Rule 5160-26-05 | Managed care: provider network and contracting requirements.
(A) Provider contracts.
(1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule, 42 C.F.R. 434.6 and 42 C.F.R 438.6 (October 1, 2024). The MCE's execution of a provider contract does not terminate the MCE's legal responsibility to the Ohio department of medicaid (ODM) to ensure all of the MCE's activities and obligations are performed in accordance with agency 5160 of the Administrative Code, as applicable, the MCE's provider agreement or contract with ODM, and all applicable federal, state, and local regulations.
(2) The MCE will make all provider contracts available to ODM upon request.
(3) Provider contracts may not include language that conflicts with the specifications identified in paragraph (C) of this rule.
(4) MCE network providers have to maintain an active, valid medicaid provider agreement as set forth in rule 5160-1-17.2 of the Administrative Code.
(5) When utilizing an out of network provider, the MCE must establish a mutually agreed upon compensation amount for the authorized service and notify the provider of the applicable provisions of the medicaid addendum (ODM 10235). For medicaid-covered non-emergency hospital services outlined in rule 5160-26-03 of the Administrative Code, the compensation amount is identified in rule 5160-26-11 of the Administrative Code.
(B) Notification.
(1) Notwithstanding applicable provisions outlined in the medicaid addendum (ODM 10235), the MCE must notify ODM of any addition to or deletion from its provider network on an ongoing basis and must follow the time restrictions contained in this paragraph unless an explanation of extenuating circumstances is accepted by ODM.
(2) At the direction of ODM, the MCE must submit evidence of the following:
(a) A copy of the provider's current licensure;
(b) Copies of written agreements with the provider, including but not limited to provider contracts, amendments, and the medicaid addendum as specified in paragraph (D) of this rule;
(c) Notification to ODM of any hospital provider contract for which a date of termination is specified; and
(d) The provider's medicaid provider identification number.
(3) The MCE will notify ODM in writing of the expiration, nonrenewal, or termination of any provider contract at least fifty-five calendar days prior to the expiration, nonrenewal, or termination of the provider contract in a manner and format directed by ODM. If the MCE receives less than fifty-five calendar days' notice from the provider, the MCE must inform ODM in writing within one working day of becoming aware of this information.
(4) If the provider contract is for a hospital:
(a) Forty-five calendar days prior to the effective date of the expiration, nonrenewal or termination of the hospital's provider contract, the MCE shall notify in writing all providers who have admitting privileges at the hospital of the impending expiration, nonrenewal, or termination of the provider contract and the last date the hospital will provide services to members under the MCE provider contract. If the MCE receives less than forty-five calendar days' notice from the hospital, the MCE shall send the notice within one working day of becoming aware of the expiration, nonrenewal, or termination of the provider contract.
(b) Forty-five calendar days prior to the effective date of the expiration, nonrenewal, or termination of the hospital's provider contract, the MCE shall notify in writing all members in the service area, or in an area authorized by ODM, of the impending expiration, nonrenewal, or termination of the hospital's provider contract. If the MCE receives less than forty-five calendar days' notice from the hospital provider, the MCE shall send the notice within one working day of becoming aware of the expiration, nonrenewal, or termination of the provider contract.
(c) The MCE shall submit a template for member and provider notifications to ODM along with the MCE's notification to ODM of the impending expiration, nonrenewal, or termination of the hospital's provider contract. The notifications shall comply with the following:
(i) The form and content of the member notice have to be prior-approved by ODM and contain an ODM designated toll-free telephone number members can call for information and assistance.
(ii) The form and content of the provider notice have to be prior-approved by ODM.
(d) ODM may require the MCE to notify additional members or providers if the impending expiration, nonrenewal, or termination of the hospital's provider contract adversely impacts additional members or providers.
(5) If the provider contract is for a primary care provider (PCP):
(a) The MCE will include the number of members that will be affected by the change in the notice to ODM; and
(b) The MCE will notify in writing all members who use or are assigned to the provider as a PCP at least forty-five calendar days prior to the effective date of the change. If the MCE receives less than forty-five calendar days prior notice from the PCP, the MCE will issue the notification within one working day of the MCE becoming aware of the expiration, nonrenewal, or termination of PCP's provider contract. The form of the notice and its content have to be prior-approved by ODM and must contain, at a minimum, all of the following information:
(i) The PCP's name and last date the PCP is available to provide care to the MCE's members;
(ii) Information regarding how members can select a different PCP; and
(iii) An MCE telephone number members can call for further information or assistance.
(6) ODM may require the MCE to notify members or providers of the expiration, nonrenewal, or termination of other provider contracts that may adversely impact the MCE's members.
(7) In order to ensure availability of services and qualifications of providers, ODM may require submission of documentation in accordance with paragraph (B) of this rule regardless of whether the MCE contracts directly for services or does so through another entity.
(8) In the event that the MCE's medicaid managed care program participation in a service area is terminated, the MCE must provide written notification to its affected contracted providers at least forty-five calendar days prior to the termination date, unless otherwise specified by ODM.
(C) Provider qualifications.
(1) The MCE must ensure that none of its employees or contracted providers are sanctioned or excluded from providing medicaid or medicare services. The MCE shall use available resources for identifying sanctioned or excluded providers, at least monthly, including, but not limited to, the following:
(a) The federal office of inspector general provider exclusion list;
(b) The ODM excluded provider web page; and
(c) The discipline pages of the applicable state boards that license providers or an alternative data resource, such as the national practitioner databank, that is as complete and accurate as the discipline pages of the applicable state boards.
(2) The MCE may not discriminate with regard to the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification. If the MCE declines to include individual or groups of providers in its network, it must give the affected providers written notice of the reasons for its decision. This paragraph may not be construed to:
(a) Require the MCE to contract with providers beyond the number necessary to meet the needs of its members as described in the MCE's provider agreement or contract with ODM;
(b) Preclude the MCE from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or
(c) Preclude the MCE from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to members.
(3) The MCE must have written policies and procedures for the selection and retention of providers that prohibit discrimination against particular providers that serve high-risk populations or specialize in conditions that require costly treatment.
(4) The MCE will accept ODM credentialing of ODM-enrolled providers and will not conduct any further credentialing activities for those providers.
(D) Provider contract specifications.
All provider contracts, including single case agreements, must include a medicaid addendum that has been approved by ODM. A template for the medicaid addendum (ODM 10235) is available on the department's website at medicaid.ohio.gov.
Last updated May 5, 2025 at 7:38 AM
Supplemental Information
Amplifies: 5162.02, 5164.02, 5167.02, 5167.03, 5167.10
Five Year Review Date: 5/5/2030
Prior Effective Dates: 4/1/1985, 10/1/1987, 2/15/1989 (Emer.), 5/8/1989, 5/1/1992, 5/1/1993, 11/1/1994, 7/1/1996, 7/1/1997 (Emer.), 9/27/1997, 12/10/1999, 7/1/2000, 10/27/2000, 7/20/2001, 7/1/2002, 7/1/2003, 1/1/2006, 6/1/2006, 1/1/2007, 7/1/2007, 1/1/2008, 7/1/2009, 8/1/2011, 7/2/2015, 8/1/2016, 5/1/2017, 2/14/2019, 7/19/2020, 7/18/2022