Rule 5160-18-02 | Pediatric recovery centers (PRCs).
(A) This rule defines coverage and payment for providers who meet the provisions in sections 5103.60, 5103.602, 5103.603, 5103.6010, 5103.6011, 5103.6017 and 5103.6018 of the Revised Code and the provisions described in this rule.
(B) Definitions. For the purpose of this rule the following definitions apply:
(1) "Clinical Director" is a practitioner of physician services who supervises day-to-day clinical operations of the pediatric recovery center (PRC) including clinical practice standards and quality improvement in collaboration with the medical director. The clinical director will also be responsible for coordinating outreach and education to referring entities.
(2) "Direct care costs" are costs for services delivered to an infant treated at a PRC through a PRC employee or contractual arrangement with a PRC. Direct care costs include wages, supervision, staff development, contracting, and consulting services.
(3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.
(4) "Medical Director" means a practitioner of physician services who assumes responsibility for administering all medical services performed by the PRC, either by performing them directly or by delegating specific responsibility to authorized program physicians and health care professionals functioning under the medical director's supervision. The medical director will have hospital admitting privileges.
(5) "Non-pharmacological care" means evidence-based treatment, excluding the use of pharmacological interventions, for withdrawal that is recognized by the American academy of pediatrics or another nationally recognized organization with expertise in withdrawal treatment.
(6) "Pediatric recovery center (PRC)" has the same meaning as "residential infant care center" in section 5103.60 of the Revised Code.
(7) "Pharmacological care" means the use of prescribed medications indicated to relieve moderate to severe signs of withdrawal and to prevent complications such as fever, weight loss, and seizures that is recognized by the American academy of pediatrics or another nationally recognized organization with expertise in withdrawal treatment.
(C) Providers:
(1) Billing ("pay-to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a covered PRC service:
(a) PRCs.
(b) Professional medical groups with a PRC specialty.
(D) Staffing:
(1) In addition to the operational requirements in section 5103.6010 of the Revised Code, a PRC will employ or contract with the following providers:
(a) Medical director with hospital admitting privileges; and
(b) Clinical director to establish, supervise and evaluate clinical services.
(2) The PRC will ensure all clinical and professional staff who provide direct care to or interact with patients and families complete training in trauma-informed care annually and for new employees within thirty calendar days of start date.
(E) Coverage:
(1) Payment may be made only for a PRC service for which the following conditions are met:
(a) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code.
(b) For admission to a PRC, the following criteria are met:
(i) The infant is recommended or referred by a practitioner of physician services, a public children services agency, a parent, guardian, or legal custodian.
(ii) The infant is considered medically stable as determined by hospital or other facility discharge; and
(iii) The infant's parent or caregiver would benefit from additional education and support services regarding care for the patient.
(c) The PRC develops and implements a program for parents and caregivers of the infant, either individually or in a group setting to address:
(i) Activities to encourage caregiver-infant bonding.
(ii) Advising on caring for infants with physical withdrawal symptoms.
(iii) Referrals for services and counseling; and
(iv) Training on caring for infants.
(F) Payment:
(1) The medicaid base per diem rate includes medically necessary PRC services provided to the infant during their stay at the PRC for up to thirty consecutive days.
(2) PRC per diem payments in excess of thirty days may be made through the prior authorization (PA) process described in rule 5160-1-31 of the Administrative Code. If treatment goals are not accomplished within a consecutive thirty day timeframe, it is the PRC's responsibility to justify why a longer stay is needed.
(a) The justification for a continued stay should be directly related to the physical withdrawal symptoms of the infant which have not improved and should include the following:
(i) A documented medical diagnosis related to significant substance exposure resulting in withdrawal.
(ii) A description of the infant's condition including on-going physical withdrawal symptoms and additional unimproved symptoms requiring medically necessary care in this setting; and
(iii) A detailed care plan with the anticipated period of time for treatment goals to be met.
(b) A lack of post-discharge options alone will not be considered a valid basis for a continued stay at a PRC.
(3) The per diem rate includes the following:
(a) Activities to encourage caregiver-infant bonding.
(b) Advising on caring for infants with physical withdrawal symptoms.
(c) Referrals for services and counseling.
(d) Direct care costs.
(e) Discharge planning.
(f) Non-pharmacological care for infants with significant substance exposure resulting in withdrawal.
(g) Pediatric medical services including but not limited to prescribing medication, administering rectal or intravenous medication, outpatient laboratory services, sick visits, and onsite well child exams.
(h) Pharmacological care for infants with significant substance exposure resulting in withdrawal; and
(i) Training on caring for infants.
(4) Services not included in the PRC per diem reimbursement rate for which a separate medicaid payment may be made include, but are not limited to:
(a) Direct services provided to medicaid eligible parents or caregivers.
(b) Healthcare-related transportation services defined in Chapter 5160-15 of the Administrative Code.
(c) Services rendered by a practitioner of physician services.
(d) Other services specifically authorized in rule promulgated under agency 5160 of the Administrative Code.
(5) For any covered PRC service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.
Last updated July 1, 2025 at 8:06 AM
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