Rule 5160-4-04 | Advanced practice registered nurse (APRN) services.
(A) Definition. "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. The term encompasses a certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse-midwife (CNM), and certified nurse practitioner (CNP).
(B) Coverage.
(1) Unless a specific exception is noted, all other rules in agency 5160 of the Administrative Code that pertain to services rendered by a physician apply also to services rendered by an APRN.
(2) For a covered service rendered by an APRN, payment may be made only if the following conditions are met:
(a) The service is rendered to an Ohio-medicaid-eligible individual in a state in which the APRN is licensed or authorized to practice;
(b) The service is within the scope of practice of the APRN's specialty;
(c) The APRN personally rendered the service to an individual patient; and
(d) The service cannot be performed by someone who lacks the skills and training of an APRN.
(C) Payment.
(1) Payment for a covered service rendered by a CRNA is made in accordance with rule 5160-4-21 of the Administrative Code.
(2) Payment for a covered service rendered by a CNS, CNM, or CNP is the lesser of the billing provider's submitted charge or the applicable amount from the following list:
(a) For a covered service rendered in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), eighty-five per cent of the medicaid maximum;
(b) For a covered service rendered in a non-hospital setting, one hundred per cent of the medicaid maximum; or
(c) For assistant-at-surgery services provided by a CNS, CNM, or CNP regardless of setting, twenty-five per cent of the medicaid maximum for the covered primary surgical procedure.
(3) Payment for services rendered by a hospital-employed APRN will be made to the hospital.
(4) In the event that payment for a covered service performed by an APRN is issued both to the APRN and to a contracting or supervising provider on behalf of the APRN, one of the issued payments is subject to recovery.
Last updated January 3, 2022 at 9:48 AM
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