Rule 5160-26-11 | Managed care: managed care plan non-contracting providers.
(A) Non-contracting providers of emergency services must accept as payment in full from a managed care organization (MCO) the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of service. Pursuant to section 5167.101 of the Revised Code, the MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM.
(B) When ODM has approved the MCO's members to be referred to a non-contracting hospital pursuant to rule 5160-26-03 of the Administrative Code, the non-contracting hospital must provide the service for which the referral was authorized and must accept as payment in full from the MCO one hundred per cent of the current Ohio medicaid program reimbursement rate in effect for the date of service. Pursuant to section 5167.101 of the Revised Code, the MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM. Non-contracting hospitals are exempted from this provision when:
(1) The hospital is located in a county in which eligible individuals were required to enroll in an MCO prior to January 1, 2006;
(2) The hospital is contracted with at least one MCO serving the eligible individuals specified in paragraph (B)(1) of this rule prior to January 1, 2006; and
(3) The hospital remains contracted with at least one MCO serving eligible individuals who are required to enroll in an MCO in the service area where the hospital is located.
(C) Non-contracting qualified family planning providers (QFPPs) must accept as payment in full from the MCO the lesser of one hundred per cent of the Ohio medicaid program reimbursement rate or billed charges, in effect for the date of service.
(D) A managed care entity (MCE) non-contracting provider may not bill the MCE member unless:
(1) The conditions described in rule 5160-1-13.1 of the Administrative Code are met; and
(2) The reason the service is not covered by the MCE is specified and is one of the following:
(a) The service is a benefit exclusion;
(b) The provider is not contracted with the MCE and the MCE has denied approval for the provider to provide the service because the service is available from a contracted provider, at no cost to the member; or
(c) The provider is not contracted with the MCE and has not requested approval to provide the service.
(E) An MCE non-contracting provider may not bill a member for a missed appointment.
(F) Non-contracting providers, including non-contracting providers of emergency services, must contact the twenty-four hour post-stabilization services phone line designated by the MCO to request authorization to provide post-stabilization services in accordance with rule 5160-26-03 of the Administrative Code.
(G) Non-contracting providers, including non-contracting providers of emergency services, must allow the MCE, ODM, and ODM's designee access to all member medical records for a period not less than ten years from the date of service or until any audit initiated within the ten year period is completed. Access must include copies of the medical records at no cost for the purpose of activities related to the annual external quality review specified by 42 C.F.R. 438.358 (October 1, 2021).
(H) If the MCE elects to impose member co-payments in accordance with rule 5160-26-12 of the Administrative Code, applicable co-payments shall also apply to services rendered by non-contracting providers. If the MCE has not elected to impose co-payments, non-contracting providers are not permitted to impose co-payments on MCE members.
Last updated September 1, 2023 at 1:10 PM
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