider to disclose
information in accordance with this rule may result in the denial, suspension,
or termination of the medicaid provider agreement or contract.
Last updated July 15, 2024 at 9:28 AM
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Rule 5160-1-17.4 | Revalidation of provider agreements.
Effective:
April 17, 2021
(A) Revalidation is the process that a
provider is required to follow to renew and revalidate its provider agreement.
Provider agreements must be revalidated no later than five years from the
effective date of the original or the last revalidated provider agreement,
whichever is applicable. In the event the center for medicare and medicaid
services (CMS) waives or modifies the deadline, provider agreement revalidation
may be delayed as authorized by the CMS waiver or modification. Provider
agreements must also be revalidated whenever there is a change in risk pursuant
to 42 C.F.R. 455.450 (as in effect October 1, 2020) The revalidation process is
as follows: (1) The Ohio department
of medicaid (ODM) shall send a revalidation notice ninety days prior to the
expiration date of the provider's time-limited agreement either to the
provider's email or mailing address on file notifying the provider that it
is required to revalidate its agreement. (2) The revalidation
notice shall instruct the provider what is required to complete the
revalidation process. Providers are expected to meet all conditions for
participation as an eligible provider that are in effect in Chapter 5160-1 of
the Administrative Code at the time of revalidation. (3) The provider shall
submit all required information before the revalidation deadline date specified
in the revalidation notice including the required fee as specified in rule
5160-1-17.8 of the Administrative Code. (4) A provider shall not
initiate revalidation prior to the receipt of the revalidation notification
sent by ODM. This rule does not negate the requirement that a provider must
properly disclose any changes to its provider agreement in accordance with rule
5160-1-17.3 of the Administrative Code. The reporting of changes does not
constitute the initiation of revalidation and remains the provider's
responsibility. (5) When a provider fails
to revalidate in the time and the manner required by ODM, as specified in this
rule and in accordance with the revalidation notice referred to in paragraph
(A)(1) of this rule, ODM shall deny an application for revalidation and
terminate the time-limited provider agreement. The denial and termination will
take effect thirty days after ODM mails a written notice to the provider by
regular mail to the address on file notifying the provider of the decision. ODM
shall specify in the notice the date on which the provider is required to cease
operating under a terminated provider agreement. (6) If a provider files
an application for revalidation within the time and in the manner required, as
specified in this rule, but the provider agreement expires before ODM acts on
the application or before the effective date of the ODM decision on the
application, the provider may continue operating under the terms of the expired
agreement until the effective date of the ODM decision. (7) If a provider files
an application for revalidation within the time and in the manner required, as
specified in this rule, but has not been able to obtain a renewal of its
licensure, certification, accreditation, or registration the application may be
accepted and processed by ODM as long as the granting official, board,
commission, department, division, bureau, or other agency of state or federal
government considers the provider in good standing and that its licensure,
certification, accreditation, or registration is still active. (B) The effective date of a new provider
agreement is the date on which the provider signs the application and meets all
of the federal and state requirements for participation in the medicaid
program. The effective date of a new provider agreement may be made retroactive
for up to twelve months prior to the date of application if the provider was
properly licensed or certified. (C) Pursuant to section 5164.38 of the
Revised Code, ODM is not required to afford hearing rights, in accordance with
Chapter 119. of the Revised Code when terminating a time-limited provider
agreement due to the provider's failure to properly file an application
for revalidation. (D) In processing an application for revalidation, ODM reserves
the right to conduct an on-site review at the provider's facility, place
of business, or both, as ODM deems necessary to ensure program
integrity.
Last updated April 17, 2021 at 10:17 AM
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Rule 5160-1-17.5 | Suspension of medicaid provider agreements.
Effective:
March 22, 2015
(A) Definitions: (1) "Credible allegation of fraud" means an accusation of fraud as defined in section 5164.36 of the Revised Code. (2) "Non-institutional provider" means any person or entity with a medicaid provider agreement other than a hospital, long-term care nursing facility, intermediate care facility for individuals with intellectual disabilities or medicaid contracting managed care plans. (B) The Ohio department of medicaid (ODM) shall suspend a medicaid provider agreement when at least one of the following conditions apply: (1) Upon determining there is a credible allegation of fraud for which an investigation is pending against a provider under the medicaid program, unless good cause to not suspend is found pursuant to 42 CFR 455.23(e) or (f), effective Feb. 2, 2011; or (2) Upon receiving notice and copy of an indictment that charges a non-institutional provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense as specified in division (E) of section 5164.37 of the Revised Code. (C) Upon suspension of the provider agreement, the following conditions apply: (1) If a provider is suspended pursuant to this rule, then any other provider agreements where the provider is an owner, officer, authorized agent, manager, or employee may also be suspended. (2) A provider, its owner or owners, officer, authorized agent, associate, manager, or employee shall not own or provide services to any other medical provider or risk contractor or arrange for, render, or order services for medicaid recipients during the period of suspension. (3) During the period of suspension, the provider owner or owners, officer, authorized agent, associate, manager, or employee shall not receive reimbursement in the form of direct payments from ODM or indirect payments of medicaid funds. (4) The suspension shall continue until either of the following: (a) The department or a prosecuting authority determines that there is insufficient evidence of fraud by the provider; (b) The proceedings in any related criminal case are completed through dismissal of the indictment or through conviction, entry of a guilty plea, or finding of not guilty. (5) If ODM commences a process to terminate the suspended provider agreement, the suspension shall continue in effect until the termination process is concluded. (D) Reconsideration of suspension: (1) A provider, owner, or owners subject to a suspension may request a reconsideration in accordance with section 5164.36 or 5164.37 of the Revised Code. A request for reconsideration is not subject to Chapter 119. of the Revised Code. (2) The reconsideration shall be conducted by the ODM director or the director's designee in the office where the contestation arose provided that the designee was not involved in the original decision. Decisions made by the director or the director's designee are not appealable or subject to further reconsideration.
Last updated September 1, 2023 at 12:56 PM
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Rule 5160-1-17.6 | Termination and denial of provider agreement.
(A) For purposes of this rule, the following definitions apply: (1) "Ownership or control interest" means having at least five per cent ownership, or interest, either directly, indirectly, or in any combination. (2) "Provider" has the same meaning as "eligible provider," as defined in rule 5160-1-17 of the Administrative Code. (3) "Provider Agreement" means an agreement as defined in rule 5160-1-17.2 of the Administrative Code or any rule contained in agency 5160 of the Administrative Code. (B) Termination for long term care nursing facilities and intermediate care facilities for individuals with intellectual disabilities is located in Chapters 5160-3 and 5123:2-7 of the Administrative Code. (C) Termination for providers enrolled in a medicaid managed care plan is located in Chapter 5160-26 of the Administrative Code. (D) A provider may voluntarily terminate a provider agreement upon written notice thirty days before the provider's chosen termination date. The Ohio department of medicaid (ODM) has the discretion to accept or deny a voluntary termination for a provider who is facing involuntary termination due to an ODM action. ODM may waive the thirty day requirement if appropriate. (E) A provider is ineligible for payment for dates of service on or after the effective date of a denial, suspension, revocation, limitation, or failure to renew a license, permit, certifcate, or certification issued by an official, board, commission, department, bureau, or other agency of the state or federal government. (F) A provider that was terminated because of a conviction that was a result of a suspension due to credible allegation of fraud is ineligible for all payments, regardless of the dates of service. (G) ODM may propose termination or denial of a provider agreement at any time it is determined that continuation or assumption of provider status is not in the best interest of recipients or the state of Ohio. The phrase "not in the best interest" shall include, but not be limited to, the following circumstances or occurrences: (1) The provider has not billed or otherwise submitted a medicaid claim to ODM for two years or longer. (2) The provider, or any person having an ownership or controlling interest in the provider, or who is an agent or employee of the provider, has been indicted or granted immunity from prosecution for, or has pled guilty to, or has been convicted of, any criminal offense against the state of Ohio or any other state or territory, whether the offense occured prior to or during the period of ownership, employment, or agency. (3) The provider has made false representations, by omission or commission, on the provider enrollment application or does not fully and accurately disclose to ODM information as required by the provider agreement, any rule contained in agency 5160 of the Administrative Code, or any provisions contained in 42 C.F.R., Part 455, Subpart B (October 1, 2014).. (4) The provider has been determined liable for negligent performance of professional services to its clientele or patients. (5) As determined by ODM, the provider has departed from or failed to conform to accepted standards of care of similar practitioners under the same or similar circumstances, whether or not actual injury to a patient is established. (6) The provider has been formally reprimanded or censured, placed on probation, suspended or placed on practice limitations for unethical conduct or improper practices by a state licensure board or by an association of its peers. (7) The provider fails to file cost reports as required. (8) The provider makes false statements, provides false information, or alters records, documents, charts, or prescriptions, or fails to cooperate or provide records or documentation upon request during an audit or review of provider activity by staff or contracting entity of ODM, any county department of job and family services, the attorney general's office, the auditor of state, the department of health and human services, or any other state or federal agency which, by law, has authorized access to records or documents. An alteration of provider records does not include records for which there is a properly documented correction. (9) The provider has not corrected deficiency(ies) after receiving a written notice of operational deficiency from ODM. (10) The provider fails to abide by, meet the requirements of, or have the capacity to comply with the terms and conditions of the provider agreement, and/or rules and regulations promulgated by ODM. (11) The provider has been suspended or terminated from participation in another government medical program other than a program that requires automatic termination. (12) The provider is found in violation of section 504 of the Rehabilitation Act of 1973, as amended (January 1, 2015), or the Civil Rights Act of 1964, as amended (January 1, 2015), in relation to the employment of individuals, the provision of services or in the purchase of goods and services. (13) The provider, by any act or omission, has negatively affected the health, safety, or welfare of the medicaid recipient or the fiscal or programmatic integrity of the medicaid program. (14) The office of the attorney general, auditor of state, or any board, bureau, commission, or department has recommended that ODM terminate the provider agreement where the reason for the request bears a reasonable relationship to the administration of the medicaid program or the integrity of state and/or federal funds. (15) As determined by ODM, the provider fails to use reasonable care or discretion in the storage, administration, dispensing, or prescribing of drugs, or fails to employ acceptable scientific methods in the selection of drugs or other modalities of treatment of disease. (16) As determined by ODM, the provider sells, gives away, personally furnishes, prescribes, or administers drugs for other than legal and legitimate therapeutic purposes. (17) The United States drug enforcement agency has suspended or revoked the provider's registration for any act or acts which would constitute a violation of paragraph (E)(5), (E)(15), or (E)(16) of this rule. (18) The provider or the provider's staff misrepresents the type and/or units of service, inflates billing codes to increase payments, or bills for, or receives payments for services not rendered, or any other practice that is a violation of any rule contained in agency 5160 of the Administrative Code. (19) As determined by ODM, the provider, or the provider's staff prescribes, authorizes, bills for, or receives payments for, services that are not medically necessary as defined in rule 5160-1-01 of the Administrative Code. (20) The provider or the provider's staff lack the ability or legal authority to provide services for which the provider has billed, because of lack of equipment or material, or a failure to comply with minimal requirements under state and federal law. (21) The provider consistently violates the prohibition against billing medicaid recipients or assigning provider claims to a factor, as found in rule 5160-1-13.1 of the Administrative Code or 42 CFR 447.10 (October 1, 2014). (22) The provider fails to notify ODM within thirty days of any changes in licensure, certification, accreditation, or registration status, ownership, closure, specialty, additions, deletions, or replacements in group memberships, and address. (23) The provider fails to repay an overpayment or recovery amount assessed as a result of a final adjudication order. (24) The provider has a previous or current exclusion, suspension, termination or involuntary withdrawal from participation in any medicaid program, or any other public or private health insurance program. (25) The provider has been convicted under federal or state law of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct. (26) The provider has not responded to two certified mail correspondences from ODM and the provider's business cannot otherwise be located. (27) The provider signed a provider agreement and failed to revalidate the provider agreement in accordance with rule 5160-1-17.4 of the Administrative Code. (28) Any reason permitted or required by federal law. (H) For any reason permitted or required by federal law, ODM may deny or exclude from participation in the medicaid program any individual, provider of services or goods, or other entity that does not possess a medicaid provider agreement. (I) ODM shall terminate or deny a provider agreement when any of the following apply: (1) Any license, permit, or certification that is required in the provider agreement or department rule has been denied, suspended, revoked, not renewed or is otherwise limited and the provider has been afforded the opportunity for a hearing in accordance with the hearing process established by the official, board, commission, department, division, bureau, or other agency of state or federal government. (2) The terms of a provider agreement require the provider to hold a license, permit, or certificate, or maintain certification, issued by an official, board, commission, department, division, bureau, or other agency of state or federal government, other than ODM, and the provider has not obtained the license, permit, certificate, or maintained the certification. (3) An official, board, commission, department, division, bureau, or other agency of this state, other than ODM, has denied, terminated, or not renewed a license, permit, certificate or certification that is required for participation, notwithstanding the fact that the provider may hold a license, permit, certificate or certification from an official, board, commission, department, division, bureau, or other agency of another state. (4) A judgment has been entered in either a criminal or civil action against a medicaid provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code, except if the provider or owner can demonstrate to ODM that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee which resulted in the conviction or entry of judgment. (5) The provider is terminated, suspended, or excluded by the medicare program and/or by the federal department of health and human services and that action is binding on the provider's participation in the medicaid program or renders federal financial participation unavailable for that provider's participation in the medicaid program. (6) The provider has been convicted of, or pled guilty to, any criminal activity materially related to either the medicare or medicaid program or has been convicted of one of the offenses that caused the provider agreement to be suspended in accordance with rule 5160-1-17.5 of the Administrative Code.. (7) The provider has failed to apply for revalidation within the time and in the manner specified for revalidation pursuant to section 5164.32 of the Revised Code. (8) The provider fails to timely submit a required background check or when the background check reveals that the provider has been convicted of, or pled guilty to a disqualifying offense unless the provider meets specific circumstances provided in agency 5160 of the Administrative Code. (9) ODM has determined that the provider facility has closed or is not providing medicaid covered services. (J) Appeal rights for the termination or denial of a provider agreement provided in this rule are found in rule 5160-1-57 of the Administrative Code. (K) In determining the length of termination, ODM shall consider the following: (1) The number and nature of program violations and other related offenses and the degree to which the provider participated in the offense; (2) The nature and extent of any adverse impact the violations have had on recipients, including but not limited to the health and safety of those recipients who are aged and/or at greater physical, mental and emotional risk; (3) The amount of any damages incurred by the medicaid program; (4) Whether there are any mitigating circumstances; (5) Any other facts bearing on the nature and seriousness of the violations or related offenses; (6) The current, pending and previous sanction record of the provider under the medicare, medicaid, or other health-related programs; and (7) Whether the provider is pending any future state or federal litigation relating to the current or any similar offense. (L) ODM reserves the right to deny twelve months retroactivity for the submission of claims to providers whose agreement is reinstated after termination for cause in accordance with this rule.
Last updated September 1, 2023 at 12:57 PM
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Rule 5160-1-17.7 | Application by a former participating medicaid provider to resume participation in the Ohio medicaid program [except for medicaid contracting managed care plans (MCPs)].
Effective:
January 13, 2017
(A) An individual or entity that at one time was a participating provider in the Ohio medicaid program and whose provider agreement was terminated either voluntarily or involuntarily in accordance with rule 5160-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program. (B) In considering an application for participation in the Ohio medicaid program by a former medicaid provider described in paragraph (A) of this rule, and except as provided by paragraphs (C) and (D) of this rule, the Ohio department of medicaid (ODM) may grant the application only if it is reasonably certain that the types of actions that formed the basis for termination or exclusion have not recurred and will not recur. In making this determination, ODM will consider, in addition to any factors set forth in state law: (1) The conduct of the former medicaid provider from the date the provider's previous provider agreement was terminated; (2) Whether all fines, and all debts due and owing, including overpayments, to any federal, state or local government that relate to any of the state health care programs, have been paid, or satisfactory arrangements have been made, that fulfill these obligations; and (3) Whether all requirements for participation are met at the time of the application filed pursuant to paragraph (A) of this rule, as evidenced by all appropriate and required documentation submitted with the application by the former medicaid provider. (C) Notwithstanding paragraph (B) of this rule, ODM shall deny the application of a former medicaid provider whose provider agreement was terminated under paragraph (I)(4) or (I)(6) of rule 5160-1-17.6 of the Administrative Code. (D) In the case of a former medicaid provider that allowed its provider agreement to lapse by failing to timely revalidate its provider agreement, and whose provider agreement has been inactive for at least sixty days, ODM may, without regard to the criteria set forth in paragraph (B) of this rule and at its discretion, grant an application that demonstrates through all appropriate and required documentation that the requirements to participate as a medicaid provider are met at the time the application is filed. (E) If ODM approves an application filed under paragraph (A) of this rule, it must give written notice to the applicant specifying the date on which participation in the Ohio medicaid program may resume. The notice shall specify whether the applicant is assigned its former provider number or a new provider number, the determination of which shall be in the sole discretion of ODM. (F) If ODM does not approve an application filed under paragraph (A) of this rule, it must give the applicant written notice of that decision. The notice will provide review rights in accordance with paragraph (D) of rule 5160-70-02 of the Administrative Code.
Last updated September 1, 2023 at 12:57 PM
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Rule 5160-1-17.8 | Provider screening and application fee.
Effective:
January 31, 2020
(A) In accordance with 42 C.F.R. 455.410
(as in effect October 1, 2019) and rule 5160-1-17 of the Administrative Code in
order to become an eligible provider, a provider must meet the screening
requirements described in this rule and in section 5164.34 of the Revised Code
and pay an applicable application fee if required in the appendix to this rule.
Provider screening and application fees are required at the time of enrollment
and revalidation as defined in rule 5160-1-17.4 of the Administrative
Code. (1) Exemptions. (a) If a provider is required to participate in the medicare
program as a condition of enrollment in medicaid or elects to participate in
the medicare program and has met the provider screening requirements and paid
an applicable application fee to the centers for medicare and medicaid services
(CMS) or its designee, the provider is exempt from the application fee
requirements set forth in this rule. (b) If a provider has met the provider screening requirements and
paid an applicable application fee to another state medicaid agency or its
designee, the provider is exempt from the application fee requirements set
forth in this rule. (c) A provider must provide documentation to support it meets the
criteria for an exemption described in paragraphs (A)(1)(a) and (A)(1)(b) of
this rule. (d) When employed by or independently contracted with an
entity certified by the Ohio department of mental health and addiction
services, the following are exempt from the provisions of paragraphs (E)(2) to
(E)(4) of this rule when providing services for the entity. (i) Certified peer
recovery supporters as defined in rule 5122-29-15.1 of the Administrative
Code; (ii) Practitioners
licensed or certified under Chapter 4757. of the Revised Code; (iii) Practitioners
licensed or certified under Chapter 4758. of the Revised Code. (2) The appendix to this
rule sets forth: (a) The screening risk level assigned to each provider type in
accordance with paragraph (B) of this rule; and (b) The provider types that must pay an application fee in
accordance with paragraph (G) of this rule. (B) The appropriate screening based on
screening risk level must be given to all service locations of an enrolled
provider. Providers must disclose all service locations at time of enrollment
and notify the department of changes or additional service locations within
thirty days of the change in order to be reimbursed for services delivered at
that location. (C) In accordance with 42 C.F.R. 455.452
(as in effect October 1, 2019), the Ohio department of medicaid (ODM) reserves
the right to conduct additional screenings and background checks as determined
necessary by ODM or its designee. (D) Screening requirements differ by risk
level. If more than one risk level could apply to a provider, the highest level
of screening is required. (1) Limited. (a) Providers are subject to verification that they meet any
applicable medicaid requirements as stated in agency 5160 of the Administrative
Code for their provider type; and (b) Providers are subject to license verifications, including
state licensure verification in states other than Ohio; and (c) Providers are subject to database checks on a pre- and
post-enrollment basis to ensure that providers continue to meet the enrollment
criteria for their provider type. (i) Database checks must
confirm the identity and exclusion status of providers and any person with a
five per cent or greater ownership or control interest; or any person who is an
agent or an individual (including a general manager, business manager,
administrator, director, or consultant) who directly or indirectly manages,
advises, or supervises any element of the practices, finances, or operations of
the provider entity. (ii) Databases to be
checked include, but are not limited to, the social security
administration's death master file, the national plan and provider
enumeration systems (NPPES), the list of excluded individuals/entities
maintained by the office of the inspector general, health and human services,
the medicare exclusion database (MED), or the system for awards management
(SAM), the list of providers terminated by another state's medicaid
program, the nurse aid registry maintained by the Ohio department of health and
the abuser registry maintained by the Ohio department of developmental
disabilities. (iii) A provider is
disqualified from receiving a medicaid provider agreement during the time the
provider is on one or more of the following registries or
databases: (a) The social security
administration's death master file; (b) The list of excluded
individuals or entities maintained by the office of the inspector general,
health and human services; (c) The medicare
exclusion database (MED; (d) The list of providers
terminated by another state's medicaid program; (e) The abuser registry
maintained by the Ohio department of developmental disabilities; (f) The system for awards
management (SAM) list of individuals or entities with an
exclusion; (g) The nurse aid
registry abuse listing maintained by the Ohio department of
health. (2) Moderate. (a) Providers are subject to the requirements in paragraph (D)(1)
of this rule; and (b) Providers are subject to on-site visits. (i) Pre- and
post-enrollment site visits by ODM or its designee will verify that information
provided to ODM or its designee is accurate and to determine compliance with
medicaid enrollment requirements. (ii) Once enrolled,
providers must allow CMS or its agents or contractors, or ODM or its agents or
contractors to conduct unannounced on-site inspections of any and all provider
locations. (3) High. (a) Providers are subject to the requirements in paragraphs
(D)(1) and (D)(2)(b) of this rule; and (b) Each person with a five per cent or greater ownership or
control interest with the provider is subject to a criminal background check
and is required to submit to a fingerprint-based background check within thirty
days of submission of the application in a form and manner determined by ODM,
or its designee. (E) The following sets forth the
exclusionary offenses and exclusion time periods from participation in the
medicaid program: (1) Tier I. Permanent
exclusion. (a) Individuals who have been convicted of or pleaded guilty to,
an offense in any of the following sections of the Revised Code are permanently
excluded from participation in the medicaid program: (i) 2903.01 (aggravated
murder); (ii) 2903.02
(murder); (iii) 2903.03 (voluntary
manslaughter); (iv) 2903.11 (felonious
assault); (v) 2903.15 (permitting
child abuse); (vi) 2903.16 (failing to
provide for a functionally-impaired person); (vii) 2903.34 (patient
abuse or neglect); (viii) 2903.341 (patient
endangerment); (ix) 2905.01
(kidnapping); (x) 2905.02
(abduction); (xi) 2905.32 (human
trafficking); (xii) 2905.33 (unlawful
conduct with respect to documents); (xiii) 2907.02
(rape); (xiv) 2907.03 (sexual
battery); (xv) 2907.04 (unlawful
sexual conduct with a minor, formerly corruption of a minor); (xvi) 2907.05 (gross
sexual imposition); (xvii) 2907.06 (sexual
imposition); (xviii) 2907.07
(importuning); (xix) 2907.08
(voyeurism); (xx) 2907.12 (felonious
sexual penetration, as that offense existed prior to September 3,
1996); (xxi) 2907.31
(disseminating matter harmful to juveniles); (xxii) 2907.32 (pandering
obscenity); (xxiii) 2907.321
(pandering obscenity involving a minor); (xxiv) 2907.322
(pandering sexually-oriented matter involving a minor); (xxv) 2907.323 (illegal
use of a minor in nudity-oriented material or performance); (xxvi) 2909.22
(soliciting or providing support for act of terrorism); (xxvii) 2909.23 (making
terroristic threats); (xxviii) 2909.24
(terrorism); (xxix) 2913.40 (medicaid
fraud); (xxx) If related to
another offense under paragraph (E)(1)(a) of this rule, 2923.01 (conspiracy),
2923.02 (attempt), or 2923.03 (complicity); or (b) A conviction related to fraud, theft, embezzlement, breach of
fiduciary responsibility, or other financial misconduct involving a federal or
state-funded program, excluding the disqualifying offenses set forth in section
2913.46 of the Revised Code (illegal use of supplemental nutrition assistance
program (SNAP) or women, infants, and children (WIC) program benefits) and
paragraph (E)(2)(a)(xiii) of this rule; or (c) A violation of an existing or former municipal ordinance or
law of this state, any other state, or the United States that is substantially
equivalent to any of the offenses or violations described in paragraph
(E)(1)(a) or (E)(1)(b) of this rule. (2) Tier II. Ten-year
exclusionary period. (a) Individuals who have been convicted of or pleaded guilty to,
an offense in any of the following sections of the Revised Code are excluded
from participation in the medicaid program for a period of ten years from the
date the individual was fully discharged from all imprisonment, probation or
parole: (i) 2903.04 (involuntary
manslaughter); (ii) 2903.041 (reckless
homicide); (iii) 2905.04 (child
stealing, as that offense existed prior to July 1, 1996); (iv) 2905.05 (child
enticement); (v) 2905.11 (extortion);
(vi) 2907.21 (compelling
prostitution); (vii) 2907.22 (promoting
prostitution); (viii) 2907.23
(enticement or solicitation to patronize a prostitute; procurement of a
prostitute for another); (ix) 2909.02 (aggravated
arson); (x) 2909.03
(arson); (xi) 2911.01 (aggravated
robbery); (xii) 2911.11 (aggravated
burglary); (xiii) 2913.46 (illegal
use of SNAP or WIC program benefits); (xiv) 2913.48
(worker's compensation fraud); (xv) 2913.49 (identity
fraud); (xvi) 2917.02 (aggravated
riot); (xvii) 2923.12 (carrying
concealed weapons); (xviii) 2923.122 (illegal
conveyance or possession of deadly weapon or dangerous ordnance in a school
safety zone, illegal possession of an object indistinguishable from a firearm
in a school safety zone); (xix) 2923.123 (illegal
conveyance, possession, or control of deadly weapon or ordnance into
courthouse); (xx) 2923.13 (having
weapons while under a disability); (xxi) 2923.161
(improperly discharging a firearm at or into a habitation or school);
(xxii) 2923.162
(discharge of firearm on or near prohibited premises); (xxiii) 2923.21
(improperly furnishing firearms to minor); (xxiv) 2923.32 (engaging
in a pattern of corrupt activity); (xxv) 2923.42
(participating in a criminal gang); (xxvi) 2925.02
(corrupting another with drugs); (xxvii) 2925.03
(trafficking in drugs); (xxviii) 2925.04 (illegal
manufacture of drugs or cultivation of marijuana); (xxix) 2925.041 (illegal
assembly or possession of chemicals for the manufacture of drugs); (xxx) 3716.11 (placing
harmful or hazardous objects in food or confection); or (xxxi) If related to an
offense under paragraph (E)(2)(a) of this rule, 2923.01 (conspiracy), 2923.02
(attempt), or 2923.03 (complicity); or (b) A violation of an existing or former municipal ordinance or
law of this state, any other state or the United States that is substantially
equivalent to any of the offenses or violations described under paragraph
(E)(2)(a) of this rule. (c) If the individual has been convicted of multiple
disqualifying offenses, including an offense listed in paragraph (E)(2)(a) or
(E)(2)(b) of this rule, and another offense or offenses listed in paragraph
(E)(2)(a), (E)(3)(a), (E)(3)(b), (E)(4)(a), or (E)(4)(b) of this rule, the
individual is subject to a fifteen-year exclusionary period beginning on the
date the individual was fully discharged from all imprisonment, probation or
parole for the most recent offense. (3) Tier III. Seven-year
exclusionary period. (a) Individuals who have been convicted of or pleaded guilty to,
an offense in any of the following sections of the Revised Code are excluded
from participation in the medicaid program for a period of seven years from the
date the individual was fully discharged from all imprisonment, probation or
parole: (i) 959.13 (cruelty to
animals); (ii) 959.131
(prohibitions concerning companion animals); (iii) 2903.12 (aggravated
assault); (iv) 2903.21 (aggravated
menacing); (v) 2903.211 (menacing by
stalking); (vi) 2905.12 (coercion);
(vii) 2909.04 (disrupting
public services); (viii) 2911.02 (robbery);
(ix) 2911.12 (burglary);
(x) 2913.47 (insurance
fraud); (xi) 2917.01 (inciting to
violence); (xii) 2917.03 (riot);
(xiii) 2917.31 (inducing
panic); (xiv) 2919.22
(endangering children): (xv) 2919.25 (domestic
violence); (xvi) 2921.03
(intimidation); (xvii) 2921.11 (perjury);
(xviii) 2921.13
(falsification, falsification in a theft offense, falsification to purchase a
firearm, or falsification to obtain a concealed handgun license); (xix) 2921.34 (escape);
(xx) 2921.35 (aiding
escape or resistance to lawful authority); (xxi) 2921.36 (illegal
conveyance of weapons, drugs or other prohibited items onto the grounds of a
detention facility or institution); (xxii) 2925.05 (funding
drug trafficking); (xxiii) 2925.06 (illegal
administration or distribution of anabolic steroids); (xxiv) 2925.24 (tampering
with drugs); (xxv) 2927.12 (ethnic
intimidation); or (xxvi) If related to an
offense under paragraph (E)(3)(a) of this rule, 2923.01 (conspiracy), 2923.02
(attempt), or 2923.03 (complicity); or (b) A violation of an existing or former municipal ordinance or
law of this state, any other state or the United States that is substantially
equivalent to any of the offenses or violations described under paragraph
(E)(3)(a) of this rule. (c) If an individual has been convicted of multiple disqualifying
offenses, including an offense listed in paragraph (E)(3)(a) or (E)(3)(b) of
this rule, and another offense or offenses listed in paragraph (E)(3)(a),
(E)(3)(b), (E)(4)(a), or (E)(4)(b) of this rule, the individual is subject to a
ten-year exclusionary period beginning on the date the individual was fully
discharged from all imprisonment, probation or parole for the most recent
offense. (4) Tier IV. Five-year
exclusionary period. (a) Individuals who have been convicted of or pleaded guilty to,
an offense in any of the following sections of the Revised Code are excluded
from participation in the medicaid program for a period of five years from the
date the individual was fully discharged from all imprisonment, probation or
parole: (i) 2903.13 (assault);
(ii) 2903.22 (menacing);
(iii) 2907.09 (public
indecency); (iv) 2907.24
(soliciting); (v) 2907.25
(prostitution); (vi) 2907.33 (deception
to obtain matter harmful to juveniles); (vii) 2911.13 (breaking
and entering); (viii) 2913.02
(theft); (ix) 2913.03
(unauthorized use of a vehicle); (x) 2913.04 (unauthorized
use of computer, cable or telecommunication property); (xi) 2913.05
(telecommunication fraud); (xii) 2913.11 (passing
bad checks); (xiii) 2913.21 (misuse of
credit cards); (xiv) 2913.31 (forgery -
forging identification cards or selling or distributing forged identification
cards); (xv) 2913.32 (criminal
simulation); (xvi) 2913.41 (defrauding
a rental agency or hostelry); (xvii) 2913.42 (tampering
with records); (xviii) 2913.43 (securing
writings by deception); (xix) 2913.44
(personating an officer); (xx) 2913.441 (unlawful
display of law enforcement emblem); (xxi) 2913.45 (defrauding
creditors); (xxii) 2913.51 (receiving
stolen property); (xxiii) 2919.12 (unlawful
abortion); (xxiv) 2919.121 (unlawful
abortion upon minor); (xxv) 2919.123 (unlawful
distribution of an abortion-inducing drug); (xxvi) 2919.23
(interference with custody); (xxvii) 2919.24
(contributing to the unruliness or delinquency of a child); (xxviii) 2921.12
(tampering with evidence); (xxix) 2921.21
(compounding a crime); (xxx) 2921.24 (disclosure
of confidential information); (xxxi) 2921.32
(obstructing justice); (xxxii) 2921.321
(assaulting or harassing a police dog, horse, or service animal); (xxxiii) 2921.51
(impersonation of peace officer); (xxxiv) 2925.09 (illegal
administration, dispensing, distribution, manufacture, possession, selling, or
using of any dangerous veterinary drug); (xxxv) 2925.11 (drug
possession, other than a minor drug possession offense); (xxxvi) 2925.13
(permitting drug abuse); (xxxvii) 2925.22
(deception to obtain a dangerous drug); (xxxviii) 2925.23
(illegal processing of drug documents); (xxxix) 2925.36 (illegal
dispensing of drug samples); (xl) 2925.55 (unlawful
purchase of pseudoephedrine product); (xli) 2925.56 (unlawful
sale of pseudoephedrine product); (xlii) If related to an
offense under paragraph (E)(4)(a) of this rule, 2923.01 (conspiracy), 2923.02
(attempt), or 2923.03 (complicity); or (b) A violation of an existing or former municipal ordinance or
law of this state, any other state or the United States that is substantially
equivalent to any of the offenses or violations described under paragraph
(E)(4)(a) of this rule. (c) If an individual has been convicted of multiple disqualifying
offenses listed in paragraph (E)(4)(a) or (E)(4)(b) of this rule, the
individual is subject to a seven-year exclusionary period beginning on the date
the individual was fully discharged from all imprisonment, probation or parole
for the most recent offense. (5) Tier V. No
exclusionary period. (a) Individuals who have been convicted of or pleaded guilty to,
an offense in any of the following sections of the Revised Code are not subject
to an exclusionary period and may participate in the medicaid
program: (i) 2919.21
(non-support/contributing to non-support of dependents); (ii) 2925.11 (drug
possession that is a minor drug possession offense); or (iii) 2925.14 (drug
paraphernalia); or (iv) 2925.141 (illegal
use or possession of marijuana drug paraphernalia); or (b) A violation of an existing or former municipal ordinance or
law of this state, any other state or the United States that is substantially
equivalent to any of the offenses or violations described under paragraph
(E)(5)(a) of this rule. (F) Pardons and certificates. A
conviction of, or a plea of guilty to, an exclusionary offense as set forth in
paragraph (E) of this rule shall not prevent a provider from enrollment if any
of the following circumstances apply: (1) The provider has been
granted an unconditional pardon for the offense pursuant to Chapter 2967. of
the Revised Code; (2) The provider has been
granted an unconditional pardon for the offense pursuant to an existing or
former law of the state of Ohio, any other state, or the United States, if the
law is substantially equivalent to Chapter 2967. of the Revised
Code; (3) The provider has been
granted a conditional pardon for the offense pursuant to Chapter 2967. of the
Revised Code, and the condition(s) under which the pardon was granted have been
satisfied; (4) The provider's
conviction or guilty plea has been set aside pursuant to law; or (5) A certificate of
qualification for employment has been issued by an Ohio court of common pleas
pursuant to section 2953.25 of the Revised Code, or an equivalent certification
has been issued by an out of state or federal jurisdiction. (6) Provider applications
that include a certificate of qualification for employment or an equivalent
certification associated with a permanent exclusion offense as stated in
paragraph (E)(1) of this rule, will be reviewed by ODM and a decision will be
rendered by ODM on a case-by-case basis as to whether a provider agreement will
be approved or not in accordance with section 2953.25 of the Revised
Code. (G) Application fee. (1) Provider types
identified as subject to an application fee in the appendix to this rule must
submit the fee in a form and manner determined by ODM at the time of
application for enrollment or revalidation as a medicaid provider. If proof of
fee payment is not submitted with the provider's application, the
application will be rejected as incomplete. (2) Individual physicians
and non-physician practitioners are exempt from paying an application fee in
accordance with 42 C.F.R. 455.460, (October 1, 2019). (3) ODM may waive an
application fee if: (a) ODM determines that imposing the fee would have an adverse
impact on beneficiary access to services; and (b) ODM has requested and CMS has approved a waiver of the
fee. (4) If ODM receives
approval from CMS to waive a medicaid application fee, providers are still
subject to the screening requirements set forth in this rule. (5) The application fee
is equal to the amount established by CMS and includes an annual adjustment for
inflation in accordance with 42 U.S.C. 1395cc(j)(2)(C)(i) (January 1,
2020). (6) The application fee
will not be refunded if: (a) Enrollment is denied as a result of failure to meet the
provider screening requirements described in this rule; (b) If enrollment is denied based on the results of the provider
screening.; or (c) If ODM or its designee identifies other circumstances under
which refunding the application fee is not warranted. (H) If enrollment is denied as a result
of failure to meet the provider screening requirements or failure to pay any
associated application fee, the provider may request a hearing pursuant to
Chapter 119. of the Revised Code.
View Appendix
Last updated June 23, 2022 at 3:41 PM
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Rule 5160-1-17.9 | Ordering or referring providers.
Effective:
January 1, 2014
(A) Definitions for purposes of this rule only: (1) A "participating provider" is an active provider who bills the medicaid program for rendered services, or who is an active provider who orders, prescribes, refers, or certifies but does not bill the medicaid program. (2) An "ordering or referring only provider" is a provider who orders, prescribes, refers, or certifies an item or service reported on a claim, and is not a billing provider in the medicaid program. For example: a provider orders items or services for the medicaid consumer, such as prescription drugs, durable medical equipment, prosthetics, orthotics, and supplies, clinical laboratory services, or imaging services, and may certify home health services for a medicaid consumer. (3) "Physician" or "supervising physician" means an individual authorized to practice medicine in Ohio or another state. (4) "Other professional" means those providers, other than physicians, who order, prescribe, refer, or certify an item or service reported on a claim. Examples include but are not limited to: physician assistant, clinical nurse specialist, nurse practitioner, clinical psychologist, certified nurse midwife, clinical social worker, and interns, residents, and fellows. (B) A physician or other professional who is an ordering or referring only provider of medicaid services must be enrolled as a participating provider with the medicaid program. (C) An ordering or referring only provider shall be considered limited risk for purposes of screening, as defined in rule 5101:3-1-17.8 of the Administrative Code. (D) Ordering and referring only providers who are enrolled with the office shall revalidate in accordance with rule 5101:3-1-17.4 of the Administrative Code. (E) Claims for services that require an order, prescription, referral, or certification will be denied if they do not include the following: (1) A valid national provider identifier (NPI) and the legal name of the ordering, prescribing, referring, or certifying provider; or, (2) If the ordering, prescribing, referring, or certifying provider is not a provider type eligible to participate in Ohio medicaid, a valid NPI and the legal name of the physician or other professional supervising the ordering or referring provider. (F) This rule does not apply to services delivered through medicaid managed care plans.
Last updated September 1, 2023 at 12:57 PM
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Rule 5160-1-17.12 | Qualified entity requirements and responsibilities for determining presumptive eligibility.
Effective:
November 9, 2019
The Ohio department of medicaid (ODM) authorizes
qualified entities (QEs) to determine presumptive eligibility (PE) based on
self-attested information to grant immediate medicaid coverage to certain
individuals seeking medicaid covered services. This rule sets forth eligibility
requirements and responsibilities to maintain designation as a QE. (A) For the purposes of this rule,
"qualified entity" has the same meaning as defined in rule
5160:1-1-01 of the Administrative Code. (B) To become a QE, the eligible entity
must: (1) Have an active
provider agreement in accordance with rule 5160-1-17.2 of the Administrative
Code; (2) Read the presumptive
eligibility training guide found on the ODM website, www.medicaid.ohio.gov;
and (3) Attest that it will meet the terms
and conditions as a QE by reading, signing, and sending ODM form 10252
"acknowledgment of terms and conditions governing the presumptive
eligibility determinations authority granted by the Ohio department of medicaid
to a qualified entity" (rev. 8/2019), found on the ODM website,
www.medicaid.ohio.gov. (C) Once designated as a QE, the QE must: (1) Remain in good
standing as an Ohio medicaid provider; (2) Follow rule
5160:1-2-13 of the Administrative Code and all other applicable federal and
state laws when determining medicaid PE; (3) Verify the individual
is not already enrolled in another category of medicaid; (4) Without compensation,
agree to perform all of the administrative functions associated with PE
including, but not limited to: (a) Provide to ODM a list of names and titles of all
employees given responsibility to determine PE and request appropriate access
to the PE portal; (b) Ensure that employees given responsibility to determine
PE have read the presumptive eligibility training guide, understand the
criteria for all medicaid eligibility categories and have been trained on how
to use the presumptive eligibility portal; (c) Ensure those who have responsibility to submit claims
to the medicaid program for reimbursement of medicaid services are not
individuals responsible for determining presumptive eligibility;
and (d) Agree to retain all records related to presumptive
eligibility determinations in accordance with rule 5160-1-27 of the
Administrative Code and provide such records to ODM, its designee, or to any
authorized state or federal agency upon request. (5) Agree that it may be
held responsible for the willful conduct of its employees who violate federal
or state law. Any employee who knowingly files a claim containing false,
incomplete, or misleading essential information to create eligibility for
medicaid or receive payment from medicaid may be punishable under federal or
state law; (6) If the QE is a hospital, agree to
provide thirty-six hours' worth of medically necessary medications to any
person enrolled presumptively by the QE at time of determination; (7) If the QE is a
federally qualified health center (FQHC) and is able to do so, provide
thirty-six hours' worth of medically necessary medications to any person
enrolled presumptively by the QE at the time of determination if such needs are
determined during a medical visit; (8) Ensure that for all
persons enrolled presumptively by the QE, at least eighty-five per cent have a
completed application for full medicaid benefits submitted no later than the
last day of the month following the month in which the QE makes the PE
determination; and (9) Ensure that for all
persons who had an application submitted for full medicaid benefits, at least
eighty-five per cent result in an awarding of medicaid
eligibility. (D) ODM may terminate authority granted under this rule
with or without written notice, for any reason supported by evidence of acts or
omissions adversely affecting the medicaid program, including, but not limited
to the following circumstances: (1) Revocation or
cancellation of the QE's Ohio medicaid provider agreement; (2) Requirements set
forth in this rule are not met; (3) Unauthorized use of MITS by the
QE; (4) Programmatic or systematic changes
related to the medicaid eligibility or enrollment system; or (5) The QE is unable to
perform its functions. (E) A QE may utilize reconsideration rights as stated in
rule 5160-70-02 of the Administrative Code to challenge a decision of ODM to
deny or terminate QE designation.
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Rule 5160-1-18 | Telehealth.
(A) For the purposes of this rule, the
following definitions apply: (1) "Patient
site" is the physical location of the patient at the time a health care
service is provided through the use of telehealth. (2) "Practitioner
site" is the physical location of the treating practitioner at the time a
health care service is provided through the use of telehealth. (3) "Telehealth" is the direct delivery of health
care services to a patient related to diagnosis, treatment, and management of a
condition. (a) Telehealth is the interaction with a patient via
synchronous, interactive, real-time electronic communication comprising both
audio and video elements; or (b) The following activities that are asynchronous or do
not have both audio and video elements: (i) Telephone
calls; (ii) Remote patient
monitoring; and (iii) Communication with
a patient through secure electronic mail or a secure patient
portal. (c) For services rendered by behavioral health providers as
defined in rule 5160-27-01 of the Administrative Code, telehealth is defined in
rule 5122-29-31 of the Administrative Code. (d) Conversations or electronic communication between
practitioners regarding a patient without the patient present is not considered
telehealth unless the service would allow billing for practitioner to
practitioner communication in a non-telehealth setting. (B) Eligible providers. (1) The following
practitioners are eligible to render services through the use of
telehealth: (a) Physicians as defined in Chapter 4731. of the Revised
Code. (b) Psychologists as defined in Chapter 4732. of the
Revised Code. (c) Physician assistants as defined in Chapter 4730. of the
Revised Code. (d) Clinical nurse specialists, certified nurse-midwives,
or certified nurse practitioners as defined in Chapter 4723. of the Revised
Code. (e) Licensed independent social workers, licensed
independent marriage and family therapists, or licensed professional clinical
counselors as defined in Chapter 4757. of the Revised Code. (f) Licensed independent chemical dependency counselors as
defined in Chapter 4758. of the Revised Code. (g) Supervised practitioners, trainees, residents, and
interns as defined in rules 5160-4-02 and 5160-8-05 of the Administrative
Code. (h) Audiologists, speech-language pathologists,
speech-language pathology aides, audiology aides, and individuals holding a
conditional license as defined in Chapter 4753. of the Revised
Code. (i) Occupational and physical therapists and occupational
and physical therapist assistants as defined in Chapter 4755. of the Revised
Code. (j) Home health and hospice aides. (k) Private duty registered nurses or licensed practical
nurses in a home health or hospice setting. (l) Dentists as defined in Chapter 4715. of the Revised
Code. (m) Medicaid school program (MSP) practitioners as
described in Chapter 5160-35 of the Administrative Code. (n) Dietitians as defined in Chapter 4759. of the Revised
Code. (o) Behavioral health practitioners as defined in rule
5160-27-01 of the Administrative Code. (p) Optometrists as defined in Chapter 4725. of the Revised
Code. (q) Pharmacists as defined in Chapter 4729. of the Revised
Code. (r) Other practitioners if specifically authorized in rule
promulgated under agency 5160 of the Administrative Code. (2) The following
provider types are eligible to bill for services rendered through the use of
telehealth. (a) Any practitioner identified in paragraph (B)(1) of this
rule, except for the following dependent practitioners: (i) Supervised
practitioners, trainees, residents, and interns as defined in rules 5160-4-02
and 5160-8-05 of the Administrative Code, except as provided in rule
5160-4-02.3 of the Administrative Code; (ii) Occupational
therapist assistants as defined in section 4755.04 of the Revised
Code; (iii) Physical therapist
assistants as defined in section 4755.40 of the Revised Code; (iv) Speech-language
pathology aides, audiology aides, and individuals holding a conditional license
as defined in Chapter 4753. of the Revised Code. (b) A professional medical group. (c) A professional dental group. (d) A federally qualified health center (FQHC) or rural
health clinic (RHC) as defined in Chapter 5160-28 of the Administrative
Code. (e) Ambulatory health care clinics (AHCC) as defined in
Chapter 5160-13 of the Administrative Code. (f) Outpatient hospitals on behalf of licensed
psychologists and independent practitioners not eligible to separately bill
when practicing in an outpatient hospital setting. (g) Medicaid school program (MSP) providers as defined in
Chapter 5160-35 of the Administrative Code. (h) Private duty nurses. (i) Home health and hospice agencies. (j) Behavioral health providers as defined in paragraphs
(A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code. (k) Hospitals operating an outpatient hospital behavioral
health program in accordance with rule 5160-2-76 of the Administrative
Code. (C) Provider responsibilities when
providing services through telehealth. (1) It is the
responsibility of the practitioner to deliver telehealth services in accordance
with all state and federal laws including the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and any HIPAA related directives from the
office for civil rights (OCR) at the department of health and human services
(HHS) issued during the COVID-19 national public health emergency and 42 C.F.R.
part 2 (January 1, 2020). (2) It is the
responsibility of the practitioner to deliver telehealth services in accordance
with rules set forth by their respective licensing board and accepted standards
of clinical practice. (3) The practitioner site is responsible
for maintaining documentation in accordance with paragraph (C)(1) of this rule
for the health care service delivered through the use of telehealth and to
document the specific telehealth modality used. (4) For practitioners who render services
to an individual through telehealth for a period longer than twelve consecutive
months, the telehealth practice or practitioner is expected to conduct at least
one in-person annual visit or refer the individual to a practitioner or their
usual source of clinical care that is not an emergency department for an
in-person annual visit. (D) Payment may be made only for the
following medically necessary health care services identified in appendix A to
this rule when delivered through the use of telehealth from the practitioner
site: (1) When provided by a
patient centered medical home as defined in rule 5160-19-01 of the
Administrative Code or behavioral health provider as defined in rule 5160-27-01
of the Administrative Code, evaluation and management of a new patient
described as "office or other outpatient visit" with medical decision
making not to exceed moderate complexity. (2) Evaluation and
management of an established patient described as "office or other
outpatient visit" with medical decision making not to exceed moderate
complexity. (3) Inpatient or office
consultation for a new or established patient when providing the same quality
and timeliness of care to the patient other than by telehealth is not possible,
as documented in the medical record. (4) Mental health or
substance use disorder services described as "psychiatric diagnostic
evaluation" or "psychotherapy." (5) Remote evaluation of
recorded video or images submitted by an established patient. (6) Virtual check-in by a
physician or other qualified health care professional who can report evaluation
and management services, provided to an established patient. (7) Online digital
evaluation and management service for an established patient. (8) Remote patient
monitoring. (9) Audiology,
speech-language pathology, physical therapy, and occupational therapy services,
including services provided in the home health setting. (10) Medical nutrition
services. (11) Lactation counseling
services. (12) Psychological and
neuropsychological testing. (13) Smoking and tobacco
use cessation counseling. (14) Developmental test
administration. (15) Limited or periodic
oral evaluation. (16) Hospice
services. (17) Private duty nursing
services. (18) State plan home
health services. (19) Dialysis related
services. (20) Services under the
specialized recovery services (SRS) program as defined in rule 5160-43-01 of
the Administrative Code. (21) Notwithstanding
paragraph (D)(2) of this rule, behavioral health services covered under Chapter
5160-27 of the Administrative Code. (22) Optometry
services. (23) Pregnancy education
services. (24) Diabetic
self-management training (DSMT) services. (25) Other services if
specifically authorized in rule promulgated under agency 5160 of the
Administrative Code. (E) Submission and payment of telehealth
claims. (1) The practitioner site
may submit either a professional or institutional claim for health care
services delivered through the use of telehealth. For any professional claim
submitted for health care services utilizing telehealth to be paid, it is the
responsibility of the provider to follow ODM billing guidelines found on the
ODM website: www.medicaid.ohio.gov. (2) An institutional
(facility) claim may be submitted by an outpatient hospital for telehealth
services provided by licensed psychologists and independent practitioners not
eligible to separately bill when practicing in an outpatient hospital setting.
Other telehealth services provided in a hospital setting may be billed in
accordance with rule 5160-2-02 of the Administrative Code. (3) Medicaid-covered services may be
provided through telehealth, as appropriate, if otherwise payable under the
medicaid school program as defined in Chapter 5160-35 of the Administrative
Code. (4) Except for services billed by
behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule
5160-27-01 of the Administrative Code and FQHC and RHC services defined in
rules 5160-28-03.1 and 5160-28-03.3 of the Administrative Code, the payment
amount for a health care service delivered through the use of telehealth is the
lesser of the submitted charge or the maximum amount shown in appendix DD to
rule 5160-1-60 of the Administrative Code for the date of service. (5) For a covered telehealth service that
is also an FQHC or RHC service, the face-to-face requirement is waived and
payment is made in accordance with Chapter 5160-28 of the Administrative
Code. (6) Individuals who meet the definition
of inmate in a penal facility or a public institution as defined in rule
5160:1-1-03 of the Administrative Code are not eligible for telehealth services
under this rule. (7) For telehealth services billed by
behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule
5160-27-01 of the Administrative Code, payment is made in accordance with
Chapter 5160-27 of the Administrative Code. (8) Unless stated otherwise in the
billing guidelines, professional claims submitted for health care services
provided through the use of telehealth have to include: (a) A "GT" modifier; (b) A place of service code that reflects the physical
location of the treating practitioner at the time a health care service is
provided through the use of telehealth. (c) A modifier as identified in appendix B to this rule if
the physical location of the patient is one of the following
locations: (i) The patient's
home (including homeless shelter, assisted living facility, group home, and
temporary lodging); (ii) School; (iii) Inpatient
hospital; (iv) Outpatient
hospital; (v) Nursing
facility; (vi) Intermediate care
facility for individuals with an intellectual disability.
Last updated July 15, 2022 at 9:52 AM
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Rule 5160-1-19 | Submission of medicaid claims.
Effective:
February 1, 2023
(A) Unless otherwise directed by the Ohio
department of medicaid (ODM), paper claims will not be accepted. Except as
otherwise provided in section 5164.46 of the Revised Code or a state
agency's interagency agreement, claims are to be submitted directly to ODM
through one of the following formats: (1) Electronic data
interchange (EDI), in accordance with rule 5160-1-20 of the Administrative
Code. (2) The ODM provider web
portal; or (3) Pharmacy
point-of-sale. (B) Claims should be submitted pursuant
to the national correct coding initiative and according to the coding standards
set forth in the following guides: (1) The healthcare common
procedure coding system; (2) The current
procedural terminology codebook; (3) The current dental
terminology codebook; or (4) The international
classification of diseases handbooks. (C) Claims for items and services that necessitate a
rendering or supervising provider, order, prescription, referral, or
certification will be denied if: (1) They do not include
the national provider identifier (NPI) and the legal name of the rendering,
supervising, ordering, prescribing, referring, or certifying provider;
and (2) The provider does not
have an active medicaid provider agreement. (D) Timely filing: (1) Claims are timely if
received by ODM within: (a) Three hundred sixty-five days of the actual date the
service was provided. (b) Three hundred sixty-five days from the date of
discharge for inpatient hospital claims. (c) Three hundred sixty-five days from the date of service
or inpatient hospital discharge, as applicable, for denied claims that are
re-submitted for payment. (2) Provider-reported underpaid claims
should be adjusted within three hundred sixty-five days from the date of
service or inpatient hospital discharge, as applicable. (E) Exceptions to timely filing
are: (1) Claims submitted via
the "automatic medicare crossover process" (the automatic process of
medicare electronically submitting a claim to ODM following medicare
adjudication and payment of a claim for a dually eligible individual) are not
subject to timely filing provisions in this rule. (2) Claims for wraparound
payment for a federally qualified health center (FQHC) or rural health center
(RHC) are timely if submitted to ODM within one hundred eighty days from the
date the claim was paid. (3) Claims submitted to ODM after three
hundred sixty-five days of the date of service or discharge, as applicable, due
to a delay in eligibility determination or a state hearing decision regarding
eligibility are timely if received by ODM within one hundred eighty days of the
notice of eligibility determination or state hearing decision to be considered
for payment. (4) Claims submitted to
ODM after three hundred sixty-five days of the date of service or discharge, as
applicable, due to a reversal of payment by a third party payer are timely if
the adjusted claim is received within one hundred eighty days of the recovery
of funds to be considered for payment. (5) Any claim delayed in submission to,
or adjudicated by ODM, due to an action or decision by ODM, at the discretion
of ODM, may be reimbursed after three hundred sixty-five days from the date of
service or inpatient hospital discharge. (F) In instances of conflict of claim payment between two
providers, ODM may adjust or void a claim as appropriate after notification to
the providers. (G) Overpaid claims. (1) When a provider
identifies an overpayment, the provider will submit an electronic adjustment to
ODM within sixty days of discovery to return the overpayment. (2) When ODM identifies
an overpayment, ODM will notify the provider of the overpayment. The provider
has sixty days to correct the overpayment. If the provider fails to correct an
identified overpayment within sixty days, ODM will make the adjustment from
subsequent payments to the provider or void the claim as appropriate. If an ODM
adjustment is not possible, ODM will issue an invoice to the provider for the
overpaid amount. The provider has sixty days from the date of the invoice to
seek reconsideration or remit payment to ODM. If the provider fails to remit
the full payment due the unpaid balance will be certified to the Ohio attorney
general for collection. (3) ODM will pursue collections by
invoice for overpayments that result in a credit balance owed to ODM that
remain outstanding for more than forty-five days. (4) Appeal rights may be exercised in
accordance with Chapter 5160-70 of the Administrative Code. All ODM recoverable
amounts are subject to the application of interest in accordance with rule
5160-1-25 of the Administrative Code. (H) ODM forms that are necessary for a claim to be
processed should only be submitted through the ODM provider web portal unless
otherwise permitted by ODM. (I) Claim adjustments should only be submitted through EDI
or the ODM provider web portal. (J) ODM will only process refund checks
from providers for an invoice for a claim overpayment, a letter of collection
of an outstanding overpayment, audit, or review, or other circumstance deemed
appropriate by ODM.
Last updated February 1, 2023 at 8:53 AM
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Rule 5160-1-20 | Electronic data interchange (EDI) trading partner enrollment and testing.
Effective:
December 1, 2022
(A) For purposes of this rule, the
following definitions apply: (1) "Covered
entity" has the same meaning as in 45 C.F.R. 160.103 (as in effect on
October 1, 2021). (2) "Electronic data
interchange (EDI) transactions" are transactions developed by standards
development organizations recognized by the federal centers for medicare and
medicaid services (CMS) and adopted by the Ohio department of medicaid (ODM).
The different EDI transactions are as follows: (a) "American national standards institute (ANSI) X12
270 eligibility, coverage, or benefit inquiry" is a transaction used to
inquire about the eligibility, benefits or coverage under a subscriber's
health care policy. (b) "ANSI X12 271 eligibility, coverage, or benefit
information response" is a transaction used to communicate information
about, or changes to, eligibility, benefits, or coverage. (c) "ANSI X12 274 provider information" is a
transaction used to exchange demographic and educational or professional
qualifications about health care providers between providers, provider
networks, or any other entity that maintains or verifies health care provider
information. (d) "ANSI X12 275 patient information" is a
transaction used to communicate individual patient information requests and
patient information (either solicited or unsolicited) between separate care
entities in a variety of settings. (e) "ANSI X12 276 health care claim status
request" is a transaction used to request the status of a health care
claim. (f) "ANSI X12 277 health care claim status
notification" is a transaction used to respond to a request regarding the
status of a health care claim. (g) "ANSI X12 278 health care services review
information request and response" is a transaction used to transmit health
care service information for the purpose of referral, certification,
authorization, notification, or reporting the outcome of a health care services
review. (h) "ANSI X12 820 premium payment" is a
transaction used to make a payment or send a remittance advice. (i) "ANSI X12 834 monthly member roster or enrollment
and disenrollment in a health plan" is a transaction used to establish
communication between the sponsor of the insurance product and the
payer. (j) "ANSI X12 835 health care claims payment and
remittance advice" or "835 remittance advice" is a transaction
used to make a payment or send an explanation of benefits remittance
advice. (k) "ANSI X12 837 health care claim" is a
transaction used to submit health care claim billing or encounter information,
or both, from providers (institutional, professional, or dental) of health care
services to payers, either directly or via clearinghouses. (3) "Trading
partner" is a covered entity as defined in 42 C.F.R. 160.103 (as in effect
October 1, 2021) that submits, receives, routes, or translates EDI transactions
directly related to the administration or provision of medical assistance
provided under a public assistance program. (B) Responsibilities of trading
partners. (1) To enroll as an EDI trading partner
with ODM under the Health Insurance Portability and Accountability Act (HIPAA)
of 1996 and be issued a trading partner number, a covered entity completes and
submits to ODM the following: (a) The electronic trading partner form available at
https://medicaid.ohio.gov. (b) The ODM form 06306 "Designation of an 835 or
834-820 Trading Partner" (rev. 4/2017). This form is submitted only if the
trading partner will be receiving the 835 remittance advice on behalf of its
clients. (c) A trading partner agreement. Trading partner agreements
are to be signed by an authorized representative of the trading
partner. (2) Once the medicaid trading partner
number is assigned, the trading partner submits EDI transactions for the
testing process in accordance with paragraph (C) of this rule. (C) Testing criteria for trading
partners. (1) All trading partners
are to abide by all ODM testing criteria as outlined in paragraph (C)(2) of
this rule and in the trading partner enrollment and testing information guide
available at www.medicaid.ohio.gov. (2) The testing criteria
to be met is as follows: (a) Trading partners are to submit three files per the
following transaction types and pass testing: 837 (professional, institutional,
dental), 270 (eligibility), and 276 (claim status inquiry). (b) Trading partners are to test the transaction types they
will be submitting in production. (c) For batch transactions, each file is to contain a
minimum of fifty claims, claim status inquiries, or eligibility
inquiries. (d) For real-time transactions of types 270 and 276,
provide at least three real-time submissions for each transaction
type. (e) All EDI files are to completely pass X12 integrity
testing, HIPAA syntax, and HIPAA situation testing. Trading partners are
expected to modify their EDI files in accordance with new federally mandated
HIPAA standards. (f) During testing, trading partners may submit one claim
file per day, per 837 transaction (one professional, one institutional, and one
dental), one eligibility inquiry, and one claim status inquiry per day.
Multiple tests per day are accepted for real-time transactions of types 270 and
276. (D) Passing criteria for transactions
tested. (1) Files containing the
270 eligibility transaction are considered passing when a successful 271
response is received without error codes 73 (invalid or missing subscriber) or
75 (subscriber not found). (2) Files containing the 275 patient
information transaction are considered passing when a successful 999 response
is received. (3) Files containing the 276 claim status
transaction are considered passing when a valid 277 response is received with
the requested claim information. (4) Files containing the 278 service
request transaction are considered passing when a valid 278 response is
received without error codes 04 (authorized quantity exceeded) or 79 (invalid
participant identification). (5) Files containing the 837 health care
claim transaction are considered passing when at least ninety per cent of the
claims are in paid status after test adjudication. (E) Trading partners that are not actively submitting and
receiving 837 health care claim transaction sets but who are actively
submitting and receiving 270/271 and 276/277 transaction sets are to provide,
in a manner specified by ODM, a report of all providers by national provider
identifier (NPI) that the trading partner represents. The first report is due
at the time of initiating a trading partner agreement with ODM. Subsequent
reports are due quarterly based on the calendar year, no later than January
first, April first, July first and October first. If the necessary reports are
not submitted, the trading partner agreement will be denied or terminated, as
applicable. (F) If a trading partner does not submit
or receive EDI transactions for a period of two years or longer, ODM may
terminate the trading partner agreement without notice. (G) Trading partners are responsible for any breach of
information and will be held fully liable for any and all costs related to such
a breach.
Last updated December 1, 2022 at 10:40 AM
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Rule 5160-1-25 | Interest on overpayments made to medicaid providers.
Effective:
September 4, 2014
(A) Except for medicaid contracting managed care plans (MCPs), and nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICF/IID) rate recalculations performed in accordance with sections 5165.41 and 5124.41 of the Revised Code, any provider of services or goods contracting with the Ohio department of medicaid (ODM) pursuant to Title XIX of the Social Security Act who, without intent, obtains payment from the medicaid program in excess of the amount to which the provider is entitled becomes liable for payment of interest charged in accordance with this rule on the amount of the overpayment. The interest rate charged is the average bank prime rate in effect on the first day of the calendar quarter during which the provider receives notice of the excess payment, as determined in accordance with section 5164.60 of the Revised Code. Interest payments shall be calculated on the basis of simple interest. (B) Interest payments shall be charged on a daily basis for the period from the date the payment was made to the date upon which repayment is received by the state. (C) The "date payment was made" shall mean the following: (1) For any reasonable cost basis, prospective payment basis, or other cost-related rate final settlement issued by ODM, the "date payment was made" shall be ten days from the date the final settlement is received by the provider as shown by the U.S. postal service return receipt slip, with a notice of rights to appeal pursuant to Chapter 119. of the Revised Code. (2) For audits conducted in accordance with rule 5160-1-27 of the Administrative Code, the "date payment was made" shall be the latest date a warrant or electronic funds transfer (EFT) was issued to pay an item included in the random sample. (3) For post-payment reviews conducted in accordance with rule 5160-1-27 of the Administrative Code, the "date payment was made" shall be the latest date a warrant or EFT was issued in payment of a claim that is included in the review. (D) The "date upon which repayment is received by the state" shall mean the following: (1) In the case of repayment by check or EFT, the "date upon which repayment is received by the state" shall be the date the repayment is date-stamped by ODM, the date the repayment is deposited as certified mail with the U.S. postal service, or the date the EFT is deposited in the state's account. (2) In the case of repayment by one or more offsets implemented by the ODM claims adjustment unit against future claims payments owed to the provider, the "date upon which repayment is received by the state" shall be the date on which the total amount of the overpayment is fully recovered. (E) ODM may waive interest when voluntary repayment is made by a provider before any notification by ODM that an overpayment has occurred.
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Rule 5160-1-27 | Review of provider records.
Effective:
September 3, 2015
(A) As specified in Chapter 5160-1 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, frequency, extent, duration, and delivery setting of services provided to medicaid recipients, and to document significant business transactions. Medicaid providers are required to provide such records and documentation to the Ohio department of medicaid (ODM) or its designee, the secretary of the federal department of health and human services, or the state medicaid fraud control unit upon request. (B) For purposes of this rule, the following definitions apply: (1) "Audit" means a postpayment examination, made in consideration of generally accepted auditing standards, of a medicaid provider's records and documentation to determine program compliance, the extent and validity of services paid for under the medicaid program and to identify any inappropriate payments. The department shall have the authority to use statistical methods to conduct audits and to determine the amount of overpayment. An audit may result in a final adjudication order by the department. (2) "Hold and Review" means a process of prepayment review of a medicaid provider's claims, including client records, medical records, or other supporting documentation, for determination of appropriate claims payment or reimbursement. (a) Hold and review administered by ODM will be done in accordance with rule 5160-1-27.1 of the Administrative Code. (b) Hold and review administered by state agencies other than ODM will be done in accordance with rule 5160-1-27.2 of the Administrative Code. (3) "Review" means a post-payment examination of a medicaid provider's paid claims to determine program compliance, validity of payments and identification of recovery of overpayments under the medicaid program. Review also means special projects or analysis to determine quality of care, compliance with accepted standards of care, and general program compliance. A review may result in an educational letter, a request for a corrective action plan subject to department approval, and/or recovery of inappropriate paid claims due to non-program compliance. (4) "Notice of operational deficiency" means a written notice issued by the department that identifies provider conduct, treatment or practices that are determined by the department not to be in the best interests of the consumer or the medicaid program and/or are noncompliant with the regulations governing the medicaid program and that must be corrected. The notice states the nature of the deficiency, the time period that the provider has to correct the deficiency and the person within the department the provider is to contact to verify that the deficiency has been corrected. (C) Records, documentation and information must be available regarding any services for which payment has been or will be claimed to determine that payment has been or will be made in accordance with applicable federal and state requirements. For the purposes of this rule, an invoice constitutes a business transaction but does not constitute a record which is documentation of a medical service. (D) Various methods of audit and review will be utilized in all cases of suspected fraud, waste and abuse, in accordance with rule 5160-1-29 of the Administrative Code. If fraud, waste and abuse are apparent, the department will take action to gain compliance and recoup inappropriate payments. (E) The provider must maintain all records as stipulated in this rule and rule 5160-1-17.2 or Chapter 5160-3 of the Administrative Code, as applicable. (F) All records, documentation and/or information requested in accordance with paragraph (B) of this rule shall be submitted to the department or its designee, in an appropriate manner as determined by the department. Records subject to audit and review must be produced at no cost to the department. (1) Records subject to audit and review must be made available for examination in the time period described in rule 5160-1-17.2 of the Administrative Code, or as determined by the department or its designee. Failure to supply requested records, documentation and/or information as indicated in this rule will result in no payment for outstanding services. (2) In all situations, the department has the authority to conduct an on-site visit with the provider at the provider's location for the examination or collection of records, and/or for compliance verification. Upon such occasions, as deemed necessary by the department or its designee, a member of the provider's staff is to be assigned to assist in collecting the information. Upon request from the department, the provider will photocopy or make the applicable records available for photocopying. (3) Services billed to and reimbursed by the department, which are not validated in the recipients' records, are subject to recoupment through the audit and review process described in this rule.
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Rule 5160-1-27.1 | Hold and review process.
Effective:
September 3, 2015
(A) "Hold and Review" is defined in accordance with rule 5160-1-27 of the Administrative Code. (1) Hold and review without prior notification. (a) The Ohio department of medicaid (ODM) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons: (i) In response to allegations of fraud or other willful misrepresentation of claims submission; or (ii) When a provider has been indicted for a criminal offense. (b) ODM shall notify the provider in writing within ten business days that the provider's claims have been, and will continue to be, subject to hold and review. (2) Hold and review with prior notification. (a) ODM may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, with prior notice to the provider under the following circumstances: (i) When the information is used to complement or follow up a provider certification or other quality review process; (ii) Upon request from the office of the attorney general, the office of inspector general or the auditor of state; (iii) A medicaid provider's agreement has been proposed for termination for reasons other than those stated in paragraph (A) of this rule; or (iv) For reasons otherwise necessary to assure the basic integrity of claims submission and payment. (b) ODM will notify the provider in writing within ten business days before the effective start date of the hold and review. (B) Review of the medicaid provider's claims and documentation for the hold and review process is subject to the provisions of rule 5160-1-27 of the Administrative Code. (C) The hold and review may be applied without regard to date of service. (D) Failure by ODM to notify a provider of a hold and review shall not impede the agency from taking actions under this rule. (E) The notice from ODM shall: (1) State the general reasons for the withholding of the medicaid provider's claims payments, but need not disclose any specific information concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation; (2) State the effective date ODM implements the hold and review process; (3) State the types of services and claims, in whole or in part, that will be subject to the hold and review process; (4) Identify the documentation required to be submitted to ODM by the provider: (5) Inform the provider of the right to submit evidence for consideration to ODM; (6) State the contact at ODM for questions regarding the hold and review process. (F) Except for medicaid providers required to submit medical claims to ODM electronically, all claims from providers placed on hold and review must be submitted in non-electronic (paper) format. (G) Providers who must submit medical claims electronically must submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by ODM. (H) ODM may, if appropriate, send copies of the notice to local, state and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment. (I) ODM has one hundred twenty days from the date each claim for payment is received to review the claim and make a determination whether or not to do one of the following: (1) Forward the claim for adjudication; (2) Forward the claim for denial; or (3) Issue a "Notice of Operation Deficiency." (J) The hold and review process is not subject to Chapter 119. of the Revised Code or any other appeal.
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Rule 5160-1-27.2 | Medicaid hold and review process for medicaid claims paid through state agencies other than the Ohio department of medicaid.
Effective:
September 3, 2015
(A) "Medicaid administrative agency" means a state agency other than the Ohio department of medicaid that: (1) Administers a component of the medicaid program under the terms of a contract with ODM under section 5162.35 of the Revised Code; and (2) Pays claims for medicaid services or reimburses local entities for claims paid for medicaid services. (B) "Hold and Review" is defined in accordance with rule 5160-1-27 of the Administrative Code. (C) Hold and review may be initiated by ODM or a medicaid administrative agency for the following reasons: (1) When the information is used to complement or follow-up a provider or certification or other quality review process; (2) In response to allegations of fraud or willful misrepresentation of claims submission; (3) Upon the request of the office of the attorney general, the office of inspector general, or the auditor of state; (4) When a provider's medicaid provider agreement is subject to termination; (5) When a provider has been indicted for a criminal offense; or (6) For reasons otherwise necessary to assure the basic integrity of claims submission and payment. (D) The hold and review may be applied without regard to date of service. (E) Hold and review initiated by medicaid administrative agencies. (1) The medicaid administrative agency shall have formal written approval from ODM to initiate a hold and review process. (2) The medicaid administrative agency may recruit the assistance of local governmental entities to review records subject to hold and review. (3) The medicaid administrative agency may initiate hold and review without prior notification to the provider when the medicaid administrative agency receives a request to initiate hold and review from the office of the attorney general, the office of inspector general, the auditor of state, or ODM. (4) When the medicaid administrative agency initiates hold and review without prior notification to the provider, the medicaid administrative agency shall provide written notice to the provider, including a copy of ODM written approval within ten business days of initiating a hold and review. (5) The medicaid administrative agency may initiate hold and review with prior notification to the provider for any purpose contained in paragraph (C) of this rule. The medicaid administrative agency shall notify the provider at least ten business days prior to subjecting the provider's claims to hold and review. (6) For claims payment that the medicaid administrative agency pays directly to the medicaid provider, the medicaid administrative agency may subject the medicaid provider's claim(s) payment, in part or in whole, to hold and review. (7) For reimbursements the medicaid administrative agency makes to local entities for claims that the local entity pays to the medicaid provider directly, the medicaid administrative agency: (a) May require the local entity to hold the medicaid provider's claim(s) payment for claims subject to hold and review; (b) May deny reimbursement to the local entity for the claims on which the hold and review was requested after allowing the local entity a reasonable time to comply; and (c) Shall not deny reimbursement to the local entity for claims that the local entity paid prior to the request. (8) A failure by the medicaid administrative agency to notify a provider of a hold and review process shall not impede the agency from taking actions under this rule. (9) Review of the medicaid provider's claims and documentation for hold and review is subject to the provisions of rule 5160-1-27 of the Administrative Code. (10) The notice from the medicaid administrative agency shall: (a) State the general reasons for subjecting the medicaid provider's claims to hold and review, but need not disclose any specific information concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation; (b) State the date the medicaid administrative agency implements the hold and review; (c) State the types of services and claims that are subject to hold and review; (d) Identify the documentation required to submit to the medicaid administrative agency; (e) Inform the provider of the right to submit evidence for consideration to the medicaid administrative agency; and (f) State the contact at the medicaid administrative agency for questions regarding the hold and review and where to send the requested documentation. (11) The medicaid administrative agency shall send copies of the notice to all local, state, and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment. (12) Providers who submit medical claims electronically may be required under this rule to submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by the medicaid administrative agency. (13) The medicaid administrative agency has one hundred twenty days from the date each claim for payment is received to review the claim and make a determination whether or not to do one of the following: (a) Forward the claim for adjudication; (b) Forward the claim for denial; or (c) Issue a "Notice of Operation Deficiency." (F) Hold and review process initiated by ODM. (1) ODM may require a medicaid administrative agency to initiate a hold and review described in this rule or to cooperate in a hold and review initiated by ODM under rule 5160-1-27.1 of the Administrative Code. (2) In cooperating with a request from ODM to initiate a hold and review, medicaid administrative agencies shall: (a) Comply with the provider notification requirements of this rule; and (b) Suspend payment or reimbursement of the claims that are subject to hold and review; and (c) Require local entities to suspend payment for the claims subject to hold and review; and (d) Obtain provider records, including client records, medical records, and other supporting documentation that ODM requests as part of the review from local entities and providers; and (e) Participate in the review of records and other supporting documentation when requested by ODM; and (f) Provide any other information requested by ODM in order to assure accurate tracking and timely resolution of the claims subject to hold and review. (3) For claims associated with alcohol and drug addiction services, ODM shall rely on the Ohio department mental health and addiction services to obtain and review provider records, including client records and medical records, as necessary to assure the special confidentiality of these records required by 42 C.F.R., part 2 as amended through October 1, 2006. (4) After requesting a hold and review and allowing the medicaid administrative agency a reasonable time to comply, ODM may stop drawing from the centers for medicare and medicaid services, and passing to the other agency, the federal match associated with the claims that are subject to the review. ODM will not withhold federal match for claims that other agencies or local entities paid prior to the ODM request. (G) For purposes of determining whether time limits for the submission of claims have been met for claims subjected to hold and review, the date of claims submission shall be the date that the medicaid administrative agency received the original claim from the provider. (H) The hold and review process is not subject to Chapter 119. of the Revised Code or any other appeal.
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Rule 5160-1-29 | Medicaid fraud, waste, and abuse.
(A) For purposes of this rule, the
following definitions apply: (1) "Abuse" has
the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1,
2023). (2) "Fraud" has
the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1,
2023). (3) "Waste"
means any preventable act such as inappropriate utilization of services or
misuse of resources that results in unnecessary expenditures to the medicaid
program. (B) The Ohio department of medicaid (ODM)
will have in effect a program to prevent and detect fraud, waste, and abuse in
the medicaid program. Where cases of suspected fraud to obtain payment from the
medicaid program are detected, providers will be subject to a review by ODM and
the case will be referred to the attorney general's medicaid fraud control
unit or the appropriate enforcement officials. If waste and abuse are suspected
or apparent, ODM, the office of the attorney general, or both will take action
to gain compliance and recoup inappropriate or excess payments in accordance
with rule 5160-1-27 or 5160-26-06 of the Administrative Code. (C) Cases of provider fraud, waste, and
abuse may include, but are not limited to, the following: (1) A pattern of
duplicate billing by a provider to obtain reimbursement to which the provider
is not entitled. (2) Misrepresentation as
to services provided, quantity provided, date of service, who performed the
service or to whom services were provided. (3) Billing for services
not provided. (4) A pattern of billing,
certifying, prescribing, or ordering services that are not medically necessary
or reimbursable in accordance with rule 5160-1-01 of the Administrative Code,
not clinically proven and effective, and not consistent with medicaid program
rules and regulations. (5) Differing charges for
the same services to medicaid versus non-medicaid recipients. For inpatient
hospital services billed by hospitals reimbursed on a prospective payment
basis, ODM will not pay, in the aggregate, more than the provider's
customary and prevailing charges for comparable services. (6) Violation of a
provider agreement by requesting or obtaining additional payment for covered
medicaid services from the recipient or the recipient's family, other than
medicaid co-payments as designated in rule 5160-1-09 of the Administrative
Code, or from other providers. (7) Collusive activities
involving the medicaid program between a medicaid provider and any person or
business entity. (8) Misrepresentation of
cost report data so as to maximize reimbursement or misrepresent gains or
losses. (9) Billing for services
that are outside the current license limitations, scope of practice, or
specific practice parameters of the person supplying the service. (10) Misrepresenting by
commission or omission any information on the provider enrollment and
revalidation application, provider agreement, or any documentation supplied by
the provider to ODM. (11) Ordering excessive
quantities of medical supplies, drugs and biologicals, or other
services. (12) Any action which
would constitute a violation of the False Claims Act (October 1, 2023), 31
U.S.C. 3729-3733. (13) Non-compliance with
the service definitions, activities, coverage, and limitations as listed in the
applicable provisions in agency 5160 of the Administrative Code. (D) ODM will not pay for services
prescribed, ordered, or rendered by a provider, when those services were
prescribed, ordered, or rendered by that provider after the date the provider
was terminated under the medicaid program in accordance with rule 5160-1-17.6
of the Administrative Code. (E) In instances when a provider
suspects that there may be fraud, waste, or abuse by a recipient, the provider
should contact the local county department of job and family services (CDJFS).
Cases of recipient fraud, waste, and abuse may include, but are not limited
to: (1) Alteration, sale, or
lending of the medicaid card to others for securing medical services, or other
related criminal activities. (2) Receiving excessive
medical visits and services. (3) Obtaining services
not personally needed and used by the recipient. (4) Any action to falsely
obtain medicaid eligibility as described in section 2913.401 of the Revised
Code. (F) Providers will assume responsibility
for the business practices of employees. In accordance with rule 5160-1-17.2 of
the Administrative Code, the Ohio medicaid provider agreement states that each
provider will comply with the terms of the provider agreement, Revised Code,
Administrative Code, and federal statutes and rules. Providers will take the
necessary time to thoroughly acquaint themselves and their employees with all
rules relative to their participation in the medicaid program. Ignorance of
medicaid program rules will not be an acceptable justification for violation of
the provider agreement, relevant statutes, or rules.
Last updated July 18, 2024 at 8:52 AM
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Rule 5160-1-31 | Prior authorization.
(A) Reimbursement for certain items or
services covered under the medicaid program is dependent on obtaining prior
authorization from the Ohio department of medicaid (ODM), its designee, or a
medicaid managed care entity (MCE). Prior authorization requests have to be
approved by ODM, its designee, or MCE before the services are rendered or the
items are delivered unless the services or items meet the provisions stated in
section 5160.34 of the Revised Code or paragraph (D) of this rule. (B) Except as authorized under section
5160.34 of the Revised Code, prior authorization requests submitted via paper
cannot be processed. All other prior authorization requests should be submitted
pursuant to the instructions located at www.medicaid.ohio.gov. (C) For services or items requiring prior
authorization, only those approved in the prior authorization determination
will be eligible for reimbursement. (D) The following exceptions to prior
authorization apply: (1) In situations where
the provider considers a delay in providing services or an item requiring prior
authorization to be detrimental to the health of the medicaid recipient, the
services or item may be rendered or delivered and approval for reimbursement
sought after the fact. (2) In cases of
emergency, for prescribed drugs requiring prior authorization, the prescribed
drug may be rendered without prior authorization in accordance with rule
5160-9-03 of the Administrative Code. (3) In the discretion of
and as instructed by ODM, a retroactive prior authorization may be
sought. (E) A medicaid provider may request a
reconsideration of an adverse prior authorization determination in accordance
with section 5160.34 of the Revised Code. A reconsideration of an adverse prior
authorization determination rendered by an MCE or transplant consortium should
be submitted and addressed in accordance with their respective processes for
reconsideration. A reconsideration of an adverse prior authorization
determination rendered by ODM or its designee should be submitted and addressed
in the following manner: (1) The request for
reconsideration has to be received by ODM or its designee within sixty calendar
days of the notification to the provider of an adverse determination. A valid
request for reconsideration should be submitted pursuant to the instructions
located at www.medicaid.ohio.gov and include the following: (a) Medicaid recipient's name and medicaid
number; (b) Name of requested service or item and billing
code; (c) Date of service or item request; (d) Clinical documentation supporting medical necessity for
the service or item; (e) A reference to any relevant federal or state law or
regulation, if applicable; (f) An explanation outlining the reason for
reconsideration, including supportive information not previously submitted as
necessary; and (g) If applicable, an indication of whether the service or
item qualifies as "urgent care services" as defined in section
5160.34 of the Revised Code. (2) ODM or its designee
will make a standard reconsideration determination within ten calendar days of
receipt. If an expedited review is requested because the service or item
qualifies as urgent care services, the reconsideration determination will be
made no later than forty-eight hours after receipt. (3) The review of the
reconsideration will be conducted by a clinical peer appointed or contracted by
ODM or its designee. (4) The provider
reconsideration process afforded under this rule does not interfere with the
medicaid recipient's right to appeal in accordance with division 5101:6
of the Administrative Code.
Last updated July 2, 2024 at 9:38 AM
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Rule 5160-1-32 | Medicaid: safeguarding and releasing information.
Effective:
November 1, 2024
(A) "Safeguarded information" includes but is not
limited to the following types of information about individual medicaid
applicants, enrollees, or former recipients: (1) Names and addresses;
(2) Social security
numbers; (3) Medical services provided;
(4) Social and economic conditions or
circumstances; (5) Agency evaluation of personal
information; (6) Medical data, including diagnosis and
past history of disease or disability; (7) Any information received in
connection with the identification of third party coverage; and (8) Any information received for
verifying income eligibility and amount of medical assistance payments. Income
information received from the social security administration (SSA) or the
internal revenue service (IRS) should be safeguarded according to the
regulations of the agency that furnished the data. (B) For the purpose of this rule, "administrative
agency" means the Ohio department of medicaid (ODM) or an agent of ODM to
determine eligibility or maintain records for a medical assistance program. The
administrative agency has the following responsibilities: (1) Implementing
administrative, physical and technical safeguards in accordance with 45 C.F.R.
164.308, 45 C.F.R. 164.310, and 45 C.F.R. 164.312 (as in effect on October 1,
2023). (2) Following the
safeguarding guidelines for protecting federal tax information (FTI) described
in the most current version of IRS publication 1075 (rev.
11/2021). (3) Safeguarding
information received or maintained about an individual connected with the
administration of the medicaid program in accordance with section 1902(a)(7) of
the Social Security Act (as in effect on October 1, 2023). (4) Publicizing
provisions governing the confidential nature of information about individuals,
including the legal sanctions imposed for improper disclosure and use, in
accordance with 42 C.F.R. 431.304 (as in effect October 1, 2023). (5) Providing copies of
the publicized provisions to individuals and to other persons and agencies to
whom information is disclosed, in accordance with 42 C.F.R. 431.304 (as in
effect October 1, 2023). (6) Protecting the types
of safeguarded information referenced in 42 C.F.R. 431.305 (as in effect
October 1, 2023). (7) Maintaining
confidentiality and safeguarding psychiatric hospitalization records, mental
health or addiction treatment records, rehabilitation and correction records,
or other sensitive records in accordance with section 5122.31 of the Revised
Code. (8) Refraining from
publishing names of individuals in accordance with 42 C.F.R. 431.306(c) (as in
effect October 1, 2023). (C) Release of information. The administrative agency has
the following responsibilities: (1) Obtaining permission
from an individual or authorized representative before releasing information,
unless that information is used to verify income or eligibility, in accordance
with 42 C.F.R. 431.306(d) (as in effect on October 1, 2023). (2) Applying policies to
all requests for information from outside sources, including governmental
bodies, courts of law, or law enforcement officials, except as provided in
sections 5160.45 to 5160.48 of the Revised Code. (3) Establishing criteria
specifying the conditions for release and use of information about individuals.
The information has to be restricted to persons or agency representatives who
are subject to standards of confidentiality that are comparable to those of the
agency in accordance with 42 C.F.R. 431.306(a) and (b) (as in effect on October
1, 2023). (4) Limiting disclosures
of protected health information (PHI) for individuals applying for, or
participating in, a medical assistance program to purposes related to payment,
treatment, or health care operations. For any other purposes, disclosures of
information about the health care of an individual, health care provided to an
individual, or payment for the provision of health care for an individual has
to include an authorization or waiver of authorization from an institutional
review board or privacy board compliant with the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) in accordance with 45 C.F.R. 164.508 and
45 C.F.R. 164.512(i) (as in effect October 1, 2023). (5) Releasing information
as permitted by and in accordance with section 5160.45 of the Revised
Code.
Last updated November 1, 2024 at 8:01 AM
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Rule 5160-1-32.1 | Standard authorization form.
Effective:
January 3, 2019
(A) In accordance with section 3798.10 of
the Revised Code, a standardized authorization form that meets all requirements
specified in 45 C.F.R. 164.508 and, where applicable, 42 C.F.R Part 2 as in
effect on October 1, 2018, for the use and disclosure of protected health
information is found in appendix A to this rule. (B) If the standardized authorization
form is properly executed, and adequately identifies the individual identified
in section I of the form found in appendix A to this rule, by either an
individual or the individual's personal representative, it shall be
accepted by any person or governmental entity in this state as valid
authorization for the use or disclosure of the individual's protected
health information to the persons or governmental entities specified in the
form. Please use the instructions found in appendix B to this rule to assist
with completing the standard authorization form. (C) A person or governmental entity is
not precluded from accepting as valid authorization for the use or disclosure
of protected health information a form other than the form prescribed in
paragraph (A) of this rule if the other form meets all requirements specified
in 45 C.F.R. 164.508 and, if applicable, 42 C.F.R Part 2 as in effect on
October 1, 2018. (D) Nothing in this rule shall require
obtaining authorization or use of the form found in appendix A to this rule
when use or disclosure of the information is required or permitted without such
authorization by 45 C.F.R. Chapter A, Subchapter C and, if applicable, 42
C.F.R. Part 2 as in effect on October 1, 2018. (E) The standard authorization form must
be accepted state-wide thirty days post effective date. Appendix A Appendix B
View Appendix
Last updated October 16, 2024 at 2:34 PM
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Rule 5160-1-33 | Medicaid: authorized representatives.
Effective:
January 13, 2017
(A) Designation of an authorized representative. (1) ) An individual may designate any person or organization to serve as that individual's authorized representative. Any person serving as an authorized representative must be at least eighteen years or older. (2) Authority for a person or organization to act on behalf of the individual accorded under state law, including but not limited to, a court order establishing legal guardianship, must be treated as a written designation by the individual of authorized representation. (3) The designation of an authorized representative must be in writing, and must identify what duties the individual is authorizing the representative to perform. (4) If the designated authorized representative is unwilling or unable to accept the responsibility of being an authorized representative, the authorized representative must inform the administrative agency and the individual of the refusal or withdrawal. (B) The authorized representative: (1) Must present proper identification, if requested by the administrative agency, prior to the disclosure of medicaid information to the authorized representative. (2) Must agree to maintain or be legally bound to maintain the confidentiality of any information regarding the individual provided by the administrative agency. (3) Will receive copies of notices and correspondence sent to the individual by the administrative agency. (4) Stands in the place of the individual. Any responsibility of the individual is a responsibility of the authorized representative. Any action taken by the authorized representative or failure to act will be accepted as the action or lack of action of the individual. (5) Shares all responsibilities set out in rule 5160:1-2-08 of the Administrative Code. (C) The administrative agency may contact the individual to clarify or verify information provided by an authorized representative if the authorized representative provides information that seems contradictory, unclear, or unrealistic. (D) The administrative agency may choose not to contact the authorized representative if the administrative agency believes that the authorized representative might endanger the individual in a situation of domestic violence, abuse, or neglect in accordance with 45 C.F.R. 164.502(g)(5) (as in effect October 1, 2015). (E) If the authorized representative is a provider or staff member or volunteer of an organization, the authorized representative must affirm that he or she will adhere to the regulations in 42 C.F.R. Part 431 Subpart F (as in effect October 1, 2015), 42 C.F.R. 447.10 (as in effect October 1, 2015), 45 C.F.R. 155.260(f) (as in effect October 1, 2015), as well as other relevant state and federal laws concerning conflicts of interest and confidentiality of information. (F) The power to act as authorized representative is valid until the individual notifies the administrative agency that the authorized representative is no longer authorized to act on his or her behalf, or the authorized representative informs the administrative agency the he or she no longer is acting in such capacity, or there is a change in the legal authority upon which the authorized representative's authority was based. Such notice should include the applicant or authorized representative's signature as appropriate. (G) Assistance from persons or organizations who are not authorized representatives. (1) A person or organization may accompany and assist an individual with portions of the application, verification, or redetermination process without being an individual's authorized representative. (2) The administrative agency must not reveal confidential information or send notices or correspondence to a person or organization who is assisting an individual, unless the person or organization is designated as an authorized representative. (3) A person or organization who is assisting an individual must provide accurate information to the administrative agency, to the best of his or her knowledge, regardless of whether the person or organization is an authorized representative.
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Rule 5160-1-39 | Verification of home care service provision to home care dependent adults.
(A) Home care service providers, as defined in this paragraph, must have a system as follows. (1) Definitions. (a) "Home care dependent adult" means a consumer who: (i) Resides in a private home or other non-institutional, unlicensed living arrangement without a parent or guardian present; (ii) Requires, due to health and safety needs, regularly scheduled home care services to remain in the home or other living arrangement; and, (iii) Is sixty years of age or older, or is at least twenty-one years of age but less than sixty years of age, and has a physical disability or mental impairment. (b) "Home care service provider" is: (i) A medicare certified home health agency or other accredited agency in accordance with Chapter 5160-12 of the Administrative Code that provides service in the home to the home care dependent adult; or (ii) A medicare certified hospice provider in accordance with Chapter 5160-56 of the Administrative Code that provides services to the terminally ill. (c) "Life-threatening condition" means a health condition that will place the consumer at risk of permanent impairment if the home care service is not provided. (d) "Mental impairment" means a consumer has a diminished capacity of judgment such that if the consumer were left alone, it would place the consumer at risk of permanent impairment. (e) "Physical disability" means a consumer's physical condition of severe functional limitations. (2) A home care service provider, who provides home care services to a home care dependent adult, must have a system which effectively monitors the delivery of services by its employee(s). The system must include: (a) A mechanism to verify whether their employees are present (e.g., at the beginning and end of a visit) at the location and time where services are to be provided for home care dependent adults who have a mental impairment or life-threatening condition; (b) Verification of whether the provider's employees have provided the services at the proper location and time at the end of each working day for all other home care dependent adults not addressed in paragraph (A)(2)(a) of this rule. (e.g., adults age sixty or older, or adults that are at least twenty-one years of age but less than sixty years of age and have a physical disability); and, (c) Implementation of a protocol for scheduling substitute employees when the monitoring system identifies that an employee has failed to provide home care services at the proper location and time. The protocol must include a standard for determining the length of time that may elapse without jeopardizing the health and safety of the home care dependent adult. (3) For the information obtained through the monitoring system in accordance with paragraph (A)(2) of this rule, the home care service provider must have procedures in place to: (a) Maintain records; (b) Compile annual reports which must include the rate at which home care services were provided at the proper location and time; (c) Conduct random checks of the accuracy of the monitoring system. For purposes of conducting these checks, a random check is considered to be a check of not more than five per cent or less than one per cent of the home care visits the provider's employees make to different home care dependent adults within a particular work shift; and, (d) Retain records in accordance with rule 5160-1-17.2 of the Administrative Code. (B) Home care service providers, as defined in paragraph (A) of this rule and as defined by the department of developmental disabilities or department of aging, shall demonstrate their verification system of home care service provision in accordance with section 121.36 of the Revised Code and paragraph (A) of this rule by: (1) Participating in periodic compliance reviews; and/or, (2) Furnishing upon request to Ohio department of medicaid (ODM), its designee or the medicaid fraud control unit any records related to the provisions outlined in section 121.36 of the Revised Code.
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Rule 5160-1-42 | Provider credentialing.
Effective:
October 1, 2022
In accordance with the federal credentialing
standards found in 42 CFR 422.204, "provider selection and
credentialing" (as in effect on October 1, 2021), this rule details the
credentialing and recredentialing process for medicaid providers. (A) For purposes of this rule, the
following definitions apply. (1) "Council for affordable quality
healthcare (CAQH)" is a non-profit organization which created a process
allowing ODM to use a single, uniform application for credentialing. This
end-to-end process simplifies data collection, primary source verification, and
sanctions monitoring, to support ODM's credentialing needs. (2) "Credentialing" means an
evaluation of the qualifications of health care providers that seek contracts
or participation agreements with ODM. (3) "Credentialing committee"
means the group of individuals appointed by ODM for provider and facility
review, as well as reconsidering providers and facilities initially denied by
credentialing as described in paragraph (K) of this rule. (4) "Delegate" means a hospital
group or physician hospital organization formed by a hospital and group of
physicians granted the authority by ODM to credential its health care providers
who require credentialing. (5) "Delegation" means the act of ODM granting
another health care entity the authority to credential its health care
providers who require credentialing. (6) "Designee"
means a third party with whom ODM has contracted to complete certain
credentialing related administrative tasks and information gathering tasks
required to fulfill credentialing and re-credentialing for those providers
whose credentialing is not completed through the process of delegation;
and (7) "Eligible
provider" has the same meaning as a person or entity who is an eligible
provider as defined in rule 5160-1-17 of the Administrative Code who is
enrolled with ODM. (B) Credentialing by ODM is mandatory for
the following practitioners: (1) Physicians as defined
in Chapter 4731. of the Revised Code; (2) Psychologists as
defined in Chapter 4732. of the Revised Code; (3) Physician assistant
as defined in Chapter 4730. of the Revised Code; (4) Dentists as defined
in Chapter 4715. of the Revised Code; (5) Optometrists as
defined in Chapter 4725. of the Revised Code; (6) Pharmacists as
defined in Chapter 4729. of the Revised Code; (7) Chiropractors as
defined in Chapter 4734. of the Revised Code; (8) Acupuncturists as
defined in Chapter 4762. of the Revised Code; (9) Clinical nurse
specialist, certified nurse-midwife, or certified nurse practitioner as defined
in Chapter 4723. of the Revised Code; (10) Licensed independent
social worker, licensed independent marriage and family therapist, or licensed
professional clinical counselor as defined in Chapter 4757. of the Revised
Code; (11) Licensed independent
chemical dependency counselor as defined in Chapter 4758. of the Revised
Code; (12) Certified Ohio
behavior analysts as defined in Chapter 4783. of the Revised Code; (13) Audiologists as
defined in Chapter 4753. of the Revised Code; (14) Occupational
therapist as defined in Chapter 4755. of the Revised Code; (15) Physical therapist
as defined in Chapter 4755. of the Revised Code; (16) Speech-language
pathologist as defined in Chapter 4753. of the Revised Code; and (17) Dietitians as
defined in Chapter 4759. of the Revised Code. (C) Credentialing by ODM is mandatory for
the following facilities: (1) Nursing facilities as
defined in Chapter 5165. of the Revised Code; (2) Hospitals as defined in Chapter 3727.
of the Revised Code; (3) Hospice as defined in Chapter 3721.
of the Revised Code; (4) Home health agencies as defined in
rule 3701-60-01 of the Administrative Code; (5) Ambulatory surgical facilities as
defined in section 3702.30 of the Revised Code; (6) Community mental health services
providers as defined in Chapter 5119. of the Revised Code; (7) Community addiction services
providers as defined in Chapter 5119. of the Revised Code; (8) End stage renal disease (ESRD)
treatment centers as described in rule 3701-83-23.1 of the Administrative
Code; (9) Radiology centers as described in
rule 3701-83-51 of the Administrative Code; and (10) Residential facility as defined in
Chapter 5119. of the Revised Code. (D) Credentialing by ODM is not mandatory
for the following practitioners: (1) Health care
professionals who are permitted to provide services only under the direct
supervision of an independently enrolled practitioner as defined in rule
5160-4-02 of the Administrative Code; (2) Hospital-based health
care professionals who provide services "incidental-to" a hospital
service and are not independently enrolled; (3) Health care
professionals who are designated as current residents, interns, or fellows as
defined in Chapter 5160-4 of the Administrative Code; and (4) Moonlighting residents as defined in 42 CFR 415.208 (as
in effect on October 1, 2021). (E) Those providers listed in paragraph
(B) of this rule will provide ODM or ODM's credentialing designee the
following information for initial credentialing verification: (1) Access to the
standard provider credentialing application form used by the council for
affordable quality healthcare (CAQH) in accordance with section 3963.05 of the
Revised Code within one-hundred-eighty days prior to credentialing
date; (2) Active provider
licensing information; (3) Board certification,
if applicable; (4) Education; (5) Clinical privileges,
if applicable; (6) Medical malpractice
insurance; (7) Drug enforcement
administration (DEA) certification, if applicable; (8) National practitioner
data bank information regarding malpractice and clinical privilege
actions; (9) Sanctions or
limitations on licensure; (10) Eligibility for
participation in medicare and medicaid, if applicable; and (11) Minimum five-year
work history. The five-year timeframe begins with date of initial licensure. If
the provider has been licensed for less than five years, available work history
should be provided. (F) The facilities listed in paragraph
(C) of this rule will provide ODM or ODM's credentialing designee access
to the following information for initial credentialing
verification: (1) The Ohio department
of insurance (ODI) form INS5036, revision date February of 2021, found at
https://insurance.ohio.gov/static/Forms/Documents/INS5036.pdf; (2) Active provider
licensing information; (3) Certification through
an accrediting body or a site visit completed by a state designated
agency; (4) Eligibility for
participation in medicare and medicaid, if applicable; (5) Verification of good
standing with applicable state and federal bodies; and (6) Active malpractice
insurance. (G) Prerequisites for becoming a delegate
as defined in paragraph (A)(4) of this rule are the following: (1) Maintain an active,
valid delegation contract approved by the credentialing committee; (2) The delegate has to
complete a pre-delegation audit prior to their becoming an active
delegate; (3) The delegate has to
adhere to the standards set forth in the delegated contract, including the time
frames and content for reporting, duties assigned, necessary processes and
procedures, and collaborating of a yearly audit; (4) The delegate has to
have their own credentialing committee, with decision making capabilities, and
delegation contract monitoring; (5) The delegate has to
report any additions, changes, and terminations in a timely manner including
both credentialed and non-credentialed practitioners and
facilities; (6) Delegates will be
audited by ODM every twelve months; and (7) Practitioners with a
delegated group understand they are still expected to update their information
in the provider data system, and to revalidate according to their ODM
determined schedule. (H) Every thirty-six months, those
providers listed in paragraph (B) of this rule will provide ODM or ODM's
credentialing designee information listed in paragraphs (E)(1) to (E)(10) of
this rule for recredentialing. (I) Every thirty-six months, facilities
listed in paragraph (C) of this rule will provide ODM or ODM's
credentialing designee the information listed in paragraphs (F)(1) to (F)(6) of
this rule for recredentialing verification. (J) The following information may be
requested by the state or its designee from providers or facilities as listed
in paragraph (B) or (C) of this rule at any time during the credentialing or
recredentialing process: (1) Demographic
information; (2) Information missing
in CAQH; (3) Verification of
certifying board names; (4) Explanation for work
history gaps; (5) Updates regarding
expired information; (6) Verification of
specialty information; (7) Information regarding
previous sanctions or affirmative responses to CAQH disclosure questions;
and (8) Continuing education (CE)
prerequisites as required by the provider's state licensing
board. (K) ODM will establish and utilize a
credentialing committee for provider and facility review and appeals when the
credentialing prerequisites specified in paragraph (K)(1) of this rule are
under review. The credentialing committee will follow the process described in
this paragraph when a provider or facility is found to be non-compliant with
the credentialing prerequisites. (1) Providers or
facilities that fail to meet the following prerequisites, have a discrepancy,
or negative findings with the information provided in paragraph (E) or (F) of
this rule, are subject to review by the state established credentialing
committee. Prerequisites are the following: (a) Previous licensing board sanctions; (b) Previous clinical actions taken by a medical group or
hospital; (c) Affirmative responses to CAQH disclosure questions,
with the exception of the following CAQH questions: (i) To your knowledge,
has information pertaining to you ever been reported to the national
practitioner data bank (NPDB) or healthcare integrity and protection data bank
(HIPDB)? (ii) Have you had any
professional liability actions (pending, settled, arbitrated, mediated or
litigated) within the past ten years? And if yes, provide information for each
case. (d) Excessive malpractice claims within the past ten years,
as defined by the credentialing committee; (e) Inappropriate training or education for disclosed
provider specialty; (f) Previous medicare or medicaid disbarments or
actions; (g) Site visit non-compliance; (h) Previous DEA actions; (i) Material misrepresentation or omission concerning
professional credentials; and (j) Prior criminal history in accordance with rule
5160-1-17.8 of the Administrative Code. (2) The following
individuals will participate in the ODM credentialing committee as determined
by ODM. Voting members are expected to attend no less than seventy-five per
cent of all meetings held to maintain voting rights, and sign
non-discrimination and conflict of interest forms. (a) Committee chair; (b) Community-based peers of providers requiring
credentialing as defined in paragraph (B) of this rule; (c) Managed care organization representatives; (d) Medical directors; and (e) Staff from ODM and ODM's designee. (3) The credentialing
committee members will carry out the following responsibilities: (a) Review the credentials of practitioners; (b) Review and approve sanctions monitoring; (c) Review and approve delegated audits, contracts, and
agreements; and (d) Review and approve credentialing reports from ODM and
ODM's designee. (4) When a provider or
facility is denied by the credentialing committee, the following process will
occur. (a) The provider or facility is sent a denial letter by ODM
outlining the unmet credentialing prerequisites or negative findings under
review, and their appeal rights and instructions for proceeding; (b) The provider or facility will have no more than thirty
calendar days to appeal to the credentialing committee; (c) The appellant provides the credentialing committee with
supplemental information which supports its appeal of the
decision; (d) Appeal decision is rendered by the credentialing
committee; and (e) Credentialing committee decisions on appeals are final,
and those providers and facilities denied by the credentialing committee are
not subject to reconsideration as found in paragraph (D) of rule 5160-70-02 of
the Administrative Code. The practitioners denied by the credentialing
committee are denied ODM enrollment. (L) Providers and facilities who do not
have any negative findings regarding the information needed for initial
credentialing verification or recredentialing listed in paragraph (E) or (F) of
this rule and meet the prerequisites listed in paragraph (K)(1) of this rule
are considered to have a clean file and have met the requirements for
credentialing with ODM. Providers and facilities with clean files and no
negative findings will not meet with the credentialing committee unless
otherwise determined by ODM and ODM's designee. Clean files for initial
credentialing and recredentialing will have a final review by ODM's
medical director.
Last updated October 3, 2022 at 8:44 AM
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Rule 5160-1-42.1 | Delegated credentialing.
Effective:
January 1, 2023
(A) The Ohio department of medicaid (ODM)
authorizes eligible provider delegates to perform credentialing activities on
behalf of individual providers in accordance with rule 5160-1-42 of the
Administrative Code. (B) "Delegate" and
"Delegation" have the same meaning as in rule 5160-1-42 of the
Administrative Code. (C) Entities seeking delegation will be
expected to meet the following criteria to become an authorized delegate and to
maintain delegate status: (1) Be an eligible
provider as defined in rule 5160-1-17 of the Administrative Code: (2) Participate with
home-state agency that administers titles XIX (medicaid), XXI (children's
health insurance program - CHIP), or XVIII (medicare) of the Social Security
Act; (3) Be based in Ohio or a
contiguous state; (4) Have at least fifty
Ohio medicaid enrolled and active affiliated individual providers; (5) Submit to the
credentialing department a request in writing; and (6) Complete a
pre-delegation audit conducted by ODM to include review of the following
information maintained by the delegate: (a) Credentialing policies and procedures; (b) Sample of practitioner credentialing
files; (c) Credentialing meeting minutes; and (d) Ongoing sanctions monitoring. (D) ODM has the right to deny or terminate delegation
status. Denial or termination of delegation status does not afford hearing
rights. (E) Delegated credentialing of facilities is not
permissible under the ODM delegated credentialing agreement.
Last updated January 3, 2023 at 9:21 AM
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Rule 5160-1-60 | Medicaid payment.
Effective:
October 1, 2024
(A) The medicaid payment for a covered
procedure, service, or supply constitutes payment in full and may not be
construed as a partial payment when the payment amount is less than the
provider's submitted charge. A provider may not collect from a medicaid
recipient nor bill a medicaid recipient for any difference between the medicaid
payment and the provider's submitted charge, nor may a provider ask a
medicaid recipient to share in the cost through a deductible, coinsurance,
copayment, or other similar charge other than medicaid copayments as defined in
rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the
Administrative Code, however, precludes a provider from requesting payment,
collecting, or waiving the collection of medicare copayments from a medicaid
recipient for medicare part D services. Medicaid recipient liability provisions
set forth in rule 5160-1-13.1 of the Administrative Code do not apply to
medicare part D services. (B) Providers are expected to submit
their usual and customary charge (the amount charged to the general public) on
all claims. The medicaid payment amount for a covered service, procedure, or
supply is the lesser of the submitted charge or the established medicaid
maximum. Medicaid maximum payment amounts for many existing services,
procedures, and supplies, particularly services rendered by practitioners of
the healing arts, are set forth in the appendix to this rule. The initial
maximum payment amount for a covered procedure, service, or supply represented
by a new procedure code that takes effect at the beginning of a calendar year
is established in accordance with paragraph (J) of this rule. Specific payment
amounts or payment formulas set forth in other rules in agency 5160 of the
Administrative Code supersede corresponding entries in the appendix to this
rule. (C) Pursuant to rule 5160-1-08 of the Administrative Code,
providers are expected to take reasonable measures to determine any third-party
resource available to a medicaid recipient and to file a claim with that third
party when required to do so under rule 5160-1-08 of the Administrative Code.
When there is a third-party payer, medicaid payment for a covered procedure,
service, or supply is the lesser of two amounts: (1) The provider's
submitted charge; or (2) The medicaid maximum
payment amount less the sum of all third-party payments and any applicable
medicaid copayment (unless the difference is zero or less, in which case
medicaid will make no further payment). (D) For services that are subject to a
copayment pursuant to rule 5160-1-09 of the Administrative Code, the total
medicaid maximum payment amount is reduced by the total medicaid copayment. The
provider may collect from the medicaid recipient or bill the medicaid recipient
for the total medicaid copayment, which is determined in accordance with the
relevant rule of the Administrative Code. (E) For dates of service on or after
August 1, 2017, the rates for the facility services provided by an ASC are
addressed in rule 5160-22-01 of the Administrative Code. (F) Except as otherwise permitted by
federal statute or regulation, the medicaid maximum payment amounts described
in this rule must not exceed the established maximum medicare allowed amounts
for the same procedures, services, or supplies. (G) Medicaid payment is not allowed for
non-covered procedures, services, and supplies nor for covered procedures,
services, or supplies that are denied by the department as a result of a
prepayment review, utilization review, or prior authorization process. (Chapter
5160-2 of the Administrative Code describes how these provisions are applied to
inpatient and outpatient hospital services.) (H) Every submitted claim must include
the most appropriate code representing each procedure, service, or supply
provided. (I) "Site differential" is a
difference in medicaid payment based on the place in which the service is
provided. When a covered service is subject to a site differential, the payment
amount is the lesser of the provider's submitted charge or the applicable
maximum facility payment amount or maximum non-facility payment
amount. (1) The maximum facility
payment amount applies to a service provided at one of the following
sites: (a) A hospital (inpatient hospital, outpatient hospital,
emergency department, or inpatient psychiatric facility); (b) A skilled nursing facility; or (c) An ambulatory surgery center (ASC). (2) The maximum
non-facility payment amount applies to a service provided at any other
site. (J) Additional information about the coverage of and payment for
certain procedures is shown in the 'prof/tech split' and 'PC/TC
indicator' columns of the appendix to this rule. (1) A 'prof/tech
split' entry indicates that the procedure is made up of both a
professional and a technical component for the time period shown. The indicator
denotes the relative proportions of the medicaid maximum payment amount
allocated to the professional and technical components. For example, the
indicator C means that the medicaid maximum payment amounts for the
professional component and for the technical component are, respectively, forty
per cent and sixty per cent of the medicaid maximum payment amount for the
total procedure. There are thirteen such indicators: (a) C: Forty per cent / sixty per cent; (b) D: Eighty per cent / twenty per cent; (c) F: Ten per cent / ninety per cent; (d) G: Twenty per cent / eighty per cent; (e) H: Twenty-five per cent / seventy-five per cent; (f) I: Thirty per cent / seventy per cent; (g) J: Thirty-five per cent / sixty-five per cent; (h) K: Fifty per cent / fifty per cent; (i) L: Sixty per cent / forty per cent; (j) M: Seventy per cent / thirty per cent; (k) O: One hundred per cent / zero per cent; (l) P: Seventy-five per cent / twenty-five per cent;
and (m) Q: Ninety per cent / ten per cent. (2) A numeric 'PC/TC
indicator' entry shows the degree to which a procedure is professional or
technical in nature or has a professional or technical component; these numeric
values are defined by the centers for medicare and medicaid services (CMS),
http://www.cms.gov. A lowercase alphabetic 'PC/TC indicator' entry
indicates a medicaid payment restriction based on the location in which the
procedure is performed (a place-of-service restriction). Meanings of these
numeric and alphabetic indicators are summarized in the appendix to this
rule. (K) The department may set payment limits based on the
characteristics of an individual procedure, service, or supply or the
relationships between procedures, services, or supplies. For example, payment
may be disallowed for a procedure if it is incompatible with another procedure
or another procedure makes it redundant. In configuring its claim-processing
system, the department may define its own limits, adopt limits established by
an authoritative source, or modify limits established by an authoritative
source. The maximum payment amounts for specimen collection and diagnostic
testing for COVID-19 are set at the Ohio medicare rate. (L) The "Healthcare Common Procedure Coding System
(HCPCS)" is a numeric and alphanumeric code set maintained and distributed
by CMS for the uniform designation of certain medical procedures and related
services. Level one of HCPCS consists of "Current Procedural Terminology
(CPT)," a comprehensive listing of medical terms and codes published by
the American medical association (AMA), http://www.ama-assn.org, for the
uniform designation of diagnostic and therapeutic procedures in surgery,
medicine, and the medical specialties. When the department initially
establishes coverage for a procedure, service, or supply the initial maximum
payment amount is set at eighty per cent of the medicare allowed amount. If no
medicare allowed amount is available the initial medicaid maximum payment
amount is set at the unweighted average of the current maximum payment amounts
for comparable procedures, services, or supplies. For convenience, a list of
such initial maximum payment amounts is posted on the department's web
site, http://medicaid.ohio.gov.
View Appendix
Last updated October 1, 2024 at 9:22 AM
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Rule 5160-1-60.2 | Direct reimbursement for out-of-pocket expenses incurred for medicaid covered services during approved eligibility periods.
(A) For purposes of this
rule: (1) "Applicant for
reimbursement" is: (a) An individual who has been determined eligible for a
retroactive eligibility period in accordance with rule 5160:1-2-01 of the
Administrative Code, and who is seeking reimbursement for medical expenses for
which the individual paid for during this approved time period; or (b) An individual who, as a result of an eligibility
determination or state hearing decision, now has effective dates of eligibility
and is seeking reimbursement for medical expenses for which the individual paid
during this approved time period; or (c) An individual who has been erroneously charged a
medicaid co-pay for services eligible for a co-pay in accordance with rule
5160-1-09 of the Administrative Code, and who is seeking reimbursement of the
co-pay amount incurred during the time period when the individual should not
have been subject to a co-pay and for which the individual paid;
or (d) A person not legally obligated to pay for an
individual's medical bills, but who does, in fact, contribute payment
toward the individual's medical bills incurred during the approved
eligibility period. (2) "Effective dates
of eligibility" means the period described in rule 5160:1-2-01 of the
Administrative Code. (3) "Medicaid covered service"
is a service or product that meets all the following criteria: (a) Medically necessary in accordance with rule 5160-1-01
of the Administrative Code; (b) Delivered by an eligible provider who qualifies for one
of the following: (i) A medicaid provider
agreement as described in rule 5160-1-17.12 of the Administrative Code;
or (ii) An approved contract
or single case agreement with a medicaid managed care entity
(MCE); (c) A reimbursable medical service as defined in rule
5160-1-02 of the Administrative Code. (d) A physician service as defined in Chapter 5160-4 of the
Administrative Code, or a dental service as defined in Chapter 5160-5 of the
Administrative Code. (4) "Payer" is
the Ohio department of medicaid (ODM), an MCE contracted with ODM, or any
entity ODM designates with the authority to issue direct
reimbursements. (5) "Retroactive eligibility
period" means the period described in rule 5160:1-2-01 of the
Administrative Code. (B) For any application for
reimbursement, the payer will make direct reimbursement, including applicable
co-pays, in accordance with 42 C.F.R. 447.25 only if all of the following are
met: (1) The individual has an
eligibility period as defined in paragraph (A)(2) or (A)(5) of this rule and
the date on which the individual received the medicaid covered service was
within the period of eligibility; (2) The service was a
medicaid covered service, and the service was not a nursing facility service
included in the nursing facility's per diem rate; (3) The applicant for
reimbursement contacts the provider and requests reimbursement, and the
provider either does not agree to reimburse the applicant or does agree to
reimburse the applicant but does not do so within ninety days; (4) Within ninety days
from the date the provider does not agree or fails to reimburse the applicant,
the applicant requests direct reimbursement from the appropriate
payer; (5) Within ninety days
from the date the applicant asks the payer for direct reimbursement described
in paragraph (B)(4) of this rule, the applicant provides the following
documentation to the payer: (a) Written verification of a bill from the provider which
specifies the medicaid covered services provided; (b) Written verification that the individual paid the
provider; (c) Any other documentation that may be requested by the
payer, including proof that the provider did not agree to reimburse the
applicant, or did agree to reimburse the applicant but did not do so within
ninety days of the request, as specified in paragraph (B)(4) of this
rule; (d) The name, address, and phone number of the provider who
rendered the medicaid covered services to the individual and the name of the
billing provider; and (e) The name, address and phone number of any third party
that paid or was liable to pay for any portion of the medicaid covered
service. (6) Requests for direct
reimbursement will qualify for reimbursement consideration only if submitted to
the payer within three hundred sixty-five days of the date of service or
hospital discharge, or within one hundred eighty days of the notice of state
hearing decision or eligibility determination; (7) Reimbursement from a
third party as defined in section 5160.35 of the Revised Code is not
available; (8) The request is not
for reimbursement of medicare part A out-of-pocket expenses. (C) Within ninety days of meeting the
conditions specified in paragraph (B) of this rule, the payer will process the
request for reimbursement. Applicants for reimbursement who receive an approval
for reimbursement will be reimbursed either the amount of their out-of-pocket
medical expenses or the co-pay charges, whichever is applicable, but in no
event will the reimbursement exceed the medicaid maximum allowed amount
identified in rule 5160-1-60 of the Administrative Code. (D) The bills identified as satisfying a
person's spenddown obligation or paid to the county to meet medicaid
eligibility are not reimbursable by the medicaid program. (E) All notice and hearing provisions set
forth in division 5101:6 of the Administrative Code apply to determinations
made under this rule.
Last updated September 17, 2024 at 3:18 PM
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Rule 5160-1-60.4 | By-report procedures, services, and supplies.
(A) The term "by-report"
identifies a covered procedure, service, or supply for which no single maximum
payment amount has been established and for which payment is not determined by
prior authorization. Claims for by-report procedures, services, and supplies
are reviewed manually by the department or its designee. The purpose of the
review is to determine whether the procedure code for the by-report procedure,
service, or supply reported on the claim is the most appropriate and, if so, to
establish a maximum payment amount for the procedure, service, or supply on a
case-by-case basis. Information must be submitted on or with the claim (e.g.,
supporting documents such as operative reports, clinical assessments, or other
medical records) to identify the particular by-report procedure, service, or
supply. (B) By-report procedures, services, and
supplies are so indicated in the relevant rule in agency 5160 of the
Administrative Code or in its associated payment schedule. (C) A non-covered procedure, service, or
supply that is reported on a claim with a by-report procedure code is
non-covered. (D) A claim for a by-report procedure,
service, or supply will not be reviewed further and may be denied under either
of the following conditions: (1) Information submitted
on or with the claim does not sufficiently identify the by-report procedure,
service, or supply, and additional documentation requested by the reviewer is
not supplied; or (2) The procedure,
service, or supply can be reported appropriately with a different procedure
code for which a specific maximum payment amount has been
established. (E) When a claim has been denied because
a different procedure code adequately describes a procedure, service, or
supply, the provider may submit a new claim with the appropriate code. The new
claim must not be submitted for by-report consideration.
Last updated September 17, 2024 at 3:18 PM
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Rule 5160-1-61 | Non-covered services.
(A) The following services are entirely
excluded from coverage: (1) A service that is experimental in
nature and is not performed in accordance with standards of medical
practice; (2) A service that is related to forensic
studies; (3) An autopsy service; (4) A service for the treatment of
infertility; (5) An abortion that does not meet the
criteria for coverage set forth in rule 5160-17-01 of the Administrative
Code; (6) A service that does not meet the
criteria for coverage set forth in any other rule in agency 5160 of the
Administrative Code; (7) A service pertaining to a pregnancy
that is a result of a contract for surrogacy services, under which a woman
agrees to become pregnant for the purpose of carrying and giving birth to a
child she will not raise but instead will relinquish to the other contracting
party; and (8) Assisted suicide and other measures
taken actively with the specific intent of causing or hastening
death. (B) In accordance with Division CC, Title II, Section 210
of the Consolidated Appropriations Act, 2021 (Pub. L. No. 116-260), payment may
be made for routine patient costs associated with participation in a qualifying
clinical trial involving an experimental procedure. (C) Neither the withholding or
withdrawing of treatment nor the provision of palliative care constitutes
assisted suicide, even if the measure may increase the likelihood of death, so
long as the measure is not taken for the specific purpose of causing
death.
Last updated March 22, 2024 at 10:32 AM
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Rule 5160-1-70 | Relocated provisions concerning episode based payments.
Effective:
December 31, 2020
Provisions concerning episode based payments are
set forth in rule 5160-19-04 of the Administrative Code.
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Rule 5160-1-71 | Relocated provisions concerning patient centered medical homes (PCMH) and eligible providers.
Effective:
October 17, 2020
Provisions concerning patient centered medical
homes (PCMH) and eligible providers are set forth in rule 5160-19-01 of the
Administrative Code. The PCMH rules implement the Ohio department of
medicaid's comprehensive primary care (CPC) program and CPC for kids
programs.
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Rule 5160-1-72 | Relocated provisions concerning patient centered medical homes (PCMH) and payments.
Effective:
October 17, 2020
Provisions concerning patient centered medical
homes (PCMH) and payments are set forth in rule 5160-19-02 of the
Administrative Code. The PCMH rules implement the Ohio department of
medicaid's comprehensive primary care (CPC) program and CPC for kids
programs.
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Rule 5160-1-73 | Behavioral health care coordination.
Effective:
January 10, 2019
(A) For the purpose of this rule, the
following definitions apply. (1) "Attributed
individual" is the Ohio medicaid covered individual for whom a qualified
behavioral health entity eligible under this rule has accountability for
providing behavioral health care coordination. (2) "Attribution" is the process through which
medicaid covered individuals are assigned to a specific qualified behavioral
health entity. The Ohio department of medicaid (ODM) is responsible for
attributing eligible individuals. (3) "Behavioral health care
coordination" (BHCC) is an evidence-based comprehensive care coordination
model that connects qualified behavioral health entities with an assigned panel
of eligible members with high-need behavioral health conditions. (4) "Comprehensive primary care
initiative" (CPC) is the ODM implementation of a patient-centered medical
home (PCMH) model as established through rules 5160-1-71 and 5160-1-72 of the
Administrative Code. (5) "Consolidated
clinical document architecture" (C-CDA) is an implementation guide
developed and maintained by "Health Level Seven International" (HL7)
which specifies a library of templates and prescribes their use for a set of
specific document types for the purpose of electronic exchange of health care
information. (6) "Eligible member" is the
medicaid covered individual who meets the diagnosis and service utilization
criteria that enables them to receive BHCC from a qualified behavioral health
entity to which they have been attributed. (7) "Fast healthcare
interoperability resources" (FHIR) is a standard developed by HL7 for
exchanging healthcare information electronically. (8) "Healthcare
effectiveness data and information set" (HEDIS) is a tool developed by the
national center for quality care (NCQA) to measure performance on dimensions of
care and service. (9) "Medication-assisted
treatment" (MAT) is the combined provision of behavioral therapy and
medications for the treatment of substance use disorders. All medications must
be approved by the United States food and drug administration (FDA) for the
treatment of a substance use disorder. (10) "National
quality forum" (NQF) refers to the performance measures endorsed by the
national quality forum. (11) "Performance
and quality improvement" (PQI) refers to the standards developed by the
council on accreditation (COA) that measure effective quality improvement
plans. (12) "Primary care practice"
(PCP) is a practice led by primary care practitioners who comprehensively
manage the health needs of individuals. (13) "Qualified behavioral health
entity" (QBHE) is the participating entity which has attributed
individuals and is responsible for the BHCC activities. (B) A QBHE must: (1) Meet the certification requirements
set forth in paragraph (A)(1) of rule 5160-27-01 of the Administrative Code and
in calendar year 2017 or later have provided both mental health and substance
use disorder treatment services under the same ownership; or (2) Meet the requirements
stated in paragraph (G)(2)(a) of rule 5160-2-75 of the Administrative Code if
an outpatient hospital provider; and (3) Within ninety calendar days of
approval to participate as a QBHE, have an active provider contract with each
medicaid managed care plan (MCP); (4) Submit an application to become a
QBHE. ODM reserves the right to deny any QBHE enrollment application it
determines is not in compliance with the requirements of this rule. A QBHE may
seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code to
challenge a decision by ODM to deny a QBHE enrollment application; (5) At the time of submitting an
enrollment application to become a QBHE, have at least one practitioner from
each of the following categories affiliated with the entity: (a) A practitioner with prescribing authority in the state
of Ohio; (b) A registered nurse or licensed practical nurse;
and (c) An other licensed professional as described in rule
5160-8-05 of the Administrative Code. (6) For the practitioner types defined in
paragraph (B)(5) of this rule, continue to have such practitioners affiliated
with the participating QBHE at all times to maintain eligibility as a
QBHE. (7) Demonstrate an organizational
commitment to integration of physical and behavioral health care at the date of
application to become a QBHE. The entity must meet one of the
following: (a) Have an ownership or membership interest in a primary
care organization where primary care services are fully integrated and
embedded; (b) Enter into a written integrated care agreement such as
a contract or memorandum of understanding with a primary care provider;
or (c) Achieve implementation of primary physical health care
standards by a national accrediting entity as an integrated primary
care-behavioral health provider, primary care medical home or behavioral health
home. (C) The QBHE must attest to the following
at the time of application: (1) That it has the
ability to share, receive, and use electronic data from a variety of sources
with other health care providers, ODM, and the MCPs; (2) That it uses consent
forms containing elements necessary to support the full exchange of health
information in compliance with all applicable state and federal
laws. (3) That it has the
ability to submit prescriptions electronically; (4) That it implements
and actively uses an electronic health record (EHR) in clinical services;
and (5) If QBHE enrolled in
the BHCC program prior to July 1, 2019, QBHE will have the ability, within six
months of July 1, 2019 service start (January 2020), to send, receive, and use
continuity of care records through the use of standard electronic formats such
as FHIR and C-CDA. If QBHE enrolled in the BHCC program after July 1, 2019,
QBHE will have the standard electronic formats prepared at the time of
application. (D) Eligible individual
requirements. (1) Except for the
following populations, all medicaid covered individuals who meet the diagnostic
and utilization criteria set forth in this rule will be attributed to a
QBHE: (a) Individuals who have been receiving inpatient care at a
hospital or residing in a nursing facility for more than ninety
days. (b) Individuals who are currently receiving another care
coordination service that substantially duplicates those activities provided
through BHCC. (2) Eligible individuals
who meet the criteria in one of the following groups are eligible for BHCC and
will be attributed to a QBHE: (a) Group 1. Claims utilization in the twelve months
preceding attribution identifies at least one of the following diagnostic
criteria or diagnoses as identified in appendix A to this rule: (i) A primary diagnosis
of schizophrenia; (ii) A primary diagnosis
of bipolar disorder with psychosis; (iii) A primary diagnosis
of major depression with psychosis; (iv) A primary diagnosis
indicating attempted suicide or self-injury; (v) A reported condition
of homicidal ideation; (vi) A reported condition
of suicidal ideation; (vii) A primary diagnosis of substance use with pregnancy or
one year postpartum; or (viii) Receipt of an injectable antipsychotic. (b) Group 2. Claims utilization in the twelve months
preceding attribution identifies a combination of the following diagnostic and
utilization criteria: (i) One or more of the
following services, service locations or medications for a behavioral-health
related condition: (a) Inpatient hospital
visit; (b) Crisis unit
visit; (c) A nursing facility
visit; (d) A rehabilitation
facility visit; (e) A medication as
identified in appendix B to this rule that was administered as a component of
MAT for treatment of a substance use disorder; or (f) For individuals under
the age of twenty-two, a therapeutic behavioral group service per diem;
and (ii) One or more of the
following primary diagnoses as identified in appendix C to this
rule: (a) Bipolar disorder
without psychosis; (b) Major depression
without psychosis; (c) Post traumatic stress
disorder; (d) Substance use
disorder; (e) Conduct
disorder; (f) Personality
disorder; (g) Psychosis; (h) Oppositional defiance
disorder; (i) Eating disorder;
or (j) Other
depression. (3) For medicaid covered
individuals who do not have sufficient claims history to substantiate the
eligibility criteria for BHCC, any provider may make a referral to the MCP to
request enrollment in BHCC and attribution to a QBHE. The provider must provide
sufficient documentation to demonstrate the individual meets the BHCC
eligibility criteria as defined in this rule. Each referral is subject to
review and approval by the MCP. (4) Eligible members who
are in foster care and meet the eligibility criteria in paragraph (D)(2) of
this rule will be attributed to a QBHE only after the guardian is notified of
eligibility by ODM or its designee, and the guardian provides consent for the
individual in foster care to receive BHCC. (5) For eligible members
who are also receiving substance use disorder (SUD) residential treatment, the
following applies: (a) The eligible member will be attributed to or maintain
attribution with a QBHE during the SUD residential treatment
period. (b) The QBHE will not be eligible for BHCC payments during
the eligible member's SUD residential treatment period because BHCC is
duplicative of the care coordination responsibilities of the SUD residential
treatment program. (c) The QBHE will immediately re-engage the eligible member
for BHCC upon discharge from the SUD residential treatment period. (6) For eligible members
who also meet criteria for assertive community treatment (ACT) or intensive
home based treatment (IHBT) as defined in Chapter 5160-27 of the Administrative
Code, the following applies: (a) The eligible member will be attributed to or maintain
attribution with a QBHE. (b) If the QBHE is certified to deliver ACT or IHBT, it
shall provide ACT or IHBT in lieu of BHCC as long as ACT or IHBT is medically
necessary. When the ACT or IHBT service is no longer medically necessary, the
eligible member shall be transitioned to BHCC. (c) If the QBHE is not an eligible provider of ACT or IHBT,
the eligible member may choose to either receive BHCC from the QBHE or opt-out
and receive ACT or IHBT from a provider eligible to deliver ACT or
IHBT. (E) Attribution. (1) At any time, the
eligible member may choose a specific QBHE or request to be re-attributed to a
different QBHE by submitting a request to the member's MCP. (2) If no choice has been
identified by the eligible member, attribution will be completed using claims
utilization data and the member's visit history, provider specialty, and
geographic proximity between the member and provider. (3) Eligible individuals
may opt-out of receiving BHCC and may opt-in at any time by making a request to
the MCP. (F) A participating QBHE must perform the
following activities as needed for their attributed individuals: (1) "Outreach and
engagement" activities which includes: (a) Conducting initial outreach and engagement with
attributed individuals upon enrollment in the BHCC program; (b) Leading initial outreach with the attributed
individual's PCP to share information regarding the BHCC program
participation and care plan development; (c) Building trust-based relationships to understand the
preferences and goals of the attributed individual and begin engaging with the
individual's family or social support system; (d) Leading development of the outreach plan that ensures
alignment with the individual's PCP and the MCP to establish a process for
information exchange and to identify each stakeholder's role in
coordinating care; (e) Establishing relationships and collaborations with a
full spectrum of providers and payers as appropriate; and (f) Educating other providers and payers about the BHCC
program and the value of collaborating to deliver medically necessary
services. (2) "Comprehensive
care plan" activities in which the QBHE must: (a) Within thirty days of the first BHCC activity
conducted, begin developing a comprehensive care plan that addresses the
individual's behavioral and physical health needs; (b) Act as the lead for creating and maintaining the
comprehensive care plan, including leading outreach to the PCP to incorporate
inputs for physical health components in the comprehensive care plan;
and (c) Develop the behavioral health components of the
comprehensive care plan. (G) "Ongoing maintenance" activities must be
performed by the QBHE including, but not limited to, the
following: (1) Relationship maintenance activities
in which the QBHE must, as a primary contact for communication about behavioral
health and physical health needs of the attributed individual, conduct regular
check-ins, educational activities and additional intensive support as needed
which include the following: (a) Directing individual and family education on behavioral
health, including self-care and adherence to the comprehensive care plan;
and (b) Conducting follow ups with the individual on behavioral
health care and updating, as appropriate, the comprehensive care plan, CPC
practice, or PCP. (2) "Individual engagement and
access to appropriate care" activities in which the QBHE
must: (a) Improve access to appropriate care by addressing
barriers such as assistance with scheduling appointments or connecting the
attributed individual to transportation; (b) Lead scheduling with guidance from the CPC practice or
PCP and work with the attributed individual to reduce barriers to attendance
for appointments; (c) Lead follow-ups with the CPC practice or PCP to
understand implications from ambulatory or acute encounters such as treatment
adherence; (d) Engage directly with the attributed individual's
health care providers as well as community resources to support care and make
necessary updates to the comprehensive care plan; (e) Be accountable for referral decision support and
scheduling for behavioral health care in both inpatient and outpatient
settings; and (f) Stabilize crises by gathering information from the
attributed individual, CPC practice or PCP, social support systems, and other
medical providers and formulating a response for immediate intervention or
stabilization. (3) "Engaging supportive
services" activities in which the QBHE must facilitate access to needed
community services such as housing or vocational services. (4) "Population health
management" activities in which the QBHE must use appropriate data to
identify high-risk individuals and utilize the appropriate resources to deliver
specialized interventions. (5) "Individual
transition" activities in which the QBHE must: (a) Ensure the attributed individual's successful
transition between providers or sites of care including triaging the individual
to medically necessary services not available at the attributed
QBHE; (b) Lead outreach to the CPC practice or PCP after major
behavioral health events such as an inpatient stay and discuss implications for
physical healthcare; (c) Follow up with the CPC practice or PCP following major
physical health related events and discuss implications for behavioral health
care as well as transition needs of the attributed individual such as
transportation and medications; and (d) Monitor the attributed individual's admission and
discharges related to behavioral health treatment by establishing relationships
with hospitals and hospital emergency departments. (H) An enrolled QBHE will be evaluated based upon its
population of attributed individuals meeting the identified thresholds for the
following HEDIS, NQF, and PQI measures, as applicable, quarterly and at the end
of each calendar year by ODM or the MCP. More detailed information regarding
these requirements can be found on the ODM website,
www.medicaid.ohio.gov. (1) Adult body mass index
(BMI) assessment; (2) Controlling high
blood pressure; (3) Comprehensive
diabetes care; eye exam (retinal) performed; (4) Comprehensive
diabetes care; HbA1c poor control (greater than nine per cent); (5) Comprehensive
diabetes care; HbA1c testing; (6) Tobacco use;
screening and cessation; (7) Follow-up within
seven days after hospitalization for mental illness; (8) Follow-up within
seven days after an emergency department visit for mental illness; (9) Follow-up within
seven days after an emergency department visit for alcohol or other drug
dependence; (10) Antidepressant medication
management; (11) Initiation and engagement of alcohol
and other drug dependence treatment; (12) Adherence to antipsychotic
medications for individuals with schizophrenia; (13) Metabolic monitoring for children and
adolescents on antipsychotics; (14) Use of multiple concurrent
antipsychotics in children and adolescents; (15) Emergency department
visits; (16) Behavioral health-related inpatient
admissions; (17) Inpatient discharges; (18) All-cause readmissions; (19) Adolescent well-care
visits; (20) Weight assessment and counseling for
nutrition and physical activity for children and adolescents including BMI
documentation; (21) Per cent of live births weighing less
than two thousand five hundred grams; (22) Prenatal care including timeliness of
care; (23) Postpartum care; (24) Use of opioids at high dosage
(greater than eighty morphine equivalent dose per day); and (25) Rate of opioid-related emergency
department visits per one-thousand member months. (I) Additional requirements for enrolled
QBHEs. (1) The QBHE must assign
at least one individual who serves as the point of contact for the MCP and ODM
or its designee to discuss performance of BHCC quality measures. (2) The QBHE must
identify a care team that includes the following roles: (a) Case manager to lead the care coordination relationship
and serve as the primary point of contact for the individual and their
family. (b) Registered nurse or licensed practical nurse to consult
and coordinate with the eligible member's other medical
providers. (c) Program administrative contact to act as the single
point of contact to fulfill records requests and perform other administrative
activities. (3) The QBHE must
maintain records that meet the requirements set forth in rule 5160-1-17.2 of
the Administrative Code. (4) For eligible members
or attributed individuals who opt-out of the BHCC program, the QBHE must
document in the medical record the circumstances regarding the
individual's decision and notify the member's MCP of this decision by
no later than the end of the following business day. (5) If a participating
QBHE chooses to terminate its designation as a QBHE, it must provide notice to
ODM and the MCPs in accordance with rule 5160-26-05 of the Administrative
Code. (J) Reimbursement. (1) QBHEs are authorized
under this rule to provide the identified BHCC activities on a monthly basis to
attributed individuals and obtain a monthly payment rate as found in appendix D
to this rule for each calendar month the BHCC specific activities are
performed. (2) To be eligible for
payment under this rule, BHCC activities must be separate and distinct from
other medicaid-covered services provided within the same calendar
month. (3) If the member is attributed prior to
July 1, 2019, the QBHE may begin submitting claims for BHCC for dates of
service in July 2019 no earlier than August 1, 2019. If the member is
attributed after July 1, 2019 for the first program year, the QBHE may begin
submitting claims for BHCC in the calendar month following the month in which
the eligible member was attributed to the QBHE. QBHEs will not be reimbursed
for BHCC services prior to July 1, 2019. (4) The BHCC activities
performed must be identified on claims for BHCC using the procedure codes and
modifiers identified in appendix D to this rule. (5) The QBHE may bill for BHCC once per
calendar month per attributed individual when the following requirements are
met: (a) For the initial payment, the QBHE may submit a claim
for the BHCC service if it has completed, at a minimum, the activity
requirements set forth in paragraphs (F)(1)(a) to (F)(1)(c) of this rule and
begin developing the comprehensive care plan as specified in paragraph (F)(2)
of this rule. (b) For ongoing payment, the QBHE may submit a claim for
BHCC if it has completed in the same calendar month, at least one of the
activity requirements set forth in paragraph (F) or (G) of this rule. Other
activities stated in paragraphs (F) and (G) of this rule must be provided as
needed. (c) At least one activity
is performed every month that involves contact with the attributed
individual. (6) For attributed individuals in the
BHCC program, payments for community psychiatric supportive treatment (CPST)
and targeted case management as described in Chapter 5160-27 of the
Administrative Code will not be made as these are considered duplicative of the
BHCC program activities. (K) Penalties. (1) The QBHE must
continue to meet all requirements as defined in this rule. If these
requirements are not met upon evaluation, payment under this rule is subject to
termination. (2) A QBHE may seek
reconsideration pursuant to rule 5160-70-02 of the Administrative Code to
challenge decisions by ODM to terminate payments described in this
rule.
View Appendix
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Rule 5160-1-80 | Substitute practitioners (locum tenens).
Effective:
October 1, 2023
(A) Definitions. (1) "Practitioner," for purposes of this rule, is a
collective term for the following professionals: (a) Doctor of medicine or osteopathy; (b) Advanced practice registered nurse; (c) Dentist; (d) Optometrist; (e) Podiatrist; or (f) Chiropractor. (2) "Regular
practitioner" is a practitioner enrolled in the Ohio medicaid program who
regularly takes care of an individual's health care needs. (3) "Substitute
practitioner" is a practitioner who generally does not maintain an
individual practice and who works in place of a regular practitioner when the
regular practitioner is absent; (B) Coverage and limitations. Payment may be made for
services rendered by a substitute practitioner only when the following
conditions are met: (1) Both the regular practitioner and the
substitute practitioner are professionals listed in paragraph (A)(1) of this
rule; (2) The regular practitioner is expected
to be absent for a period of not longer than sixty days unless there are
extenuating circumstances (e.g., active duty in the armed forces, pregnancy,
extended illness); (3) The substitute practitioner has the
status of an independent contractor rather than of an employee; (4) The substitute practitioner meets the
applicable provider screening requirements described in rule 5160-1-17.8 of the
Administrative Code; (5) The substitute practitioner has not
been sanctioned under medicare, medicaid, or Title XX and is not otherwise
prohibited from providing services to medicare, medicaid, or Title XX
beneficiaries; and (6) The substitute practitioner receives
payment from the regular practitioner as a fixed amount per diem or on a
similar fee-for-time basis.
Last updated October 2, 2023 at 8:23 AM
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Rule 5160-1-97 | One-time medicaid provider relief payments.
The department of medicaid (ODM) will make relief
payments available to Ohio medicaid hospitals defined in paragraph (A) of this
rule, as authorized under Section 270.15 of Amended Substitute House Bill 45 of
the 134th General Assembly: (A) ODM will make available a one-time
lump sum payment to the following hospital types: (1) "Critical access
hospitals," as defined in rule 5160-2-05 of the Administrative
Code. (2) "Rural
hospitals," as defined in rule 5160-2-05 of the Administrative
Code. (B) The payment will be established in
the following manner: (1) The total sum to be
made available to all eligible Ohio medicaid hospitals as defined in paragraph
(A) of this rule is sixty-two million dollars less the amount described in
paragraph (B)(2) of this rule. (2) Any hospital located
in a county in the Northwest region as defined in the appendix of rule
5160-2-05 of the Administrative Code with a population of less than forty-two
thousand residents and less than three hundred square land miles according to
the United States census bureau (July 1, 2021) will qualify for an additional
payment of two million one hundred thousand dollars. (3) No individual hospital will receive a
total calculated payment that exceeds three million dollars. (4) For each hospital, the value of the
final one-time payment will be calculated as follows: (a) Base payment data to be utilized for establishing
provider payment amounts are fee-for-service (FFS) payments for state fiscal
year 2022 and reflected in the ODM management information technology system
(MITS) on January 31, 2023. (b) Each payment is the product of the ratio of each
hospital's total FFS payments to the total FFS payments for all eligible
hospitals as defined in paragraph (A) of this rule, multiplied by the amount
listed in paragraph (B)(1) of this rule. (c) For each hospital, if the total calculated payment in
paragraph (B)(4)(b) of this rule exceeds the amount described in paragraph
(B)(3) of this rule, the hospital's payment amount is limited to the
amount defined in (B)(3) of this rule. (d) For hospitals with a payment amount limited as
described in paragraph (B)(4)(c) of this rule: (i) Subtract the amount
calculated in paragraph (B)(4)(c) of this rule from the amount determined in
paragraph (B)(4)(b) of this rule then sum these amounts for these hospitals.
(ii) Distribute the sum
of the amounts determined in paragraph (B)(4)(d)(i) of this rule, to all
hospitals that have not exceeded the payment amount calculated in paragraph
(B)(3) of this rule, using the same methodology described in paragraph
(B)(4)(b) of this rule until all remaining funds from the amount calculated in
paragraph (B)(4)(d)(i) of this rule are expended. (5) If a hospital's calculated
payment amount in paragraph (B)(4)(b) of this rule is less than four thousand
dollars, no payment will be made to that hospital.
Last updated May 30, 2023 at 8:24 AM
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Rule 5160-1-98 | Deposits to the health care/medicaid support and recoveries fund for program support.
Effective:
December 12, 2024
(A) The Ohio department of medicaid (ODM)
will deposit a portion of the intergovernmental transfers (IGT) that are paid
under any state directed payment (SDP) program as authorized under 42 CFR
438.6(c) effective as of July 9, 2024. (B) On or after the effective date of
this rule and for each year thereafter: (1) Pursuant to paragraph
(A) of this rule, each provider eligible to receive a directed SDP program
payment will submit to ODM an additional IGT which is to be four per cent of
the provider's computed IGT amount. (2) In subsequent SDP
program years, ODM may establish a rate higher or lower than the rate described
in paragraph (B)(1) of this rule as approved by the medicaid director.
Last updated December 12, 2024 at 8:13 AM
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