Rule 5160-8-42 | Lactation consultation services.
(A) Definitions applicable to this rule.
(1) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.
(2) "Lactation consultation" is the development and implementation of management strategies for complex problems related to breastfeeding and human lactation.
(3) "International Board-Certified Lactation Consultant (IBCLC)" is a professional member of the healthcare team who has earned and maintains the credential established by the "International Board of Lactation Consultant Examiners," which attests to expertise in breastfeeding management and care, including the insight, skills, and knowledge needed to identify complex breastfeeding problems, to provide education about breastfeeding, and to facilitate an optimal breastfeeding experience and environment.
(B) Providers.
(1) Rendering providers. The following eligible providers may receive medicaid payment for rendering a lactation consultation service:
(a) An IBCLC;
(b) An advanced practice registered nurse;
(c) A physician; or
(d) A physician assistant.
(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for lactation consultation services on behalf of a rendering provider:
(a) The rendering provider;
(b) A professional medical group practice;
(c) A professional dental group practice;
(d) A pharmacy;
(e) A federally qualified health center (FQHC);
(f) A rural health clinic (RHC); or
(g) An ambulatory health care clinic.
(C) Coverage.
(1) Payment for a lactation consultation service is made separately from payment for other professional services. No separate payment, however, is made for a lactation consultation service provided in conjunction with nurse home visiting services (which are addressed in rule 5160-21-05 of the Administrative Code).
(2) For a lactation consultation service, the practitioner order specified in rule 5160-1-17 of the Administrative Code is waived.
(D) Claim payment.
(1) Payment for a covered lactation consultation service provided in a hospital is made in accordance with Chapter 5160-2 of the Administrative Code.
(2) Payment for a covered lactation consultation service provided by an FQHC or RHC is made in accordance with Chapter 5160-28 of the Administrative Code.
(3) Payment for a covered lactation consultation service rendered in other settings is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.
(4) Payment for lactation pumps and supplies is made in accordance with rule 5160-10-25 of the Administrative Code.
Last updated October 1, 2024 at 9:07 AM
Supplemental Information