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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Rule 5160-27-03 | Reimbursement for community behavioral health services.

 

(A) This rule sets forth the reimbursement requirements and rates for behavioral health services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code.

(B) Providers rendering community behavioral health services shall abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code.

(C) Records related to services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456.3 (October 1, 2016) and rule 5160-01-27 of the Administrative Code.

(D) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, medicaid reimbursement rates for services and practitioners described in Chapter 5160-27 of the Administrative Code are listed in the appendix to this rule. Ohio medicaid shall reimburse the provider the lower of either their usual and customary charges or the reimbursement amount described in the appendix to this rule.

(1) The reimbursement rate for physicians, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(2) The reimbursement rate for clinical nurse specialists, certified nurse practitioners, and physician assistants, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is eighty-five per cent of the medicaid maximum rate stated in the appendix to this rule; except for evaluation and management office/outpatient visits, psychiatric diagnostic evaluations, and smoking and tobacco cessation counseling the reimbursement rate is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(3) The reimbursement rate for practitioners described in paragraph (A)(5) of rule 5160-27-01 of the Administrative Code is the reimbursement rate percentage described in rule 5160-8-05 of the Administrative Code (medicaid maximum rate stated in the appendix to this rule). The reimbursement rates for services not defined in rule 5160-8-05 of the Administrative Code are stated in the appendix to this rule.

(4) The reimbursement rates for practitioners described in rule 5160-27-01 of the Administrative Code and not otherwise addressed in paragraph (D) of this rule, are stated in the appendix to this rule.

(5) The reimbursement rate for pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code is set forth in rule 5160-8-52 of the Administrative Code.

(E) The medicaid reimbursement rate for any of the following services provided for more than ninety minutes by the same billing provider, to the same recipient, on the same calendar day will be fifty per cent of the rate listed in appendix to this rule.

(1) Community psychiatric supportive treatment as described in rule 5122-29-17 of the Administrative Code.

(2) Therapeutic behavioral service as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(3) Psychosocial rehabilitation as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(4) Substance use disorder targeted case management as described in rule 5160-27-10 of the Administrative Code.

(F) Providers identified in rule 5160-27-01 of the Administrative Code must identify the rendering practitioner as follows:

(1) For practitioners who are eligible to enroll with Ohio medicaid and who meet the requirements of Chapter 5160-27 of the Administrative Code, list their national provider identifier number in the rendering field on the claim, or

(2) For licensed practitioners who do not have an independent professional scope or for practitioners that are unlicensed, include the modifier that accurately describes their credentials.

(G) Medicaid reimbursement is contingent upon providers maintaining complete and accurate documentation as required by Chapter 5160-27 of the Administrative Code.

(H) Medicaid behavioral health claims submitted for reimbursement must comply with the requirements of the national correct coding initiative of the centers for medicare and medicaid services.

(I) Behavioral health services that are reimbursable by medicare shall be billed first to medicare in accordance with rule 5160-1-05 of the Administrative Code unless otherwise provided by paragraph (K) of this rule. Failure to do so may result in denial of the medicaid claim.

(J) Behavioral health services that are reimbursable by a third party health care insurer shall be billed first to the third party health care insurer in accordance with rule 5160-1-08 of the Administrative Code unless otherwise provided by paragraph (K) of this rule. Failure to do so may result in denial of the medicaid claim.

(K) If a behavioral health provider, as defined in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code, has billed a third party in accordance with either paragraph (I) or paragraph (J) of this rule and the third party has not paid the claim within thirty days, and the provider has concerns regarding the recipient's access to care, the provider may submit the claim for medicaid reimbursement. The provider must include, with the submitted claim, a certification statement that the provider waited thirty days, access to care for the recipient is a concern, and no response was received from the third party.

(L) Place of service codes for behavioral health services as described in paragraph (G) of rule 5160-27-02 of the Administrative Code are stated in the appendix to this rule.

View Appendix

Last updated October 15, 2021 at 9:25 AM

Supplemental Information

Authorized By: 5162.02, 5164.02
Amplifies: 5162.05, 5164.02 , 5164.03, 5164.15, 5164.76
Five Year Review Date: 1/1/2023
Prior Effective Dates: 1/1/2018, 1/2/2018 (Emer.), 5/3/2018, 8/1/2019 (Emer.), 11/29/2019, 1/17/2021