Skip to main content
Back To Top Top Back To Top
This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

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 December 22, 2023 at 9:37 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2023
Prior Effective Dates: 4/7/1977, 12/21/1977, 12/30/1977, 1/8/1979, 2/1/1980, 5/19/1986, 7/1/1987, 4/1/1988, 9/1/1989, 1/1/2001, 8/2/2011