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

Chapter 5160-1 | General Provisions

 
 
 
Rule
Rule 5160-1-01 | Medicaid medical necessity: definitions and principles.
 

(A) Medical necessity for individuals covered by early and periodic screening, diagnosis and treatment (EPSDT) is criteria of coverage for procedures, items, or services that prevent, diagnose, evaluate, correct, ameliorate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability.

(B) Medical necessity for individuals not covered by EPSDT is criteria of coverage for procedures, items, or services that prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without which the person can be expected to suffer prolonged, increased or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort.

(C) Conditions of medical necessity for a procedure, item, or service are met if all the following apply:

(1) It meets generally accepted standards of medical practice;

(2) It is clinically appropriate in its type, frequency, extent, duration, and delivery setting;

(3) It is appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome;

(4) It is the lowest cost alternative that effectively addresses and treats the medical problem;

(5) It provides unique, essential, and appropriate information if it is used for diagnostic purposes; and

(6) It is not provided primarily for the economic benefit of the provider nor for the sole convenience of the provider or anyone else other than the recipient.

(D) The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment.

(E) The definition and conditions of medical necessity articulated in this rule apply throughout the entire medicaid program. More specific criteria regarding the conditions of medical necessity for particular categories of service may be set forth within the Ohio department of medicaid (ODM) coverage policies or rules.

Last updated February 24, 2022 at 8:25 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 2/24/2027
Prior Effective Dates: 12/21/1977, 7/1/2006
Rule 5160-1-02 | General reimbursement principles.
 

This rule describes general principles regarding reimbursement of services by medicaid. Reimbursement may be subject to additional administrative criteria as described in agency 5160 of the Administrative Code.

(A) A medical service is reimbursable if:

(1) The service is determined medically necessary as defined in rule 5160-1-01 of the Administrative Code.

(2) The service is agreed to by the medicaid-covered individual or the medicaid-covered individual's authorized representative.

(3) The service is rendered to a medicaid-covered individual as defined in division 5160:1 of the Administrative Code.

(4) The service is provided within the limits of the medicaid-covered individual's medicaid benefit package.

(5) The service is provided within the scope of practice of the rendering provider as defined by applicable federal, state, and local laws and regulations.

(6) The service is rendered by a provider assigned to or selected by the medicaid-covered individual or medicaid-covered individual's authorized representative, with the exception of medicaid-covered individuals enrolled in the coordinated services program as defined in Chapter 5160-20 of the Administrative Code.

(7) The service is rendered by an eligible provider or panel provider for managed care plan participating provider.

(B) Special conditions regarding medicaid reimbursement.

(1) If a service is charged to medicaid at a rate greater than the provider's usual and customary charge to other patients for comparable services, the provider will be reimbursed at the provider's usual and customary charge or medicaid permitted reimbursement rate, whichever is lower.

(2) Inpatient and outpatient hospital services billed by hospitals reimbursed on a prospective payment basis, as defined in Chapter 5160-2 of the Administrative Code, will not be paid, in the aggregate, more than the provider's customary and prevailing charges for comparable services.

(3) Medicaid will not provide reimbursement for a provider-preventable condition as defined in 42 CFR 447.26 (as in effect on October 1, 2018). The prohibition on provider-preventable conditions shall not result in a loss of access to care or services for medicaid-covered individuals.

(C) Additional reimbursement principles are applicable to the following:

(1) Services delivered through the medicaid managed plans as described in Chapter 5160-26 of the Administrative Code.

(2) Habilitation services as defined in 42 USC 1396n(c)(5) (as in effect on October 1, 2018) and permitted in agency 5160 of the Administrative Code.

(D) Commingling is prohibited. For the purposes of this rule commingling occurs when the sharing of office space, staff (employed or contracted), supplies, equipment, or other resources with an on-site practice or provider organization owned or operated by the same provider, physician, or non-physician practitioners results in one or both of the following:

(1) Duplicate medicaid reimbursement for services performed; or

(2) A provider selectively choosing a higher reimbursement rate for the services performed.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 12/1/2024
Prior Effective Dates: 12/21/1977
Rule 5160-1-04 | Employee access to confidential personal information.
 

(A) Definitions.

For the purposes of rules promulgated by this agency in accordance with section 1347.15 of the Revised Code effective April 9, 2009, the following definitions apply:

(1) "Access" as a noun means an instance of copying, viewing, or otherwise perceiving; whereas, "access" as a verb means to copy, view, or otherwise perceive.

(2) "Acquisition of a new computer system" means the purchase of a "computer system," as defined in this rule, that is not a computer system currently in place nor one for which the acquisition process has been initiated as of April 7, 2009.

(3) "Confidential personal information" (CPI) has the meaning as defined by division (A)(1) of section 1347.15 of the Revised Code. The appendix to this rule identifies, in accordance with division (B)(3) of section 1347.15 of the Revised Code, the federal statutes and regulations and state statutes and administrative rules that make personal information maintained by the agency confidential.

(4) "Employee of the state agency" means each employee of a state agency regardless of whether he or she holds an elected or appointed office or position within the state agency. "Employee of the state agency" is limited to the specific employing state agency.

(5) "Incidental contact" means contact with the information that is secondary or tangential to the primary purpose of the activity that resulted in the contact.

(6) "Individual" means a natural person and in the context used in division (C)(1)(b) of section 1347.15 of the Revised Code, and paragraph (E)(4)(b)(iv) of this rule, means the subject of the confidential personal information or the subject of the confidential personal information's authorized representative, legal counsel, legal custodian or legal guardian, and anyone as otherwise permitted under state or federal law acting on behalf of, or in furtherance of, the interests of the subject of the confidential personal information. "Individual" does not include an opposing party in litigation, or the opposing party's legal counsel, or an investigator, auditor or any other party who is not acting on behalf of, or in furtherance of the interests of, the subject of the confidential personal information, even if such individual has obtained a signed release from the subject of the confidential personal information.

(7) "Information owner" means the individual appointed in accordance with division (A) of section 1347.05 of the Revised Code to be directly responsible for a system.

(8) "Interconnection of Systems" Refers to a linking of systems that belong to more than one agency, or to an agency, and other organization, which linking of systems results in a system that permits each agency or organization involved in the linking to have unrestricted access to the systems of the other agencies and organizations.

(9) "Person" means a natural person.

(10) "Personal information" has the same meaning as defined in division (E) of section 1347.01 of the Revised Code.

(11) "Personal information system" means a "system" that "maintains" "personal information" as those terms are defined in section 1347.01 of the Revised Code. "System" includes manual and computer systems.

(12) "Research" means a methodical investigation into a subject.

(13) "Routine" means commonplace, regular, habitual, or ordinary.

(14) "Routine information that is maintained for the purpose of internal office administration, the use of which would not adversely affect a person" as that phrase is used in division (F) of section 1347.01 of the Revised Code means personal information relating to employees and maintained by the agency for internal administrative and human resource purposes.

(15) "System or Information System" As defined in section 1347.01 of the Revised Code, "system" means any collection or group of related records that are kept in an organized manner and that are maintained by a state or local agency, and from which personal information is retrieved using the person's name or by an identifying number, symbol, or other identifier assigned to the person. "System" includes both records that are manually stored and records that are stored using electronic data processing equipment.

(16) "Upgrade" means a substantial redesign of an existing computer system for the purpose of providing a substantial amount of new application functionality, or application modifications that would involve substantial administrative or fiscal resources to implement, but would not include maintenance, minor updates and patches, or modifications that entail a limited addition of functionality due to changes in business or legal requirements.

(B) Procedures for accessing confidential personal information.

(1) Criteria for accessing confidential personal information.

Personal information systems of the Ohio department of medicaid (ODM) are managed on a "need-to-know" basis whereby the information owner determines the level of access required for an employee of the agency to fulfill his or her job duties. The determination of access to confidential personal information shall be approved by the employee's supervisor, the information's owner, designee operating under guidlines approved by the information's owner before providing the employee with access to confidential personal information within a personal information system. The agency shall establish procedures for determining a revision to an employee's access to confidential personal information upon a change to that employee's job duties including, but not limited to, transfer or termination. Whenever an employee's job duties no longer require access to confidential personal information in a personal information system, the employee's access to confidential personal information shall be removed.

(2) Individual's request for a list of confidential personal information.

Based upon a request of any individual for a list of confidential personal information about the individual maintained by ODM, or its predecessor ODJFS, ODM shall do the following:

(a) Verify the identity of the individual by a method that provides safeguards commensurate with the risk associated with the confidential personal information.

(b) Provide to the individual the confidential personal information that does not relate to an investigation about the individual or is otherwise not excluded from being released under Chapter 1347. of the Revised Code, or other federal/state laws or regulations.

(c) If all information relates to an investigation about that individual, inform the individual that the agency has no confidential personal information about the individual that is responsive to the individual's request.

(d) Notifications made under this section shall be made in compliance with all applicable state and federal regulations.

(3) Notice of invalid access.

(a) Upon discovery or notification that confidential personal information of a person has been accessed by an employee for an invalid reason, the agency shall notify the person whose information was invalidly accessed as soon as practical and to the extent known at the time. However, the agency shall delay notification for a period of time necessary to ensure that the notification would not delay or impede an investigation or jeopardize homeland or national security. Additionally, the agency may delay the notification consistent with any measures necessary to determine the scope of the invalid access, including which individuals' confidential personal information was invalidly accessed, and to restore the reasonable integrity of the system. "Investigation" as used in this paragraph means the investigation of the circumstances and involvement of an employee surrounding the invalid access of the confidential personal information. Once the agency determines that notification would not delay or impede an investigation, the agency shall disclose the access to confidential personal information made for an invalid reason to the person.

(b) Notification provided by the agency shall inform the person of the type of confidential personal information accessed and the date or dates of the invalid access, if known.

(c) Notification may be made by any method reasonably designed to accurately inform the person of the invalid access, including written, electronic, or telephone notice.

(d) Notifications made under this section shall be made in compliance with all applicable state and federal regulations.

(4) Appointment of a data privacy point of contact and completion of a risk of harm assessment.

(a) The ODM director shall designate an employee of ODM to serve as the data privacy point of contact under the working title of "ODM HIPAA privacy official."

(b) The ODM HIPAA privacy official shall work with the state of Ohio chief privacy officer and the state of Ohio chief information security officer within the state of Ohio office of information technology to assist ODM with both the implementation of privacy protections for the confidential personal information that ODM maintains and compliance with section 1347.15 of the Revised Code and the rules adopted thereunder.

(c) The ODM HIPAA privacy official shall ensure the timely completion of the "privacy impact assessment" developed by the state of Ohio office of information technology.

(C) Valid reasons for accessing confidential personal information.

Pursuant to the requirements of division (B)(2) of section 1347.15 of the Revised Code, this rule contains a list of valid reasons, directly related to the ODM exercise of its powers or duties, for which only employees of the agency may access confidential personal information regardless of whether the personal information system is a manual system or computer system.

Except as prohibited by federal and state law, performing the following functions constitute valid reasons for authorized employees of the agency to access confidential personal information:

(1) Responding to a public records request, which would require all appropriate redaction of any responsive records as required by law;

(2) Responding to a request from an individual for the list of the confidential personal information the agency maintains on that individual;

(3) Administering a constitutional provision or duty;

(4) Administering a statutory provision or duty;

(5) Administering an administrative rule provision or duty;

(6) Complying with any state or federal program requirements;

(7) Processing or payment of claims or otherwise administering a program with individual participants or beneficiaries;

(8) Auditing purposes;

(9) Licensure (or permit, eligibility, filing, etc.) processes;

(10) Investigation or law enforcement purposes;

(11) Administrative hearings;

(12) Litigation, complying with an order of the court, or subpoena;

(13) Human resource matters (for example, hiring, promotion, demotion, discharge, salary/compensation issues, leave requests/issues, time card approvals/issues);

(14) Complying with an executive order or policy;

(15) Complying with an agency policy or a state administrative policy issued by the department of administrative services, the office of budget and management, or other similar state agency;

(16) Complying with a collective bargaining agreement provision; or

(17) Research in the furtherance of agency specific programs in so far as allowed by statute.

(D) Confidentiality statutes and administrative rules.

The federal statutes and regulations and state statutes and administrative rules listed in the appendix to this rule make personal information maintained by the agency confidential and identify the confidential personal information that are subject to rules promulgated by this agency in accordance with section 1347.15 of the Revised Code.

(E) Restricting and logging access to confidential personal information systems.

For personal information systems that are computer systems and contain confidential personal information, ODM shall do the following:

(1) Access restrictions.

Access to confidential personal information that is kept electronically shall require a password or other sufficient authentication measure as determined by the ODM HIPAA privacy official in conjunction with the chief information security official will determine what constitutes sufficient authentitication measures.

(2) Acquisition of a new computer system.

When the agency acquires a new computer system that stores, manages, or contains confidential personal information, ODM shall include a mechanism for recording specific access by employees of ODM to confidential personal information in the system.

(3) Upgrading existing computer systems.

When ODM modifies an existing computer system that stores, manages, or contains confidential personal information, that results in over half of the lines of code associated with that system being modified, then that system must have an automated mechanism for recording specific access by employees of ODM to any confidential personal information that is accessed via that system.

(4) Logging requirements regarding confidential personal information in existing ODM computer systems.

(a) ODM shall require employees who access confidential personal information within ODM computer systems to maintain a log that records that access.

(b) Access to confidential information is not required to be entered into the log under the following circumstances:

(i) The ODM employee is accessing confidential personal information for official agency purposes including research, and the access is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(ii) The ODM employee is accessing confidential personal information for routine office procedures and the access is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(iii) The ODM employee comes into incidental contact with confidential personal information and the access of the information is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(iv) The employee of the agency accesses confidential personal information about an individual based upon a request made under either of the following circumstances:

(a) The individual requests confidential personal information about himself or herself; or

(b) The individual makes a request that ODM take some action on that individual's behalf and accessing the confidential personal information is required in order to consider or process that request.

(v) ODM shall use a consistent electronic means for logging where reasonably possible. If the logging requirements are already being met through existing means, then no additional logging is required in those instances.

(5) Log management.

Each office within ODM shall use the log provided by the agency, currently identified as "CPI Log", or its successor system. Nothing in this rule limits the agency from requiring logging in any circumstance that it deems necessary.

Supplemental Information

Authorized By: 5164.02
Amplifies: 1347.15, 1347.05, 1347.01
Five Year Review Date: 8/1/2021
Rule 5160-1-05 | Medicaid coordination of benefits with the medicare program (Title XVIII).
 

Paragraphs (A)(7) to (F)(4) of this rule do not apply to pharmacy services covered under the medicare part D program. Pharmacy services covered under the medicare part D program should be billed in accordance with rule 5160-9-06 of the Administrative Code.

(A) Definitions.

(1) "Medicare" is a federally financed program of hospital insurance (part A) and supplemental medical insurance (also called SMI or part B) for aged and disabled persons.

(2) "Medicare Benefits" means the health care services available to an individual through the medicare program where payment for the services is either completely the obligation of the medicare program or in part the obligation of the medicare program with the remaining payment obligations belonging to the individual, some other third party payer, or medicaid.

(3) "Traditional Medicare" is a health plan that pays for medicare benefits provided to individuals on a fee-for-service basis.

(4) "Medicare Advantage Plan (also known as medicare part C plan)" is a managed care delivery system that includes coverage for both hospital insurance and SMI, but the delivery of health care services are contracted to and provided by an approved medicare managed care plan, preferred provider organization, private fee-for-service plans, or medicare specialty plans.

(5) "Medicare Cost Sharing" for the purpose of this rule means the portion of a medicare crossover claim paid by medicaid.

(6) "Dual Eligibles or Dually Eligible Individuals" are individuals who are entitled to medicare hospital insurance and SMI and are eligible for medicaid to pay some form of medicare cost sharing. The following is a list of dual eligibles or dually eligible individuals that qualify to have medicaid pay all or part of the cost sharing portion of a paid medicare claim:

(a) "Qualified Medicare Beneficiaries without Other Medicaid (QMB Only)" are individuals entitled to medicare hospital insurance, have income of one hundred per cent of the federal poverty level (FPL) or less and resources that do not exceed the maximum amount of resources allowed under section 1905(p)(1) of the Social Security Act (as in effect on October 1, 2018), as adjusted annually according to the change in the consumer price index for urban areas (CPI-U), and are not otherwise eligible for full medicaid benefits.

(b) "QMBs with Full Medicaid (QMB Plus)" are individuals entitled to medicare hospital insurance, have incomes of one hundred per cent FPL or less and resources that do not exceed the maximum amount of resources allowed under section 1905(p)(1) of the Social Security Act (as in effect on October 1, 2018), as adjusted annually according to the change in the consumer price index for urban areas (CPI-U), and are eligible for full medicaid benefits.

(c) "Specified Low-Income Medicare Beneficiaries with Full Medicaid (SLMB Plus)" are individuals entitled to medicare hospital insurance, have income of greater than one hundred per cent FPL, but less than one hundred twenty per cent FPL and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full medicaid benefits.

(d) "Medicaid Only Dual Eligibles (for example Non QMB)" are individuals entitled to medicare hospital insurance and SMI and are eligible for full medicaid benefits. They are not eligible for medicaid in any of the other dual eligible categories (for example QMB).

(7) "Medicare Crossover Claim" means any claim that has been submitted to the Ohio department of medicaid (ODM) for medicare cost sharing payments after the claim has been adjudicated and paid by the medicare central processor, medicare carrier/intermediary or the medicare managed care plan. Claims denied by the medicare carrier/intermediary or the medicare managed care plan are not considered medicare crossover claims. See paragraphs (E) and (F) of this rule for policy on services denied or not covered by medicare.

(a) "Automatic Crossover Claim" is a medicare claim submitted to ODM via the automatic medicare crossover process described in paragraph (B)(2)(a) of this rule.

(b) "Provider-Submitted Crossover Claim" means a medicare crossover claim submitted to ODM as described in paragraph (B)(2)(b) of this rule.

(B) Medicare crossover process.

(1) Medicare crossover claims must meet the claim submission guidelines in accordance with rule 5160-1-19 of the Administrative Code.

(2) The medicare program determines the portion of medicare cost sharing, if any, due to the provider based on medicare's business rules and submits the claim for payment to ODM using the automatic medicare crossover process.

(a) The "Automatic Medicare Crossover Process" is the coordination of benefit (COB) process whereby the provider bills medicare for services provided to a dual eligible or a dually eligible individual described in paragraph (A)(6) of this rule. Medicare adjudicates the claim, pays the provider and electronically submits the claim to ODM for the medicare cost sharing determination. Then, when appropriate, the provider is paid by medicaid within ninety days from the date of payment by medicare.

(b) When the automatic medicare crossover process does not work (i.e., the provider has received payment by medicare, has not received a payment from medicaid for the medicare cost sharing portion and at least ninety days has elapsed from the date of the receipt of the medicare payment), the provider must submit a medicare crossover claim directly to ODM. This is considered the "Provider-Submitted Crossover Claim Process."

(3) For a provider to receive reimbursement through the automatic medicare crossover process, all of the following criteria must be met:

(a) The provider must be recognized as both a medicare and medicaid provider;

(b) The provider must accept medicare assignment; and

(c) The individual must be receiving health care benefits under the traditional medicare part A and part B program (i.e., the individual is not enrolled in a medicare managed care plan). At this time ODM does not have payer-to-payer COB arrangements with medicare managed care plans.

(4) For medicare crossover claims, the total sum of the payments made by ODM, medicare and all other third party payers is considered payment in full and no additional payment may be requested from the individual with the exception of medicare co-payments as specified in paragraph (E)(5) of this rule. This is true whether or not the provider normally accepts assignment under medicare.

(a) When the provider's total reimbursement from medicare and all other third party payers equals or exceeds the medicare approved amount, no additional payment will be made by ODM.

(b) If payment (other than the cost sharing amounts) is inadvertently received from both medicare and medicaid for the same service, the provider must notify the ODM claims adjustment unit in accordance with the provisions set forth in rule 5160-1-19 of the Administrative Code.

(5) Provider submitted crossover claims must be submitted timely in accordance with rule 5160-1-19 of the Administrative Code.

(6) Crossover claims are not subject to medicaid co-payments in accordance with rule 5160-1-09 of the Administrative Code.

(C) When the individual receiving medicaid is covered by other third party payers, in addition to medicare, medicaid is the payer of last resort. Whether or not medicare is the primary payer, providers must bill all other third party payers prior to submitting a crossover claim to ODM in accordance with rule 5160-1-08 of the Administrative Code.

(D) ODM will not pay for services denied by medicare for lack of medical necessity, but may pay claims denied for reasons other than lack of medical necessity in accordance with paragraph (F) of this rule as long as the services are covered under the medicaid program. ODM will not pay for any service payable by, but not billed to, medicare.

(E) Reimbursement for medicare cost sharing on medicare crossover claims.

Reimbursement for medicare crossover claims is limited to the dual eligibles or dually eligible individuals listed in paragraph (A)(6) of this rule.

(1) The medicaid maximum reimbursement for the medicare cost sharing of hospital inpatient, outpatient or emergency room services is set forth in rule 5160-2-25 of the Administrative Code for individuals that elected to receive medicare benefits under traditional medicare.

(2) The medicaid maximum reimbursement for the medicare cost sharing of nursing facility services included in the nursing facility per diem is set forth in Chapter 5160-3 of the Administrative Code for individuals that elected to receive medicare benefits under traditional medicare.

(3) The medicaid maximum reimbursement for the medicare cost sharing of all other part B services not included in paragraph (E)(1) or paragraph (E)(2) of this rule is set forth in rule 5160-1-05.3 of the Administrative Code for individuals that elected to receive medicare benefits under traditional medicare.

(4) The medicaid maximum reimbursement for the medicare cost sharing of all advantage plan (part C) services is set forth in rule 5160-1-05.1 of the Administrative Code for individuals that elected to receive medicare benefits under a medicare advantage plan.

(5) Cost sharing for medicare part D services is not reimbursable by ODM in accordance with rule 5160-9-06 of the Administrative Code. Dual eligibles or dually eligible individuals may be required to pay medicare co-payments for prescription drugs that are covered by medicare part D.

(F) Services that are not covered by medicare must be submitted to ODM as a regular medicaid claim and should never be submitted as a medicare crossover claim.

With the exception of long term care nursing facilities, when the service is denied by medicare, and is also denied by medicaid with an error message indicating that the service is covered under medicare and the provider has documentation to support the service is not covered under medicare, the provider must do all of the following when requesting payment consideration from ODM:

(1) Submit the appropriate claim in accordance with rule 5160-1-19 of the Administrative Code;

(2) Attach the summary notice of medicare benefits that shows the denied medicare services, and the denial reason code with the denial reason code explanation from the medicare summary of benefits, the provider is requesting ODM to consider for payment;

(3) Attach a completed "ODM 06653 Medical Claim Review Request Form (rev. 7/2014 )" with supporting documentation; and

(4) Submit all forms together to the address indicated on the instruction page accompanying the ODM 06653 form.

(G) Long term care nursing facility providers must submit the appropriate claim in accordance with Chapter 5160-3 of the Administrative Code.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.01, 5165.47, 5162.03, 5164.02
Five Year Review Date: 9/16/2024
Prior Effective Dates: 10/1/1984, 1/9/1989 (Emer.), 4/10/1989, 5/30/2002, 7/31/2009 (Emer.), 10/29/2009
Rule 5160-1-05.1 | Payment for "Medicare Part C" cost sharing.
 

(A) For qualified medicare beneficiaries and medicaid recipients enrolled in medicare part C managed health care plans (medicare advantage plans) the department will pay as cost sharing the lesser of the following amounts:

(1) The provider's billed charges for the service (except for hospital and nursing facility services); or

(2) The deductible, coinsurance and co-payment amount as provided by the medicare part C plan; or

(3) The difference between the medicare part C plan's payment to a provider for a service or services identified and the medicaid maximum allowable reimbursement rate for the same identified service or services; or

(4) The medicaid liability for the cost sharing if the service had been rendered under medicare part A or part B (calculated as twenty-five per cent of the medicare maximum allowed amount).

(B) The department will not make any additional payment to the provider, or will make a payment of zero dollars, when payment for part C cost sharing is made using the method described in paragraph (A)(3) of this rule, and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid maximum allowed amount.

(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims and retention of relevant documents to support claims submitted for payment and any other business transactions in accordance with rule 5160-1-17.2 of the Administrative Code.

(D) Any costs beyond the medicare advantage plan's maximum out-of-pocket (MOOP) limit are not subject to cost sharing pursuant to 42 C.F.R. 422.100 (as in effect January 1, 2023).

Last updated July 27, 2023 at 8:36 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2028
Rule 5160-1-05.3 | Payment for "Medicare Part B" cost sharing.
 

(A) The reimbursement methodology set forth in paragraph (B) of this rule is limited to medicare part B services that meet all of the following criteria:

(1) Are not hospital services defined in accordance with Chapter 5160-2 of the Administrative Code;

(2) Are not nursing facility services included in the nursing facility per diem as defined in accordance with Chapter 5160-3 of the Administrative Code;

(3) Are covered as supplemental medical insurance benefits under the medicare program; and

(4) Are provided to dual eligibles, defined in accordance with paragraph (A)(6) of rule 5160-1-05 of the Administrative Code, who elect to receive their medicare part B benefits through the original medicare program.

(B) The Ohio department of medicaid (ODM) will pay the lesser of the following calculations for part B cost sharing described in this rule:

(1) The sum of the deductible and coinsurance medicare specifies ODM is obligated to pay for crossover claims; or

(2) The difference between the medicare approved amount and the sum of the amount medicare paid and all other third party (insurance other than medicare or medicaid) payments; or

(3) The difference between the sum of the amount medicare paid and any third party payments, and the medicaid maximum allowable reimbursement rate for the same identified service or services.

(C) When payment for part B cost sharing is made using the method described in paragraph (B)(2) or (B)(3) of this rule and the sum of the amounts paid by medicare and all other third party insurers exceeds the medicare or medicaid approved amount, ODM will not make any additional payment to the provider, or will make a payment of zero dollars, and the service(s) are considered to be paid in full to the provider.

Supplemental Information

Authorized By: 5164.02
Amplifies: Section 323.230 of Am. Sub. HB. 59
Five Year Review Date: 11/21/2023
Prior Effective Dates: 10/29/2009
Rule 5160-1-06.1 | Home and community-based service waivers: PASSPORT.
 

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the preadmission screening system providing options and resources today (PASSPORT) medicaid waiver program. ODA will administer the waiver pursuant to an interagency agreement with the Ohio department of medicaid in accordance with section 5162.35 of the Revised Code.

(B) The PASSPORT waiver provides home and community based services (HCBS) to individuals enrolled in the waiver in accordance with rule 5160-31-03 of the Administrative Code.

(C) The PASSPORT HCBS waiver covered services and eligibility requirements are set forth in Chapter 5160-31 of the Administrative Code.

(D) The maximum allowable payment rates for PASSPORT HCBS waiver program services are listed in the appendix to this rule.

(E) PASSPORT HCBS payment will be provided in accordance with paragraphs (A) to (C) of rule 5160-1-60 of the Administrative Code.

View Appendix

Last updated October 1, 2024 at 9:06 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 173.52
Five Year Review Date: 10/1/2029
Prior Effective Dates: 7/1/2006, 7/2/2007 (Emer.), 9/30/2008, 7/1/2011 (Emer.), 9/29/2011, 3/1/2014, 3/23/2020
Rule 5160-1-06.5 | Home and community based services (HCBS) waivers: assisted living.
 

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the assisted living HCBS waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM), in accordance with section 5162.35 of the Revised Code.

(B) The assisted living HCBS waiver is an alternative to nursing facility placement for persons age twenty-one and over who require an intermediate level of care or a skilled level of care as set forth in rule 5160-3-08 of the Administrative Code and are enrolled in the waiver.

(1) The assisted living HCBS waiver's services and program eligibility criteria are set forth in Chapter 5160-33 of the Administrative Code.

(2) The maximum allowable reimbursement rates for assisted living HCBS waiver program services are listed in appendix A to this rule.

(3) Assisted living HCBS reimbursement are provided in accordance with rule 5160-1-60 of the Administrative Code.

(4) The billing maximum for the community transition service listed in appendix A to this rule represents the cumulative maximum for the items purchased or deposits made through the community transition service as set forth in rule 173-39-02.17 of the Administrative Code.

View Appendix

Last updated July 1, 2024 at 4:38 PM

Supplemental Information

Authorized By: 5166.02
Amplifies: 173.54
Five Year Review Date: 1/1/2029
Prior Effective Dates: 7/1/2006, 3/22/2008, 9/27/2013, 11/1/2021, 1/1/2024
Rule 5160-1-08 | Coordination of benefits.
 

(A) Definitions.

(1) "Coordination of benefits" (COB) means the process of determining which health plan or insurance policy will pay first or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits for a medicaid covered individual.

(2) "Coordination of benefits claim" (COB claim) means any claim that meets either the definition of third party claim as described in paragraph (A)(7) of this rule or the definition of medicare crossover claim as described in rule 5160-1-05 of the Administrative Code.

(3) "Explanation of benefits" (EOB) or "remittance advice" means the information sent to providers or plan beneficiaries (covered individuals) by any other third party payer, medicare, or medicaid to explain the adjudication of the claim.

(4) "Medicare benefits" has the same meaning as in rule 5160-1-05 of the Administrative Code.

(5) "Third party" (TP) has the same meaning as in section 5160.35 of the Revised Code.

(6) "Third party benefit" means any health care service available to individuals through any medical insurance policy or through some other resource that covers medical benefits and the payment for those services is either completely the obligation of the third party payer (TPP) or in part the obligation of the individual, the third party payer, or medicaid (examples of a third party benefit include private health or accidental insurance, medicare, CHAMPUS or worker's compensation).

(7) ) "Third party claim" means any claim submitted to the Ohio department of medicaid (ODM) for reimbursement after all TPPs have met their payment obligations. In addition, the following will be considered third party claims by ODM:

(a) Any claim received by ODM that shows no prior payment by a TPP, but, ODM's records indicate the medicaid covered individual has third party benefits.

(b) Any claim received by ODM that shows no prior payment by a TPP but the provider's records indicate the medicaid covered individual has third party benefits.

(8) "Third party liability" (TPL) means the payment obligations of the third party payer for health care services rendered to eligible medicaid covered individuals when the individual also has third party benefits as described in paragraph (A)(6) of this rule.

(9) "Third party payer" (TPP) means an entity, other than the medicaid or medicare programs, responsible for adjudicating and paying claims for third party benefits rendered to an eligible medicaid covered individual.

(B) If the existence of a third party benefit is known to ODM, a code number that represents the name of the third party payer covering the individual will be indicated on the individual's medicaid card. The provider shall obtain from the medicaid covered individual the name and address of the insurance company, and any other necessary information, and bill the insurance company prior to billing ODM.

(C) The provider must always review the individual's Ohio medicaid card for evidence of third party benefits. Whether there is or is not an indication of a TPP on the medicaid card, the provider must always request from the medicaid covered individual, or the individual's representative, information about any third party benefit(s). If the medicaid covered individual specifies no TP coverage and the medicaid card does not indicate TP coverage, the provider may submit a claim to medicaid (and the claim for the service is not considered a TP claim). If, as a result of this process, the provider or ODM determines that TP liability exists, the provider may only submit a claim for reimbursement if it first takes reasonable measures to obtain TP payments as set forth in paragraph (E) of this rule.

(D) The medicaid program must be the last payer to receive and adjudicate the claim except for the following:

(1) Medicaid pays after any TPL and medicare but before:

(a) The children with medical handicaps program under sections 3701.021 to 3701.0210 of the Revised Code.

(b) The state sponsored program awarding reparations to victims of crime under sections 2743.51 to 2743.72 of the Revised Code.

(2) Medicaid pays before any TPL and medicare for preventive pediatric services identified in 42 C.F.R. 433.139 (as in effect October 1, 2018).

(E) ODM reimburses for medically necessary covered services only after the provider takes reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing ODM. Providers who have gone through reasonable measures to obtain all third party payments, but who have not received payment from a TPP, or have gone through reasonable measures and received partial payment, may use an appropriate code on the claim to obtain payment and submit a claim to ODM requesting reimbursement for the rendered service.

(1) Providers are considered by ODM to have taken reasonable measures to obtain all third party payments if they comply with one of the following requirements:

(a) The provider submits a claim first to the TPP and receives a remittance advice indicating that a valid reason for non-payment applies for the service as described in paragraph (E)(2) of this rule.

(b) The provider submits a claim first to the TPP for the rendered service no less than three times within a ninety-day period and does not receive a remittance advice or other communication from the TPP within ninety days of the last submission to the TPP. Providers must be able to document each claim submission and the date of the submission.

(c) The provider followed the process described in paragraph (C) of this rule for the billed service and meets the following requirements:

(i) The provider did not find a change in third party coverage;

(ii) The billed service was previously rendered to the medicaid covered individual by the provider within the last three hundred sixty-five days; and

(iii) The claim for the previously rendered service met the requirements of paragraph (E)(1)(a) or paragraph (E)(1)(d) of this rule.

(d) The provider did not send a claim to the TPP, but has received and retained at least one of the following types of documentation that indicates a valid reason for non-payment for the service(s) as set forth in paragraph (E)(2) of this rule:

(i) Written documentation from the TPP;

(ii) Written documentation from the TPP's automated eligibility and claim verification system;

(iii) Written documentation from the TPP's member benefits reference guide or manual; or

(iv) Any other reliable method for obtaining information or documentation from the TPP that there is no third party benefit coverage for the rendered service(s).

(e) The provider submits a claim first to the TPP and receives a partial payment along with a remittance advice documenting the allocation of the billed charges.

(2) Valid reasons for non-payment from a third party payer to the provider for a third party benefit claim include, but are not limited to, the following:

(a) The service is not covered under the medicaid covered individual's third party benefits.

(b) The medical expenses for the medicaid covered individual were incurred prior to the third party benefit's coverage dates.

(c) The medical expenses for the medicaid covered individual were incurred after the third party benefits coverage was terminated.

(d) The medicaid covered individual does not have third party benefits through the TPP for the date of service.

(e) All of the provider's billed charges or the TPP's approved rate was applied to the medicaid covered individual's third party benefit deductible amount.

(f) All of the provider's billed charges or the TPP's approved rate was applied in total across the medicaid covered individual's deductible, coinsurance, or co-payment for the third party benefit.

(g) The medicaid covered individual has not met eligibility requirements, out-of-pocket expenses, required waiting periods, or residency requirements for the third party benefits.

(h) The medicaid covered individual is a dependent of the individual with third party benefits, but the benefits do not cover the individual's dependents.

(i) The medicaid covered individual has reached the lifetime benefit maximum for the medical service being billed to the third party payer.

(j) The medicaid covered individual has reached the benefit maximum of the third party benefits.

(k) The TPP is disputing or contesting its liability to pay the claim or cover the service.

(l) The claim was submitted timely and with the correct information to the TPP but the claim was rejected by the TPP.

(F) Providers who have gone through reasonable measures as described in paragraph (E) of this rule to obtain all third party payments, but who have not received payment from a TPP, or received a partial payment, may submit a claim to ODM requesting reimbursement for the rendered service. If payment from the TPP is received after ODM has made payment, the provider is required to repay ODM any overpaid amount. The provider must not reimburse any overpaid amounts to the medicaid covered individual.

(G) Providers who have billed the TPP and the TPP submits payment directly to the medicaid covered individual should contact the individual to request the payment be remitted to the provider. If the individual is uncooperative with the request, the provider should contact the county department of job and family services (CDJFS).

(H) Third party claims must meet the claim submission guidelines in accordance with rule 5160-1-19 of the Administrative Code.

(I) Medicaid reimbursement for third party claims will not exceed the medicaid maximum payment for the service, determined in accordance with applicable rules for the service, less all third party payments for the service. If the result is less than or equal to zero dollars, there will be no further medicaid payment for the service.

(J) ODM will reject a TP claim when a third party claim indicates coverage by a TPP, or when the existence of third party benefits is known to ODM, and the submitted claim does not indicate collection of the third party payment or does not indicate compliance with paragraph (E) of this rule. Providers should complete their investigation of available third party benefits before submitting a TP claim to ODM for payment.

(K) The provider is prohibited from billing the medicaid covered individual any charges in accordance with rule 5160-1-60 of the Administrative Code.

(L) If the medicaid covered individual states his or her private health insurance has changed or been terminated, the provider should advise the individual to contact his or her county caseworker to correct the case record. If the individual is not cooperative in pursuing third party liability as required by rule 5160:1-2-10 of the Administrative Code, the provider should contact the CDJFS. Once the case record has been corrected, the provider may bill ODM directly.

(M) ODM has right of recovery pursuant to section 5160.37 of the Revised Code (medicaid, or any federal or state funded public health program) against the liability of a third party for the cost of medical services paid by ODM, or billable to ODM for payment at a later date. Section 5160.37 of the Revised Code requires that a medicaid covered individual provide notice to ODM prior to initiating any action against a liable third party. ODM will take steps to protect its rights of recovery if that notice is not provided. If any person, whether the medicaid covered individual or an individual acting on the behalf of a medicaid covered individual requests a financial statement from a medicaid provider for services paid by ODM or to be billed to ODM on behalf of the medicaid covered individual, the provider shall meet all of the following requirements:

(1) Require that the medicaid covered individual or the individual's representative make a request for access to financial statements in writing.

(2) Notify ODM immediately upon receipt of the medicaid covered individual's written request and forward a copy of the request to ODM, bureau of claims operations, coordination of benefits section.

(3) Release the financial statement to the medicaid covered individual or the individual's representative no later than thirty days after the date the request is received.

(4) Stamp or type on each page of the financial statement in bold font "SUBJECT TO RIGHT OF RECOVERY PURSUANT TO SECTION 5160.37 OF THE OHIO REVISED CODE. FAILURE TO COMPLY MAY RESULT IN PERSONAL LIABILITY."

(5) This rule applies to financial statements whether or not the provider has received reimbursement from ODM. This rule is not intended to prevent or restrict the provider from furnishing records of medical treatment and condition to the medicaid covered individual.

(N) Except as otherwise provided in paragraph (D)(2) of this rule, when the medicaid covered individual is covered by medicare, in addition to other third party payers, medicaid is the payer of last resort. Whether or not a TPP is the primary payer, providers must bill all other third party payers and medicare prior to submitting a claim to ODM in accordance with rule 5160-1-05 of the Administrative Code.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 9/16/2024
Prior Effective Dates: 12/21/1977, 4/1/1979
Rule 5160-1-09 | Co-payments.
 

This rule sets forth requirements regarding co-payments by individuals for medicaid-covered services.

(A) Certain medicaid services are subject to individual co-payments. Information regarding these services and co-payment amounts can be found in the following Administrative Code rules:

(1) Co-payments for dental services are described in rule 5160-5-01 of the Administrative Code.

(2) Co-payments for vision services are described in rule 5160-6-01 of the Administrative Code.

(3) Co-payments for non-emergency emergency department services are described in rule 5160-2-21.1 of the Administrative Code.

(4) Co-payments for pharmacy services are described in rule 5160-9-09 of the Administrative Code.

(5) Co-payment requirements for services provided through a medicaid managed care plan are described in Chapter 5160-26-12 of the Administrative Code.

(B) With regard to the application of individual payments, the following apply:

(1) No provider may deny services to an individual who is eligible for the services on account of the individual's inability to pay the medicaid co-payment. Individuals who are not able to pay their medicaid co-payment may declare their inability to pay for services or medication and receive their services or medication without paying their medicaid co-payment amount. With regard to an individual who is unable to pay a required medicaid co-payment in accordance with this paragraph, this does not:

(a) Relieve the individual from the obligation to pay a medicaid co-payment; or

(b) Prohibit the provider from attempting to collect an unpaid medicaid co-payment.

(2) No provider shall waive an individual's obligation to pay a provider a medicaid co-payment except when paragraph (A)(5) of this rule applies.

(3) No provider or drug manufacturer, including the manufacturer's representative, employee, independent contractor, or agent, shall pay any co-payment on behalf of an individual.

(4) If it is the routine business practice of the provider to refuse service to any individual who owes an outstanding debt to the provider, the provider may consider an unpaid medicaid co-payment as an outstanding debt and refuse service to an individual who owes the provider an outstanding debt. If the provider intends to refuse service to an individual who owes the provider an outstanding debt, the provider shall notify the individual of the provider's intent to refuse services. In determining outstanding debt of an individual, the following apply:

(a) A provider's decision to continue rendering services to an individual who has an unpaid co-payment shall not be considered an outstanding debt of an individual.

(b) Charges which are prohibited in accordance with paragraph (A) of rule 5160-1-60 of the Administrative Code may not be considered an outstanding debt of an individual.

(C) The following individuals are excluded from the co-payment requirement for dental, vision, non-emergency emergency department services and pharmacy services:

(1) Children and youth under the age of twenty-one.

(a) The provider may use the individual's date of birth to identify if this exclusion applies; or

(b) The provider may submit the claim to the Ohio department of medicaid (department). During adjudication of the claim, if the department identifies the individual as a child or youth under the age of twenty-one, the department will not reduce the medicaid payment by the co-payment amount.

(2) Pregnant women during pregnancy and women with post-partum coverage as defined in rule 5160-4-04 of the Administrative Code. The following also apply:

(a) Routine eye examinations and the dispensation of eyeglasses during an individual's pregnancy are subject to co-payment.

(b) For all other claims, the provider may accept the individual's self-declaration of her pregnancy if the pregnancy/ post-partum co-payment exclusion applies. If the provider reports this exclusion applies, the medicaid payment will not be reduced by the co-payment amount.

(3) Residents of a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) The provider may use the individual's address to validate whether the individual resides in a NF or ICF/IID; or

(b) The provider may submit the claim to the department. During the adjudication of the claim, if the department identifies the individual as a resident of a NF or ICF/IID, the department will not reduce the medicaid payment by the co-payment amount.

(4) Individuals receiving emergency services are excluded from co-payment when they are provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy;

(5) Individuals receiving family planning services defined as pregnancy/contraception management services in rule 5160-21-02 of the Administrative Code are excluded from co-payment when these services are provided to an individual of child-bearing age. The provider may determine on the basis of his or her professional judgment that the individual is receiving pregnancy prevention/ contraceptive services and the co-payment exclusion applies.

(6) Individuals receiving hospice services are excluded from co-payment obligations. The provider may accept the individual's self-declaration that he or she is enrolled in hospice. If the provider reports that the individual is enrolled in hospice, the medicaid payment will not be reduced by the co-payment amount.

(7) Individuals receiving medicaid because of the state's election to provide coverage under the breast and cervical cancer option pursuant to 42 CFR 447.56(a)(1)(xi).

(D) Medicare cross-over claims as defined in rule 5160-1-05 of the Administrative Code are not subject to medicaid co-payments.

Last updated September 12, 2022 at 8:13 AM

Supplemental Information

Authorized By: 5162.20, 5164.02
Amplifies: 5162.20, 5164.02
Five Year Review Date: 7/3/2022
Prior Effective Dates: 1/1/2006, 10/1/2011
Rule 5160-1-10 | Limitations on elective obstetric deliveries.
 

(A) Payment for any cesarean section, labor induction, or any delivery following labor induction is subject to the following criteria:

(1) Gestational age of the fetus must be determined to be at least thirty-nine weeks; or

(2) If a delivery occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions must indicate medical necessity for the delivery.

(B) Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to thirty-nine weeks gestation that are not considered medically necessary are not eligible for payment.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 5/1/2020
Rule 5160-1-11 | Out-of-state coverage.
 

(A) Out-of-state providers:

(1) Should be licensed, accredited, or certified by their respective states to be considered eligible to receive reimbursement for services provided to Ohio medicaid covered individuals.

(2) Should meet any standards applicable to the provision of the service in the state in which the service is being furnished, as well as those standards set forth in the Ohio medicaid program and in the Administrative Code.

(3) Except as provided in paragraph (A)(4) of this rule, need to enroll as Ohio medicaid providers in order to obtain payment and follow appropriate billing procedures in accordance with Chapter 5160-1 of the Administrative Code and Chapter 5160-3 of the Administrative Code for long term care nursing facility services.

(4) Who are rendering services to medicaid covered individuals enrolled in a managed care plan (MCP) are not required to enroll with the Ohio department of medicaid (ODM) when:

(a) The out-of-state provider is not in the MCP's network and is providing services under a single case agreement; or

(b) The out-of-state provider is a pharmacy that is in-network with the MCP under a national contract.

(5) May have their out-of-state provider's enrollment application denied by ODM based on the denial, censure or revocation of their professional license by the applicable licensing board of any other state, or if the applicable licensing board in Ohio denies, censures or revokes a professional license even if another state's licensing board approves the respective provider.

(B) Ohio medicaid covered services will be reimbursed when rendered by out-of-state providers only under the following circumstances:

(1) The medically necessary services are not available within the state of Ohio, and the use of out-of-state providers to perform the services is authorized by the department or its designee, or authorized in accordance with rule 5160-1-31 of the Administrative Code; or

(2) The medical need arose as a result of an emergency, an accident, or an illness which occurred during a period of time the medicaid covered individual was temporarily absent from Ohio; or

(3) The individual's health would have been endangered if care was postponed until the individual returned to Ohio or attempted to return to Ohio; or

(4) The provider location for the medically necessary service is in a bordering state of Ohio, and it is the usual practice of residents in that community to utilize out-of-state providers, so long as the cost of the service does not exceed the cost of the service if provided by in-state providers; or

(5) The state determines on the basis of medical advice, that the needed medical services or necessary supplementary resources are more readily available in another state.

Last updated April 8, 2021 at 1:29 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 4/4/2026
Prior Effective Dates: 12/30/1977, 10/1/1987, 11/2/2014
Rule 5160-1-13.1 | Medicaid recipient liability.
 

(A) In accordance with 42 C.F.R. 447.15 (as in effect October 1, 2018), the medicaid payment for a covered service constitutes payment-in-full. It shall not be construed as a partial payment even when the payment amount is less than the provider's charge.

(1) The provider shall not collect nor bill a medicaid recipient for any difference between the medicaid payment and the provider's charge, nor shall the provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, co-payment, missed appointment fee or other similar charge, other than medicaid co-payments as defined in rule 5160-1-09 of the Administrative Code and patient liability as described in Chapter 5160-3 and rule 5160:1-6-07 of the Administrative Code.

(2) The provider shall not charge a medicaid recipient a down payment, refundable or otherwise.

(3) Should the individual become eligible for medicaid after the date of service and the eligibility span includes the date of service, the individual may not be financially responsible.

(B) A medicaid recipient cannot be billed when a medicaid claim has been denied for any of the following reasons:

(1) Unacceptable or untimely submission of a claim;

(2) Failure to request a prior authorization; or

(3) A retroactive finding by a peer review organization (PRO) that a rendered service was not medically necessary.

(C) A provider may bill a medicaid recipient for a medicaid covered service in lieu of submitting a claim to the Ohio department of medicaid (ODM) only if all of the following conditions are met:

(1) The provider explains to the medicaid recipient that the service is a covered medicaid service and other medicaid providers may render the service at no cost to the individual;

(2) Prior to each date of service for the specific service rendered, the provider notifies the medicaid recipient in writing that the provider will not submit a claim to ODM for the service;

(3) The medicaid recipient agrees to be liable for payment of the service and signs a written statement to that effect before the service is rendered; and

(4) The medicaid covered service is not a prescription for a controlled substance as defined in section 3719.01 of the Revised Code.

(D) Services that are not covered by the medicaid program, including services requiring prior authorization that have been denied by ODM, may be billed to a medicaid recipient when the conditions in paragraphs (C)(2) to (C)(4) of this rule are met.

(E) Any individual not covered by medicaid on the date of service is financially responsible for those services unless the individual qualifies for the hospital care assurance program (HCAP) in accordance with section 5168.14 of the Revised Code.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/1/2025
Prior Effective Dates: 6/3/1983, 1/1/2004, 7/1/2005, 1/6/2006
Rule 5160-1-14 | Healthchek: early and periodic screening, diagnostic, and treatment (EPSDT) covered services.
 

(A) Definitions.

(1) "Healthchek" is Ohio's early and periodic screening, diagnostic, and treatment (EPSDT) benefit for all medicaid recipients younger than twenty-one years of age, described in 42 U.S.C. 1396d(r) (as in effect 10/2017).

(2) "Bright futures guidelines" are the American academy of pediatrics bright futures guidelines for preventive health care (rev. 2/2017), available at http://www.aap.org.

(3) "Medical necessity" and "medically necessary" have the same meaning as in rule 5160-1-01 of the Administrative Code.

(4) "Prior authorization" is one of two processes:

(a) For members of a medicaid managed care plan (MCP), it is the process established by the medicaid MCP as required by rule 5160-26-05.1 of the Administrative Code.

(b) For all other medicaid recipients, it is the process outlined in rule 5160-1-31 of the Administrative Code.

(B) Providers. Healthchek screening, diagnostic, and treatment services may be rendered by eligible providers in an appropriate discipline, acting within the scope of practice authorized under state law and as set forth in agency 5160 of the Administrative Code.

(C) Coverage. For medicaid-eligible individuals younger than twenty-one years of age, healthchek covers the following services and items:

(1) Screening services.

(a) Healthchek screening services include, but are not limited to, all of the following procedures:

(i) A comprehensive health and developmental history, including assessment of both physical and mental health development, as well as substance abuse disorders;

(ii) A comprehensive unclothed physical exam, when appropriate;

(iii) Immunizations appropriate to age and health history;

(iv) Laboratory tests, including lead blood level assessment appropriate to age and risk factors, as required by the centers for medicare and medicaid services (CMS);

(v) Nutritional status assessment; and

(vi) Health education, counseling, anticipatory guidance, and risk factor reduction intervention provided to an individual younger than twenty-one years of age and, as applicable, to another person responsible for the individual younger than twenty-one years of age.

(b) Healthchek screening services are covered at the following frequency:

(i) For immunizations, in accordance with the schedule regarding the appropriate periodicity, dosage, and contraindications applicable to pediatric vaccines established by the advisory committee on immunization practices of the centers for disease control and prevention, found at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html;

(ii) For other screening services, at ages and intervals in accordance with the bright futures guidelines; and

(iii) For all screening services, at such other intervals indicated as medically necessary to determine the existence of physical or mental illnesses or conditions.

(2) Vision services.

(a) Healthchek vision services include but are not limited to diagnosis and treatment for defects in vision, including eyeglasses.

(b) Healthchek vision services are covered at the following frequency:

(i) At intervals that meet reasonable standards of medical practice in accordance with the bright futures guidelines; and

(ii) At such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(3) Dental services.

(a) Healthchek dental services include but are not limited to relief of pain and infections, restoration of teeth, and maintenance of dental health.

(b) Healthchek dental services are covered at the following frequency:

(i) For individuals six years of age or younger, at intervals that meet reasonable standards of dental practice in accordance with the bright futures guidelines;

(ii) For individuals older than six and younger than twenty-one years of age, at least once every one hundred eighty days; and

(iii) For all individuals younger than twenty-one years of age, at such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(4) Hearing services.

(a) Healthchek hearing services include but are not limited to diagnosis and treatment for defects in hearing, including hearing aids.

(b) Healthchek hearing services are covered at the following frequency:

(i) At intervals that meet reasonable standards of medical practice in accordance with the bright futures guidelines; and

(ii) At such other intervals indicated as medically necessary to determine the existence of a suspected illness or condition.

(5) All medically necessary services and items set forth in agency 5160 of the Administrative Code.

(6) All medically necessary screenings, health care, diagnostic services, treatment, and other measures described in 42 U.S.C. 1396d(a) (as in effect 10/2017) to correct or ameliorate defects and physical and mental illnesses and conditions, regardless of whether such measures are addressed in agency 5160 of the Administrative Code.

(D) Additional provisions.

(1) Coverage limits that have been established may be exceeded, with prior authorization, for medically necessary services rendered to medicaid-eligible individuals younger than twenty-one years of age.

(2) Separate payment may be made for additional medically necessary services rendered during, as part of, or as a result of a screening visit. Payment may be made to a provider for necessary follow-up services rendered at the time of the screening visit if the provider is qualified to perform them.

(3) In accordance with guidance issued by CMS in "EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents" (June 2014, found at http://www.medicaid.gov), when a screening examination indicates the need for further evaluation of a child's health, the child must be appropriately referred without delay for diagnosis, necessary treatment, and follow-up.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 11/1/2022
Prior Effective Dates: 3/20/2000
Rule 5160-1-16 | Preventive services.
 

(A) "Preventive service" is a procedure, treatment, or other measure that is included in either of two groups:

(1) Services addressed in any of the following sources:

(a) "USPSTF A and B Recommendations" (January 2017), published by the United States preventive services task force and available at http://www.uspreventiveservicestaskforce.org;

(b) Immunization schedules for January 2017 published by the centers for disease control and prevention and available at http://www.cdc.gov;

(c) "Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, 4th Edition" (2017), published by the American academy of pediatrics and available at http://www.aap.org; or

(d) "Recommendations for Preventive Services for Women" (December 2016), published by the women's preventive services initiative and available at http://www.womenspreventivehealth.org; or

(2) Medically necessary procedures that meet the definition of "early and periodic screening, diagnostic, and treatment services" set forth in 42 U.S.C. 1396d(r) (as in effect in January 2017).

(B) Payment may be made for a preventive service and necessary related services (e.g., medications, procedures, devices, tests, education, and counseling) when both of the following conditions are met:

(1) A practitioner in an appropriate discipline, acting within the scope of practice authorized under state law, has determined, on the basis of at least one risk factor, that the preventive service is indicated for a particular individual; and

(2) The preventive service is provided in accordance with nationally recognized, evidence-based frequency schedules.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/1/2022
Prior Effective Dates: 10/1/1987, 12/31/2001 (Emer.)
Rule 5160-1-17 | Eligible providers.
 

This rule sets forth eligibility requirements for practitioners, group practices, or organizational providers enrolling with, and seeking reimbursement from, the Ohio medicaid program.

(A) Eligible provider means any practitioner, group practice, or organization identified by the Ohio department of medicaid (ODM) as a type of provider eligible to enroll in the medicaid program that:

(1) Meets the applicable provider requirements and standards in agency 5160 of the Administrative Code that address applicable service categories and provider types covered under the Ohio medicaid program;

(2) Meets additional requirements and standards set forth in this rule;

(3) Meets provider screening requirements and, when applicable, pays the fee for enrollment as a provider in the medicaid program in accordance with rule 5160-1-17.8 of the Administrative Code; and

(4) Is approved for participation in the medicaid program by ODM as evidenced by the issuance of both a signed "provider agreement" and an Ohio medicaid provider number.

(B) Eligible practitioners licensed by an Ohio licensing board may enroll as a medicaid provider in accordance with their active licensure and scope of practice as determined by the licensing entity.

(C) A provider can be assigned a professional group provider type when organized for the purpose of providing professional services under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755., 4757., 4759., or 4762. of the Revised Code, and meets the requirements in either paragraph (C)(1) or (C)(2) of this rule, and meets the additional requirements set forth in paragraphs (C)(3) to (C)(5) of this rule.

(1) A professional practice that is owned by an individual may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule, and the owner or member of the practice possesses a valid license, certificate, or other legal authorization issued under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755., 4757., 4759., or 4762. of the Revised Code, and also meets the requirements found in paragraph (A)(1) of this rule.

A provider enrolling with the medicaid program that does not meet the provisions listed in paragraph (C) of this rule may only be enrolled as an individual provider.

(2) Any group of two or more individuals may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule. ODM recognizes two types of professional group practices, a professional medical group and a professional dental group.

(a) A professional medical group is a group that consists of individual practitioners recognized by ODM as eligible members. These eligible members include but are not limited to: physicians, osteopaths, advanced practice nurses, physician assistants, psychologists, podiatrists, optometrists, chiropractors, licensed independent social workers, licensed professional clinical counselors, independent marriage and family counselors, licensed independent chemical dependency counselors, occupational therapists, physical therapists, speech therapists, acupuncturists, audiologists, opticians, ocularists, licensed dietitians and registered dietitian nutritionists. With the exception of an incorporated individual in accordance with paragraph (C)(3)(b) of this rule, the professional medical practice must consist of two or more members, of like or different scopes of practice or licensure.

(b) A professional dental group is a group that consists only of dentists. With the exception of an incorporated individual in accordance with paragraph (C)(3)(b) of this rule, the practice must consist of two or more dentists.

(c) An out of state professional medical group must abide by the requirements stated in rule 5160-1-11 of the Administrative Code.

(3) For the purposes of the Ohio medicaid program, a professional group practice may be organized in accordance with one of the following organization structures:

(a) A corporation formed under Chapter 1701. of the Revised Code.

(b) A limited liability company formed under Chapter 1705. of the Revised Code.

(c) A non-profit corporation formed under Chapter 1702. of the Revised Code.

(d) A professional association formed under Chapter 1785. of the Revised Code.

(e) A partnership formed under Chapters 1776. and 1782. of the Revised Code.

(4) With the exception of hospitals, long term care facilities, home health agencies, hospice programs, and intermediate care facilities, each practitioner employed by or under contract with a group practice or an organization, including, but not limited to professional group practices, clinics, federally qualified health centers, and behavioral health facilities, who also meet the respective requirements in paragraph (A) of the rule, must have an approved individual provider agreement with ODM.

(5) Each practitioner, employed or under contract with a group practice or an organization that is actively enrolled as a provider in the Ohio medicaid program, shall affiliate themselves with their respective group practices or organizational providers when applying for a provider agreement with ODM.

(D) Requirements for obtaining and using national provider identifiers (NPI).

(1) For the purposes of receiving reimbursement for services rendered to medicaid recipients, ODM shall require providers and practitioners enrolling in the medicaid program to obtain a NPI.

(2) Providers, and practitioners, whether practicing independently or employed or under contract with a group practice or organization, who are identified by the american medical association's national uniform claim committee with a provider taxonomy number shall obtain a NPI and shall divulge the NPI to ODM upon enrollment.

(3) The name and NPI of the practitioner who furnishes services to medicaid recipients shall be on claims submitted to ODM for reimbursement. Claims submitted without a NPI will be denied.

(4) An organization with components or subparts is responsible for determining if any components or subpart of its organization require a separate NPI and, if so, shall obtain it for that component or subpart.

(E) As part of the initial medicaid provider application, an applicant shall include a list of all geographical locations at which it renders services under its NPI. An existing provider shall submit to ODM any additions or deletions to the list of locations within thirty calendar days of the change. An enrolled provider must also notify ODM of any provider affiliation additions or deletions within thirty days of the change. Failure to follow the requirements of this paragraph may prevent an applicant from being enrolled as a medicaid provider or if enrolled, may result in the termination of a provider agreement as provided for in rule 5160-1-17.6 of the Administrative Code.

(F) ODM does not enroll providers located outside of the United States and its territories.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02, 5164.06, 5164.31
Five Year Review Date: 11/25/2024
Prior Effective Dates: 4/7/1977, 3/22/1997
Rule 5160-1-17.2 | Provider agreement for providers.
 

Provisions of provider agreements for long term care nursing facilities are defined in Chapter 5160-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5160-26 of the Administrative Code.

A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid program. All medicaid provider applications must be submitted through the medicaid information technology system (MITS) web portal. Provider applications submitted in paper format will be returned to the provider unprocessed.

If a provider application requires additional supporting documentation by the department for the application process to be completed, the supporting documentation may be sent through the MITS web portal or sent to the department through regular mail service.

A provider agreement is a contract between the Ohio department of medicaid (ODM) and a provider of medicaid covered services. By signing this agreement the provider agrees to comply with the terms of the provider agreement, Revised Code, Administrative Code, and federal statutes and rules; and the provider certifies and agrees:

(A) To render medical services as medically necessary for the patient and only in the amount required by the patient without regard to race, creed, color, age, sex, national origin, source(s) of payment, or disability; submit claims only for services actually performed; and, bill ODM for no more than the usual and customary fee charged other patients for the same service.

(B) To ascertain and recoup any third-party resource(s) available to the consumer prior to billing ODM. ODM will then pay any unpaid balance up to the lesser of the provider's billed charge or the maximum allowable reimbursement as set forth in agency 5160 of the Administrative Code.

(C) To accept the allowable reimbursement for all covered services as payment-in-full, except as required in paragraph (B) of this rule. The provider will not seek reimbursement for that service, except as defined in rule 5160-1-09 of the Administrative Code, from the patient, any member of the family, or any other person.

(D) To maintain all records necessary and in such form so as to fully disclose the extent of services provided and significant business transactions. The provider will maintain such records for a period of six years from the date of receipt of payment or until any audit initiated within the required six year record maintenance period is completed.

(E) To furnish to ODM, the secretary of the department of health and human services, or the Ohio medicaid fraud control unit or their designees any information maintained under paragraph (D) of this rule for audit and review purposes. Audits may use statistical sampling. Failure to supply requested records within thirty days shall result in withholding of medicaid payments and may result in termination from the medicaid program.

(F) To inform ODM within thirty days of any changes including, but not limited to changes in licensure, certification, or registration status; ownership; specialty; additions, deletions, or replacements in group membership and hospital-based physician affiliations; and address, including all locations where services are rendered.

(G) To disclose ownership and control information, and to disclose the identity of any person who has been convicted of a criminal offense related to medicare, medicaid, or services provided under Title XX of the Social Security Act as in effect on November 15, 2018 (Title XX), as specified in rule 5160-1-17.3 of the Administrative Code.

(H) That neither the individual practitioner, nor the company, nor any owner, director, officer, or employee of the company, nor any independent contractor retained by the company, is currently subject to sanction under medicare, medicaid, or Title XX; or, is otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries.

(I) To provide to ODM, through the court of jurisdiction, notice of any bankruptcy action brought by the provider. Notice shall be mailed to: office of legal services, Ohio department of medicaid.

(J) To comply with the appropriate advance directives requirements for hospitals, providers of home health care, personal care services, and hospices as specified in Chapter 3701-83 of the Administrative Code.

(K) To comply with the confidentiality safeguards and the use and release of information regarding public assistance recipients as described in section 5101.27 of the Revised Code.

(L) To comply with section 121.36 of the Revised Code and rule 5160-1-39 of the Administrative Code when providing home care services.

Last updated September 1, 2023 at 12:55 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03; 5164.02
Five Year Review Date: 9/19/2024
Prior Effective Dates: 1/1/1979, 5/30/2002, 8/11/2005
Rule 5160-1-17.3 | Provider disclosure requirements.
 

(A) For the purposes of this rule, the following definitions apply:

(1) "Affiliation" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(2) "Agent" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(3) "Disclosable event" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(4) "Disclosing provider" means a medicaid provider, managed care entity, or fiscal agent under contract with the department of medicaid (department) in accordance with 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(5) "Indirect ownership interest" means an ownership interest in an entity that has direct or indirect ownership in the disclosing provider.

(6) "Managing employee" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(7) "Person with an ownership or control interest" means a person or corporation that meets any of the following:

(a) Has an ownership interest totaling five per cent or more in the disclosing provider;

(b) Has an indirect ownership interest equal to five per cent or more in the disclosing provider;

(c) Has a combination of direct and indirect ownership interest equal to five per cent or more in the disclosing provider;

(d) Owns an interest of five per cent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five per cent of the value of the property or assets of the disclosing provider;

(e) Is an officer or director of the disclosing provider that is organized as a corporation or non-profit; or

(f) Is a partner in the disclosing provider that is organized as a partnership or limited liability company.

(8) "Significant business transaction" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023).

(B) Disclosing providers will disclose the following information to the department in accordance with 42 C.F.R. 455.104 to 42 C.F.R 455.106 (as in effect on October 1, 2023):

(1) The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing provider.

(a) In the case of an individual, date of birth and social security number.

(b) In the case of a corporation, other tax identification number with an ownership or control interest in the disclosing provider or in any subcontractor in which the disclosing provider has a five per cent or more interest.

(2) Whether the person (individual or corporation) with an ownership or control interest in the disclosing provider is related to another person with ownership or control interest in the disclosing provider as a spouse, parent, child, or sibling.

(3) Whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing provider has a five per cent or more interest is related to another person with ownership or control interest in the disclosing provider as a spouse, parent, child, or sibling.

(4) The name of any disclosing provider in which an owner of the disclosing provider has an ownership or control interest.

(5) The name, address, date of birth, and social security number of any managing employee of the disclosing provider.

(6) The identity of any person who has ownership or control interest in the disclosing provider or is an agent or managing employee of the disclosing provider, and has been convicted of a criminal offense related to that person's involvement in any program under medicare, medicaid, or the title XX services program since the inception of those programs.

(7) The ownership of any subcontractor with whom the disclosing provider has had business transactions totaling more than twenty-five thousand dollars during the preceding twelve-month period ending on the date the disclosure is due.

(8) Any significant business transaction between the disclosing provider and any wholly owned supplier, or between the disclosing provider and any subcontractor, during the preceding five-year period ending on the date the disclosure is due.

(C) Disclosing providers, prior to initial enrollment or revalidation with the Ohio department of medicaid (department), who are not enrolled in medicare, will at the request of the department disclose when a managing employee, within the past five years, has an affiliation with a currently or formerly enrolled medicare, medicaid, or child health insurance program (CHIP) provider or supplier that has had a disclosable event in accordance with 42 C.F.R. 455.107 (as in effect on October 1, 2023).

(1) Applicable disclosing providers will disclose the following information about each affiliation:

(a) General identifying information including:

(i) Legal name of the provider as reported to either the internal revenue service (IRS) or social security administration (SSA);

(ii) Legal name of any managing employees as reported to either the IRS or SSA;

(iii) Tax identification number (TIN); and

(iv) National provider identifier (NPI);

(b) Length of the relationship;

(c) Type of affiliation;

(d) Degree or extent of affiliation; and

(e) If the affiliation has ended, the reason for the termination.

(2) The department, in consultation with the center for medicare and medicaid services (CMS), will decide, utilizing the factors found in 42 C.F.R 455.107 (as in effect on October 1, 2023), whether the affiliation poses an undue risk of fraud, waste, and abuse.

(a) If the department determines the provider's affiliation poses an undue risk, the provider's application will be denied or if enrolled, will result in the termination of the provider agreement.

(b) If enrollment is denied or the provider agreement terminated as a result of the department determining the provider's affiliation poses an undue risk of fraud, waste, and abuse, the provider may request a hearing pursuant to Chapter 119. of the Revised Code.

(D) Disclosures will be due at any of the following times in accordance with 42 C.F.R. 455.104 (as in effect on October 1, 2023):

(1) Prior to entering into a medicaid provider agreement or contract, during a procurement process or as part of a request for proposal.

(2) Prior to revalidating a medicaid provider agreement, or the renewal or extension of the contract.

(3) Within thirty-five days of any change in ownership.

(4) At any time within thirty-five days upon written request from the department.

(E) Failure by the disclosing provider to disclose information in accordance with this rule may result in the denial, suspension, or termination of the medicaid provider agreement or contract.

Last updated July 15, 2024 at 9:28 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/15/2029
Prior Effective Dates: 4/7/1977, 3/23/1979, 7/1/1980, 10/1/1987, 5/30/2002
Rule 5160-1-17.4 | Revalidation of provider agreements.
 

(A) Revalidation is the process that a provider is required to follow to renew and revalidate its provider agreement. Provider agreements must be revalidated no later than five years from the effective date of the original or the last revalidated provider agreement, whichever is applicable. In the event the center for medicare and medicaid services (CMS) waives or modifies the deadline, provider agreement revalidation may be delayed as authorized by the CMS waiver or modification. Provider agreements must also be revalidated whenever there is a change in risk pursuant to 42 C.F.R. 455.450 (as in effect October 1, 2020) The revalidation process is as follows:

(1) The Ohio department of medicaid (ODM) shall send a revalidation notice ninety days prior to the expiration date of the provider's time-limited agreement either to the provider's email or mailing address on file notifying the provider that it is required to revalidate its agreement.

(2) The revalidation notice shall instruct the provider what is required to complete the revalidation process. Providers are expected to meet all conditions for participation as an eligible provider that are in effect in Chapter 5160-1 of the Administrative Code at the time of revalidation.

(3) The provider shall submit all required information before the revalidation deadline date specified in the revalidation notice including the required fee as specified in rule 5160-1-17.8 of the Administrative Code.

(4) A provider shall not initiate revalidation prior to the receipt of the revalidation notification sent by ODM. This rule does not negate the requirement that a provider must properly disclose any changes to its provider agreement in accordance with rule 5160-1-17.3 of the Administrative Code. The reporting of changes does not constitute the initiation of revalidation and remains the provider's responsibility.

(5) When a provider fails to revalidate in the time and the manner required by ODM, as specified in this rule and in accordance with the revalidation notice referred to in paragraph (A)(1) of this rule, ODM shall deny an application for revalidation and terminate the time-limited provider agreement. The denial and termination will take effect thirty days after ODM mails a written notice to the provider by regular mail to the address on file notifying the provider of the decision. ODM shall specify in the notice the date on which the provider is required to cease operating under a terminated provider agreement.

(6) If a provider files an application for revalidation within the time and in the manner required, as specified in this rule, but the provider agreement expires before ODM acts on the application or before the effective date of the ODM decision on the application, the provider may continue operating under the terms of the expired agreement until the effective date of the ODM decision.

(7) If a provider files an application for revalidation within the time and in the manner required, as specified in this rule, but has not been able to obtain a renewal of its licensure, certification, accreditation, or registration the application may be accepted and processed by ODM as long as the granting official, board, commission, department, division, bureau, or other agency of state or federal government considers the provider in good standing and that its licensure, certification, accreditation, or registration is still active.

(B) The effective date of a new provider agreement is the date on which the provider signs the application and meets all of the federal and state requirements for participation in the medicaid program. The effective date of a new provider agreement may be made retroactive for up to twelve months prior to the date of application if the provider was properly licensed or certified.

(C) Pursuant to section 5164.38 of the Revised Code, ODM is not required to afford hearing rights, in accordance with Chapter 119. of the Revised Code when terminating a time-limited provider agreement due to the provider's failure to properly file an application for revalidation.

(D) In processing an application for revalidation, ODM reserves the right to conduct an on-site review at the provider's facility, place of business, or both, as ODM deems necessary to ensure program integrity.

Last updated April 17, 2021 at 10:17 AM

Supplemental Information

Authorized By: 5164.02; 5164.32
Amplifies: 5162.03; 5164.02; 5164.32
Five Year Review Date: 4/17/2026
Prior Effective Dates: 8/31/1979, 1/1/1995, 8/11/2005, 10/18/2019
Rule 5160-1-17.5 | Suspension of medicaid provider agreements.
 

(A) Definitions:

(1) "Credible allegation of fraud" means an accusation of fraud as defined in section 5164.36 of the Revised Code.

(2) "Non-institutional provider" means any person or entity with a medicaid provider agreement other than a hospital, long-term care nursing facility, intermediate care facility for individuals with intellectual disabilities or medicaid contracting managed care plans.

(B) The Ohio department of medicaid (ODM) shall suspend a medicaid provider agreement when at least one of the following conditions apply:

(1) Upon determining there is a credible allegation of fraud for which an investigation is pending against a provider under the medicaid program, unless good cause to not suspend is found pursuant to 42 CFR 455.23(e) or (f), effective Feb. 2, 2011; or

(2) Upon receiving notice and copy of an indictment that charges a non-institutional provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense as specified in division (E) of section 5164.37 of the Revised Code.

(C) Upon suspension of the provider agreement, the following conditions apply:

(1) If a provider is suspended pursuant to this rule, then any other provider agreements where the provider is an owner, officer, authorized agent, manager, or employee may also be suspended.

(2) A provider, its owner or owners, officer, authorized agent, associate, manager, or employee shall not own or provide services to any other medical provider or risk contractor or arrange for, render, or order services for medicaid recipients during the period of suspension.

(3) During the period of suspension, the provider owner or owners, officer, authorized agent, associate, manager, or employee shall not receive reimbursement in the form of direct payments from ODM or indirect payments of medicaid funds.

(4) The suspension shall continue until either of the following:

(a) The department or a prosecuting authority determines that there is insufficient evidence of fraud by the provider;

(b) The proceedings in any related criminal case are completed through dismissal of the indictment or through conviction, entry of a guilty plea, or finding of not guilty.

(5) If ODM commences a process to terminate the suspended provider agreement, the suspension shall continue in effect until the termination process is concluded.

(D) Reconsideration of suspension:

(1) A provider, owner, or owners subject to a suspension may request a reconsideration in accordance with section 5164.36 or 5164.37 of the Revised Code. A request for reconsideration is not subject to Chapter 119. of the Revised Code.

(2) The reconsideration shall be conducted by the ODM director or the director's designee in the office where the contestation arose provided that the designee was not involved in the original decision. Decisions made by the director or the director's designee are not appealable or subject to further reconsideration.

Last updated September 1, 2023 at 12:56 PM

Supplemental Information

Authorized By: 5164.01, 5164.36, 5164.37
Amplifies: 5164.36, 5164.37
Five Year Review Date: 3/22/2020
Rule 5160-1-17.6 | Termination and denial of provider agreement.
 

(A) For purposes of this rule, the following definitions apply:

(1) "Ownership or control interest" means having at least five per cent ownership, or interest, either directly, indirectly, or in any combination.

(2) "Provider" has the same meaning as "eligible provider," as defined in rule 5160-1-17 of the Administrative Code.

(3) "Provider Agreement" means an agreement as defined in rule 5160-1-17.2 of the Administrative Code or any rule contained in agency 5160 of the Administrative Code.

(B) Termination for long term care nursing facilities and intermediate care facilities for individuals with intellectual disabilities is located in Chapters 5160-3 and 5123:2-7 of the Administrative Code.

(C) Termination for providers enrolled in a medicaid managed care plan is located in Chapter 5160-26 of the Administrative Code.

(D) A provider may voluntarily terminate a provider agreement upon written notice thirty days before the provider's chosen termination date. The Ohio department of medicaid (ODM) has the discretion to accept or deny a voluntary termination for a provider who is facing involuntary termination due to an ODM action. ODM may waive the thirty day requirement if appropriate.

(E) A provider is ineligible for payment for dates of service on or after the effective date of a denial, suspension, revocation, limitation, or failure to renew a license, permit, certifcate, or certification issued by an official, board, commission, department, bureau, or other agency of the state or federal government.

(F) A provider that was terminated because of a conviction that was a result of a suspension due to credible allegation of fraud is ineligible for all payments, regardless of the dates of service.

(G) ODM may propose termination or denial of a provider agreement at any time it is determined that continuation or assumption of provider status is not in the best interest of recipients or the state of Ohio. The phrase "not in the best interest" shall include, but not be limited to, the following circumstances or occurrences:

(1) The provider has not billed or otherwise submitted a medicaid claim to ODM for two years or longer.

(2) The provider, or any person having an ownership or controlling interest in the provider, or who is an agent or employee of the provider, has been indicted or granted immunity from prosecution for, or has pled guilty to, or has been convicted of, any criminal offense against the state of Ohio or any other state or territory, whether the offense occured prior to or during the period of ownership, employment, or agency.

(3) The provider has made false representations, by omission or commission, on the provider enrollment application or does not fully and accurately disclose to ODM information as required by the provider agreement, any rule contained in agency 5160 of the Administrative Code, or any provisions contained in 42 C.F.R., Part 455, Subpart B (October 1, 2014)..

(4) The provider has been determined liable for negligent performance of professional services to its clientele or patients.

(5) As determined by ODM, the provider has departed from or failed to conform to accepted standards of care of similar practitioners under the same or similar circumstances, whether or not actual injury to a patient is established.

(6) The provider has been formally reprimanded or censured, placed on probation, suspended or placed on practice limitations for unethical conduct or improper practices by a state licensure board or by an association of its peers.

(7) The provider fails to file cost reports as required.

(8) The provider makes false statements, provides false information, or alters records, documents, charts, or prescriptions, or fails to cooperate or provide records or documentation upon request during an audit or review of provider activity by staff or contracting entity of ODM, any county department of job and family services, the attorney general's office, the auditor of state, the department of health and human services, or any other state or federal agency which, by law, has authorized access to records or documents. An alteration of provider records does not include records for which there is a properly documented correction.

(9) The provider has not corrected deficiency(ies) after receiving a written notice of operational deficiency from ODM.

(10) The provider fails to abide by, meet the requirements of, or have the capacity to comply with the terms and conditions of the provider agreement, and/or rules and regulations promulgated by ODM.

(11) The provider has been suspended or terminated from participation in another government medical program other than a program that requires automatic termination.

(12) The provider is found in violation of section 504 of the Rehabilitation Act of 1973, as amended (January 1, 2015), or the Civil Rights Act of 1964, as amended (January 1, 2015), in relation to the employment of individuals, the provision of services or in the purchase of goods and services.

(13) The provider, by any act or omission, has negatively affected the health, safety, or welfare of the medicaid recipient or the fiscal or programmatic integrity of the medicaid program.

(14) The office of the attorney general, auditor of state, or any board, bureau, commission, or department has recommended that ODM terminate the provider agreement where the reason for the request bears a reasonable relationship to the administration of the medicaid program or the integrity of state and/or federal funds.

(15) As determined by ODM, the provider fails to use reasonable care or discretion in the storage, administration, dispensing, or prescribing of drugs, or fails to employ acceptable scientific methods in the selection of drugs or other modalities of treatment of disease.

(16) As determined by ODM, the provider sells, gives away, personally furnishes, prescribes, or administers drugs for other than legal and legitimate therapeutic purposes.

(17) The United States drug enforcement agency has suspended or revoked the provider's registration for any act or acts which would constitute a violation of paragraph (E)(5), (E)(15), or (E)(16) of this rule.

(18) The provider or the provider's staff misrepresents the type and/or units of service, inflates billing codes to increase payments, or bills for, or receives payments for services not rendered, or any other practice that is a violation of any rule contained in agency 5160 of the Administrative Code.

(19) As determined by ODM, the provider, or the provider's staff prescribes, authorizes, bills for, or receives payments for, services that are not medically necessary as defined in rule 5160-1-01 of the Administrative Code.

(20) The provider or the provider's staff lack the ability or legal authority to provide services for which the provider has billed, because of lack of equipment or material, or a failure to comply with minimal requirements under state and federal law.

(21) The provider consistently violates the prohibition against billing medicaid recipients or assigning provider claims to a factor, as found in rule 5160-1-13.1 of the Administrative Code or 42 CFR 447.10 (October 1, 2014).

(22) The provider fails to notify ODM within thirty days of any changes in licensure, certification, accreditation, or registration status, ownership, closure, specialty, additions, deletions, or replacements in group memberships, and address.

(23) The provider fails to repay an overpayment or recovery amount assessed as a result of a final adjudication order.

(24) The provider has a previous or current exclusion, suspension, termination or involuntary withdrawal from participation in any medicaid program, or any other public or private health insurance program.

(25) The provider has been convicted under federal or state law of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.

(26) The provider has not responded to two certified mail correspondences from ODM and the provider's business cannot otherwise be located.

(27) The provider signed a provider agreement and failed to revalidate the provider agreement in accordance with rule 5160-1-17.4 of the Administrative Code.

(28) Any reason permitted or required by federal law.

(H) For any reason permitted or required by federal law, ODM may deny or exclude from participation in the medicaid program any individual, provider of services or goods, or other entity that does not possess a medicaid provider agreement.

(I) ODM shall terminate or deny a provider agreement when any of the following apply:

(1) Any license, permit, or certification that is required in the provider agreement or department rule has been denied, suspended, revoked, not renewed or is otherwise limited and the provider has been afforded the opportunity for a hearing in accordance with the hearing process established by the official, board, commission, department, division, bureau, or other agency of state or federal government.

(2) The terms of a provider agreement require the provider to hold a license, permit, or certificate, or maintain certification, issued by an official, board, commission, department, division, bureau, or other agency of state or federal government, other than ODM, and the provider has not obtained the license, permit, certificate, or maintained the certification.

(3) An official, board, commission, department, division, bureau, or other agency of this state, other than ODM, has denied, terminated, or not renewed a license, permit, certificate or certification that is required for participation, notwithstanding the fact that the provider may hold a license, permit, certificate or certification from an official, board, commission, department, division, bureau, or other agency of another state.

(4) A judgment has been entered in either a criminal or civil action against a medicaid provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code, except if the provider or owner can demonstrate to ODM that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee which resulted in the conviction or entry of judgment.

(5) The provider is terminated, suspended, or excluded by the medicare program and/or by the federal department of health and human services and that action is binding on the provider's participation in the medicaid program or renders federal financial participation unavailable for that provider's participation in the medicaid program.

(6) The provider has been convicted of, or pled guilty to, any criminal activity materially related to either the medicare or medicaid program or has been convicted of one of the offenses that caused the provider agreement to be suspended in accordance with rule 5160-1-17.5 of the Administrative Code..

(7) The provider has failed to apply for revalidation within the time and in the manner specified for revalidation pursuant to section 5164.32 of the Revised Code.

(8) The provider fails to timely submit a required background check or when the background check reveals that the provider has been convicted of, or pled guilty to a disqualifying offense unless the provider meets specific circumstances provided in agency 5160 of the Administrative Code.

(9) ODM has determined that the provider facility has closed or is not providing medicaid covered services.

(J) Appeal rights for the termination or denial of a provider agreement provided in this rule are found in rule 5160-1-57 of the Administrative Code.

(K) In determining the length of termination, ODM shall consider the following:

(1) The number and nature of program violations and other related offenses and the degree to which the provider participated in the offense;

(2) The nature and extent of any adverse impact the violations have had on recipients, including but not limited to the health and safety of those recipients who are aged and/or at greater physical, mental and emotional risk;

(3) The amount of any damages incurred by the medicaid program;

(4) Whether there are any mitigating circumstances;

(5) Any other facts bearing on the nature and seriousness of the violations or related offenses;

(6) The current, pending and previous sanction record of the provider under the medicare, medicaid, or other health-related programs; and

(7) Whether the provider is pending any future state or federal litigation relating to the current or any similar offense.

(L) ODM reserves the right to deny twelve months retroactivity for the submission of claims to providers whose agreement is reinstated after termination for cause in accordance with this rule.

Last updated September 1, 2023 at 12:57 PM

Supplemental Information

Authorized By: 5164.02, 5164.33
Amplifies: 5164.32, 5164.33, 5164.38
Five Year Review Date: 4/9/2020
Prior Effective Dates: 12/30/1977, 3/23/1979, 7/1/1980, 8/1/1996, 5/30/2002, 8/11/2005
Rule 5160-1-17.7 | Application by a former participating medicaid provider to resume participation in the Ohio medicaid program [except for medicaid contracting managed care plans (MCPs)].
 

(A) An individual or entity that at one time was a participating provider in the Ohio medicaid program and whose provider agreement was terminated either voluntarily or involuntarily in accordance with rule 5160-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program.

(B) In considering an application for participation in the Ohio medicaid program by a former medicaid provider described in paragraph (A) of this rule, and except as provided by paragraphs (C) and (D) of this rule, the Ohio department of medicaid (ODM) may grant the application only if it is reasonably certain that the types of actions that formed the basis for termination or exclusion have not recurred and will not recur. In making this determination, ODM will consider, in addition to any factors set forth in state law:

(1) The conduct of the former medicaid provider from the date the provider's previous provider agreement was terminated;

(2) Whether all fines, and all debts due and owing, including overpayments, to any federal, state or local government that relate to any of the state health care programs, have been paid, or satisfactory arrangements have been made, that fulfill these obligations; and

(3) Whether all requirements for participation are met at the time of the application filed pursuant to paragraph (A) of this rule, as evidenced by all appropriate and required documentation submitted with the application by the former medicaid provider.

(C) Notwithstanding paragraph (B) of this rule, ODM shall deny the application of a former medicaid provider whose provider agreement was terminated under paragraph (I)(4) or (I)(6) of rule 5160-1-17.6 of the Administrative Code.

(D) In the case of a former medicaid provider that allowed its provider agreement to lapse by failing to timely revalidate its provider agreement, and whose provider agreement has been inactive for at least sixty days, ODM may, without regard to the criteria set forth in paragraph (B) of this rule and at its discretion, grant an application that demonstrates through all appropriate and required documentation that the requirements to participate as a medicaid provider are met at the time the application is filed.

(E) If ODM approves an application filed under paragraph (A) of this rule, it must give written notice to the applicant specifying the date on which participation in the Ohio medicaid program may resume. The notice shall specify whether the applicant is assigned its former provider number or a new provider number, the determination of which shall be in the sole discretion of ODM.

(F) If ODM does not approve an application filed under paragraph (A) of this rule, it must give the applicant written notice of that decision. The notice will provide review rights in accordance with paragraph (D) of rule 5160-70-02 of the Administrative Code.

Last updated September 1, 2023 at 12:57 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 1/13/2022
Rule 5160-1-17.8 | Provider screening and application fee.
 

(A) In accordance with 42 C.F.R. 455.410 (as in effect October 1, 2019) and rule 5160-1-17 of the Administrative Code in order to become an eligible provider, a provider must meet the screening requirements described in this rule and in section 5164.34 of the Revised Code and pay an applicable application fee if required in the appendix to this rule. Provider screening and application fees are required at the time of enrollment and revalidation as defined in rule 5160-1-17.4 of the Administrative Code.

(1) Exemptions.

(a) If a provider is required to participate in the medicare program as a condition of enrollment in medicaid or elects to participate in the medicare program and has met the provider screening requirements and paid an applicable application fee to the centers for medicare and medicaid services (CMS) or its designee, the provider is exempt from the application fee requirements set forth in this rule.

(b) If a provider has met the provider screening requirements and paid an applicable application fee to another state medicaid agency or its designee, the provider is exempt from the application fee requirements set forth in this rule.

(c) A provider must provide documentation to support it meets the criteria for an exemption described in paragraphs (A)(1)(a) and (A)(1)(b) of this rule.

(d) When employed by or independently contracted with an entity certified by the Ohio department of mental health and addiction services, the following are exempt from the provisions of paragraphs (E)(2) to (E)(4) of this rule when providing services for the entity.

(i) Certified peer recovery supporters as defined in rule 5122-29-15.1 of the Administrative Code;

(ii) Practitioners licensed or certified under Chapter 4757. of the Revised Code;

(iii) Practitioners licensed or certified under Chapter 4758. of the Revised Code.

(2) The appendix to this rule sets forth:

(a) The screening risk level assigned to each provider type in accordance with paragraph (B) of this rule; and

(b) The provider types that must pay an application fee in accordance with paragraph (G) of this rule.

(B) The appropriate screening based on screening risk level must be given to all service locations of an enrolled provider. Providers must disclose all service locations at time of enrollment and notify the department of changes or additional service locations within thirty days of the change in order to be reimbursed for services delivered at that location.

(C) In accordance with 42 C.F.R. 455.452 (as in effect October 1, 2019), the Ohio department of medicaid (ODM) reserves the right to conduct additional screenings and background checks as determined necessary by ODM or its designee.

(D) Screening requirements differ by risk level. If more than one risk level could apply to a provider, the highest level of screening is required.

(1) Limited.

(a) Providers are subject to verification that they meet any applicable medicaid requirements as stated in agency 5160 of the Administrative Code for their provider type; and

(b) Providers are subject to license verifications, including state licensure verification in states other than Ohio; and

(c) Providers are subject to database checks on a pre- and post-enrollment basis to ensure that providers continue to meet the enrollment criteria for their provider type.

(i) Database checks must confirm the identity and exclusion status of providers and any person with a five per cent or greater ownership or control interest; or any person who is an agent or an individual (including a general manager, business manager, administrator, director, or consultant) who directly or indirectly manages, advises, or supervises any element of the practices, finances, or operations of the provider entity.

(ii) Databases to be checked include, but are not limited to, the social security administration's death master file, the national plan and provider enumeration systems (NPPES), the list of excluded individuals/entities maintained by the office of the inspector general, health and human services, the medicare exclusion database (MED), or the system for awards management (SAM), the list of providers terminated by another state's medicaid program, the nurse aid registry maintained by the Ohio department of health and the abuser registry maintained by the Ohio department of developmental disabilities.

(iii) A provider is disqualified from receiving a medicaid provider agreement during the time the provider is on one or more of the following registries or databases:

(a) The social security administration's death master file;

(b) The list of excluded individuals or entities maintained by the office of the inspector general, health and human services;

(c) The medicare exclusion database (MED;

(d) The list of providers terminated by another state's medicaid program;

(e) The abuser registry maintained by the Ohio department of developmental disabilities;

(f) The system for awards management (SAM) list of individuals or entities with an exclusion;

(g) The nurse aid registry abuse listing maintained by the Ohio department of health.

(2) Moderate.

(a) Providers are subject to the requirements in paragraph (D)(1) of this rule; and

(b) Providers are subject to on-site visits.

(i) Pre- and post-enrollment site visits by ODM or its designee will verify that information provided to ODM or its designee is accurate and to determine compliance with medicaid enrollment requirements.

(ii) Once enrolled, providers must allow CMS or its agents or contractors, or ODM or its agents or contractors to conduct unannounced on-site inspections of any and all provider locations.

(3) High.

(a) Providers are subject to the requirements in paragraphs (D)(1) and (D)(2)(b) of this rule; and

(b) Each person with a five per cent or greater ownership or control interest with the provider is subject to a criminal background check and is required to submit to a fingerprint-based background check within thirty days of submission of the application in a form and manner determined by ODM, or its designee.

(E) The following sets forth the exclusionary offenses and exclusion time periods from participation in the medicaid program:

(1) Tier I. Permanent exclusion.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are permanently excluded from participation in the medicaid program:

(i) 2903.01 (aggravated murder);

(ii) 2903.02 (murder);

(iii) 2903.03 (voluntary manslaughter);

(iv) 2903.11 (felonious assault);

(v) 2903.15 (permitting child abuse);

(vi) 2903.16 (failing to provide for a functionally-impaired person);

(vii) 2903.34 (patient abuse or neglect);

(viii) 2903.341 (patient endangerment);

(ix) 2905.01 (kidnapping);

(x) 2905.02 (abduction);

(xi) 2905.32 (human trafficking);

(xii) 2905.33 (unlawful conduct with respect to documents);

(xiii) 2907.02 (rape);

(xiv) 2907.03 (sexual battery);

(xv) 2907.04 (unlawful sexual conduct with a minor, formerly corruption of a minor);

(xvi) 2907.05 (gross sexual imposition);

(xvii) 2907.06 (sexual imposition);

(xviii) 2907.07 (importuning);

(xix) 2907.08 (voyeurism);

(xx) 2907.12 (felonious sexual penetration, as that offense existed prior to September 3, 1996);

(xxi) 2907.31 (disseminating matter harmful to juveniles);

(xxii) 2907.32 (pandering obscenity);

(xxiii) 2907.321 (pandering obscenity involving a minor);

(xxiv) 2907.322 (pandering sexually-oriented matter involving a minor);

(xxv) 2907.323 (illegal use of a minor in nudity-oriented material or performance);

(xxvi) 2909.22 (soliciting or providing support for act of terrorism);

(xxvii) 2909.23 (making terroristic threats);

(xxviii) 2909.24 (terrorism);

(xxix) 2913.40 (medicaid fraud);

(xxx) If related to another offense under paragraph (E)(1)(a) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(b) A conviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the Revised Code (illegal use of supplemental nutrition assistance program (SNAP) or women, infants, and children (WIC) program benefits) and paragraph (E)(2)(a)(xiii) of this rule; or

(c) A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations described in paragraph (E)(1)(a) or (E)(1)(b) of this rule.

(2) Tier II. Ten-year exclusionary period.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are excluded from participation in the medicaid program for a period of ten years from the date the individual was fully discharged from all imprisonment, probation or parole:

(i) 2903.04 (involuntary manslaughter);

(ii) 2903.041 (reckless homicide);

(iii) 2905.04 (child stealing, as that offense existed prior to July 1, 1996);

(iv) 2905.05 (child enticement);

(v) 2905.11 (extortion);

(vi) 2907.21 (compelling prostitution);

(vii) 2907.22 (promoting prostitution);

(viii) 2907.23 (enticement or solicitation to patronize a prostitute; procurement of a prostitute for another);

(ix) 2909.02 (aggravated arson);

(x) 2909.03 (arson);

(xi) 2911.01 (aggravated robbery);

(xii) 2911.11 (aggravated burglary);

(xiii) 2913.46 (illegal use of SNAP or WIC program benefits);

(xiv) 2913.48 (worker's compensation fraud);

(xv) 2913.49 (identity fraud);

(xvi) 2917.02 (aggravated riot);

(xvii) 2923.12 (carrying concealed weapons);

(xviii) 2923.122 (illegal conveyance or possession of deadly weapon or dangerous ordnance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone);

(xix) 2923.123 (illegal conveyance, possession, or control of deadly weapon or ordnance into courthouse);

(xx) 2923.13 (having weapons while under a disability);

(xxi) 2923.161 (improperly discharging a firearm at or into a habitation or school);

(xxii) 2923.162 (discharge of firearm on or near prohibited premises);

(xxiii) 2923.21 (improperly furnishing firearms to minor);

(xxiv) 2923.32 (engaging in a pattern of corrupt activity);

(xxv) 2923.42 (participating in a criminal gang);

(xxvi) 2925.02 (corrupting another with drugs);

(xxvii) 2925.03 (trafficking in drugs);

(xxviii) 2925.04 (illegal manufacture of drugs or cultivation of marijuana);

(xxix) 2925.041 (illegal assembly or possession of chemicals for the manufacture of drugs);

(xxx) 3716.11 (placing harmful or hazardous objects in food or confection); or

(xxxi) If related to an offense under paragraph (E)(2)(a) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(b) A violation of an existing or former municipal ordinance or law of this state, any other state or the United States that is substantially equivalent to any of the offenses or violations described under paragraph (E)(2)(a) of this rule.

(c) If the individual has been convicted of multiple disqualifying offenses, including an offense listed in paragraph (E)(2)(a) or (E)(2)(b) of this rule, and another offense or offenses listed in paragraph (E)(2)(a), (E)(3)(a), (E)(3)(b), (E)(4)(a), or (E)(4)(b) of this rule, the individual is subject to a fifteen-year exclusionary period beginning on the date the individual was fully discharged from all imprisonment, probation or parole for the most recent offense.

(3) Tier III. Seven-year exclusionary period.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are excluded from participation in the medicaid program for a period of seven years from the date the individual was fully discharged from all imprisonment, probation or parole:

(i) 959.13 (cruelty to animals);

(ii) 959.131 (prohibitions concerning companion animals);

(iii) 2903.12 (aggravated assault);

(iv) 2903.21 (aggravated menacing);

(v) 2903.211 (menacing by stalking);

(vi) 2905.12 (coercion);

(vii) 2909.04 (disrupting public services);

(viii) 2911.02 (robbery);

(ix) 2911.12 (burglary);

(x) 2913.47 (insurance fraud);

(xi) 2917.01 (inciting to violence);

(xii) 2917.03 (riot);

(xiii) 2917.31 (inducing panic);

(xiv) 2919.22 (endangering children):

(xv) 2919.25 (domestic violence);

(xvi) 2921.03 (intimidation);

(xvii) 2921.11 (perjury);

(xviii) 2921.13 (falsification, falsification in a theft offense, falsification to purchase a firearm, or falsification to obtain a concealed handgun license);

(xix) 2921.34 (escape);

(xx) 2921.35 (aiding escape or resistance to lawful authority);

(xxi) 2921.36 (illegal conveyance of weapons, drugs or other prohibited items onto the grounds of a detention facility or institution);

(xxii) 2925.05 (funding drug trafficking);

(xxiii) 2925.06 (illegal administration or distribution of anabolic steroids);

(xxiv) 2925.24 (tampering with drugs);

(xxv) 2927.12 (ethnic intimidation); or

(xxvi) If related to an offense under paragraph (E)(3)(a) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(b) A violation of an existing or former municipal ordinance or law of this state, any other state or the United States that is substantially equivalent to any of the offenses or violations described under paragraph (E)(3)(a) of this rule.

(c) If an individual has been convicted of multiple disqualifying offenses, including an offense listed in paragraph (E)(3)(a) or (E)(3)(b) of this rule, and another offense or offenses listed in paragraph (E)(3)(a), (E)(3)(b), (E)(4)(a), or (E)(4)(b) of this rule, the individual is subject to a ten-year exclusionary period beginning on the date the individual was fully discharged from all imprisonment, probation or parole for the most recent offense.

(4) Tier IV. Five-year exclusionary period.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are excluded from participation in the medicaid program for a period of five years from the date the individual was fully discharged from all imprisonment, probation or parole:

(i) 2903.13 (assault);

(ii) 2903.22 (menacing);

(iii) 2907.09 (public indecency);

(iv) 2907.24 (soliciting);

(v) 2907.25 (prostitution);

(vi) 2907.33 (deception to obtain matter harmful to juveniles);

(vii) 2911.13 (breaking and entering);

(viii) 2913.02 (theft);

(ix) 2913.03 (unauthorized use of a vehicle);

(x) 2913.04 (unauthorized use of computer, cable or telecommunication property);

(xi) 2913.05 (telecommunication fraud);

(xii) 2913.11 (passing bad checks);

(xiii) 2913.21 (misuse of credit cards);

(xiv) 2913.31 (forgery - forging identification cards or selling or distributing forged identification cards);

(xv) 2913.32 (criminal simulation);

(xvi) 2913.41 (defrauding a rental agency or hostelry);

(xvii) 2913.42 (tampering with records);

(xviii) 2913.43 (securing writings by deception);

(xix) 2913.44 (personating an officer);

(xx) 2913.441 (unlawful display of law enforcement emblem);

(xxi) 2913.45 (defrauding creditors);

(xxii) 2913.51 (receiving stolen property);

(xxiii) 2919.12 (unlawful abortion);

(xxiv) 2919.121 (unlawful abortion upon minor);

(xxv) 2919.123 (unlawful distribution of an abortion-inducing drug);

(xxvi) 2919.23 (interference with custody);

(xxvii) 2919.24 (contributing to the unruliness or delinquency of a child);

(xxviii) 2921.12 (tampering with evidence);

(xxix) 2921.21 (compounding a crime);

(xxx) 2921.24 (disclosure of confidential information);

(xxxi) 2921.32 (obstructing justice);

(xxxii) 2921.321 (assaulting or harassing a police dog, horse, or service animal);

(xxxiii) 2921.51 (impersonation of peace officer);

(xxxiv) 2925.09 (illegal administration, dispensing, distribution, manufacture, possession, selling, or using of any dangerous veterinary drug);

(xxxv) 2925.11 (drug possession, other than a minor drug possession offense);

(xxxvi) 2925.13 (permitting drug abuse);

(xxxvii) 2925.22 (deception to obtain a dangerous drug);

(xxxviii) 2925.23 (illegal processing of drug documents);

(xxxix) 2925.36 (illegal dispensing of drug samples);

(xl) 2925.55 (unlawful purchase of pseudoephedrine product);

(xli) 2925.56 (unlawful sale of pseudoephedrine product);

(xlii) If related to an offense under paragraph (E)(4)(a) of this rule, 2923.01 (conspiracy), 2923.02 (attempt), or 2923.03 (complicity); or

(b) A violation of an existing or former municipal ordinance or law of this state, any other state or the United States that is substantially equivalent to any of the offenses or violations described under paragraph (E)(4)(a) of this rule.

(c) If an individual has been convicted of multiple disqualifying offenses listed in paragraph (E)(4)(a) or (E)(4)(b) of this rule, the individual is subject to a seven-year exclusionary period beginning on the date the individual was fully discharged from all imprisonment, probation or parole for the most recent offense.

(5) Tier V. No exclusionary period.

(a) Individuals who have been convicted of or pleaded guilty to, an offense in any of the following sections of the Revised Code are not subject to an exclusionary period and may participate in the medicaid program:

(i) 2919.21 (non-support/contributing to non-support of dependents);

(ii) 2925.11 (drug possession that is a minor drug possession offense); or

(iii) 2925.14 (drug paraphernalia); or

(iv) 2925.141 (illegal use or possession of marijuana drug paraphernalia); or

(b) A violation of an existing or former municipal ordinance or law of this state, any other state or the United States that is substantially equivalent to any of the offenses or violations described under paragraph (E)(5)(a) of this rule.

(F) Pardons and certificates. A conviction of, or a plea of guilty to, an exclusionary offense as set forth in paragraph (E) of this rule shall not prevent a provider from enrollment if any of the following circumstances apply:

(1) The provider has been granted an unconditional pardon for the offense pursuant to Chapter 2967. of the Revised Code;

(2) The provider has been granted an unconditional pardon for the offense pursuant to an existing or former law of the state of Ohio, any other state, or the United States, if the law is substantially equivalent to Chapter 2967. of the Revised Code;

(3) The provider has been granted a conditional pardon for the offense pursuant to Chapter 2967. of the Revised Code, and the condition(s) under which the pardon was granted have been satisfied;

(4) The provider's conviction or guilty plea has been set aside pursuant to law; or

(5) A certificate of qualification for employment has been issued by an Ohio court of common pleas pursuant to section 2953.25 of the Revised Code, or an equivalent certification has been issued by an out of state or federal jurisdiction.

(6) Provider applications that include a certificate of qualification for employment or an equivalent certification associated with a permanent exclusion offense as stated in paragraph (E)(1) of this rule, will be reviewed by ODM and a decision will be rendered by ODM on a case-by-case basis as to whether a provider agreement will be approved or not in accordance with section 2953.25 of the Revised Code.

(G) Application fee.

(1) Provider types identified as subject to an application fee in the appendix to this rule must submit the fee in a form and manner determined by ODM at the time of application for enrollment or revalidation as a medicaid provider. If proof of fee payment is not submitted with the provider's application, the application will be rejected as incomplete.

(2) Individual physicians and non-physician practitioners are exempt from paying an application fee in accordance with 42 C.F.R. 455.460, (October 1, 2019).

(3) ODM may waive an application fee if:

(a) ODM determines that imposing the fee would have an adverse impact on beneficiary access to services; and

(b) ODM has requested and CMS has approved a waiver of the fee.

(4) If ODM receives approval from CMS to waive a medicaid application fee, providers are still subject to the screening requirements set forth in this rule.

(5) The application fee is equal to the amount established by CMS and includes an annual adjustment for inflation in accordance with 42 U.S.C. 1395cc(j)(2)(C)(i) (January 1, 2020).

(6) The application fee will not be refunded if:

(a) Enrollment is denied as a result of failure to meet the provider screening requirements described in this rule;

(b) If enrollment is denied based on the results of the provider screening.; or

(c) If ODM or its designee identifies other circumstances under which refunding the application fee is not warranted.

(H) If enrollment is denied as a result of failure to meet the provider screening requirements or failure to pay any associated application fee, the provider may request a hearing pursuant to Chapter 119. of the Revised Code.

View Appendix

Last updated June 23, 2022 at 3:41 PM

Supplemental Information

Authorized By: 5164.02, 5164.31
Amplifies: 5164.02, 5164.31, 5164.34
Five Year Review Date: 1/31/2025
Prior Effective Dates: 3/31/2012, 10/25/2018, 10/1/2019 (Emer.)
Rule 5160-1-17.9 | Ordering or referring providers.
 

(A) Definitions for purposes of this rule only:

(1) A "participating provider" is an active provider who bills the medicaid program for rendered services, or who is an active provider who orders, prescribes, refers, or certifies but does not bill the medicaid program.

(2) An "ordering or referring only provider" is a provider who orders, prescribes, refers, or certifies an item or service reported on a claim, and is not a billing provider in the medicaid program. For example: a provider orders items or services for the medicaid consumer, such as prescription drugs, durable medical equipment, prosthetics, orthotics, and supplies, clinical laboratory services, or imaging services, and may certify home health services for a medicaid consumer.

(3) "Physician" or "supervising physician" means an individual authorized to practice medicine in Ohio or another state.

(4) "Other professional" means those providers, other than physicians, who order, prescribe, refer, or certify an item or service reported on a claim. Examples include but are not limited to: physician assistant, clinical nurse specialist, nurse practitioner, clinical psychologist, certified nurse midwife, clinical social worker, and interns, residents, and fellows.

(B) A physician or other professional who is an ordering or referring only provider of medicaid services must be enrolled as a participating provider with the medicaid program.

(C) An ordering or referring only provider shall be considered limited risk for purposes of screening, as defined in rule 5101:3-1-17.8 of the Administrative Code.

(D) Ordering and referring only providers who are enrolled with the office shall revalidate in accordance with rule 5101:3-1-17.4 of the Administrative Code.

(E) Claims for services that require an order, prescription, referral, or certification will be denied if they do not include the following:

(1) A valid national provider identifier (NPI) and the legal name of the ordering, prescribing, referring, or certifying provider; or,

(2) If the ordering, prescribing, referring, or certifying provider is not a provider type eligible to participate in Ohio medicaid, a valid NPI and the legal name of the physician or other professional supervising the ordering or referring provider.

(F) This rule does not apply to services delivered through medicaid managed care plans.

Last updated September 1, 2023 at 12:57 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 7/1/2018
Rule 5160-1-17.12 | Qualified entity requirements and responsibilities for determining presumptive eligibility.
 

The Ohio department of medicaid (ODM) authorizes qualified entities (QEs) to determine presumptive eligibility (PE) based on self-attested information to grant immediate medicaid coverage to certain individuals seeking medicaid covered services. This rule sets forth eligibility requirements and responsibilities to maintain designation as a QE.

(A) For the purposes of this rule, "qualified entity" has the same meaning as defined in rule 5160:1-1-01 of the Administrative Code.

(B) To become a QE, the eligible entity must:

(1) Have an active provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code;

(2) Read the presumptive eligibility training guide found on the ODM website, www.medicaid.ohio.gov; and

(3) Attest that it will meet the terms and conditions as a QE by reading, signing, and sending ODM form 10252 "acknowledgment of terms and conditions governing the presumptive eligibility determinations authority granted by the Ohio department of medicaid to a qualified entity" (rev. 8/2019), found on the ODM website, www.medicaid.ohio.gov.

(C) Once designated as a QE, the QE must:

(1) Remain in good standing as an Ohio medicaid provider;

(2) Follow rule 5160:1-2-13 of the Administrative Code and all other applicable federal and state laws when determining medicaid PE;

(3) Verify the individual is not already enrolled in another category of medicaid;

(4) Without compensation, agree to perform all of the administrative functions associated with PE including, but not limited to:

(a) Provide to ODM a list of names and titles of all employees given responsibility to determine PE and request appropriate access to the PE portal;

(b) Ensure that employees given responsibility to determine PE have read the presumptive eligibility training guide, understand the criteria for all medicaid eligibility categories and have been trained on how to use the presumptive eligibility portal;

(c) Ensure those who have responsibility to submit claims to the medicaid program for reimbursement of medicaid services are not individuals responsible for determining presumptive eligibility; and

(d) Agree to retain all records related to presumptive eligibility determinations in accordance with rule 5160-1-27 of the Administrative Code and provide such records to ODM, its designee, or to any authorized state or federal agency upon request.

(5) Agree that it may be held responsible for the willful conduct of its employees who violate federal or state law. Any employee who knowingly files a claim containing false, incomplete, or misleading essential information to create eligibility for medicaid or receive payment from medicaid may be punishable under federal or state law;

(6) If the QE is a hospital, agree to provide thirty-six hours' worth of medically necessary medications to any person enrolled presumptively by the QE at time of determination;

(7) If the QE is a federally qualified health center (FQHC) and is able to do so, provide thirty-six hours' worth of medically necessary medications to any person enrolled presumptively by the QE at the time of determination if such needs are determined during a medical visit;

(8) Ensure that for all persons enrolled presumptively by the QE, at least eighty-five per cent have a completed application for full medicaid benefits submitted no later than the last day of the month following the month in which the QE makes the PE determination; and

(9) Ensure that for all persons who had an application submitted for full medicaid benefits, at least eighty-five per cent result in an awarding of medicaid eligibility.

(D) ODM may terminate authority granted under this rule with or without written notice, for any reason supported by evidence of acts or omissions adversely affecting the medicaid program, including, but not limited to the following circumstances:

(1) Revocation or cancellation of the QE's Ohio medicaid provider agreement;

(2) Requirements set forth in this rule are not met;

(3) Unauthorized use of MITS by the QE;

(4) Programmatic or systematic changes related to the medicaid eligibility or enrollment system; or

(5) The QE is unable to perform its functions.

(E) A QE may utilize reconsideration rights as stated in rule 5160-70-02 of the Administrative Code to challenge a decision of ODM to deny or terminate QE designation.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02
Five Year Review Date: 11/9/2024
Rule 5160-1-18 | Telehealth.
 

(A) For the purposes of this rule, the following definitions apply:

(1) "Patient site" is the physical location of the patient at the time a health care service is provided through the use of telehealth.

(2) "Practitioner site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth.

(3) "Telehealth" is the direct delivery of health care services to a patient related to diagnosis, treatment, and management of a condition.

(a) Telehealth is the interaction with a patient via synchronous, interactive, real-time electronic communication comprising both audio and video elements; or

(b) The following activities that are asynchronous or do not have both audio and video elements:

(i) Telephone calls;

(ii) Remote patient monitoring; and

(iii) Communication with a patient through secure electronic mail or a secure patient portal.

(c) For services rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is defined in rule 5122-29-31 of the Administrative Code.

(d) Conversations or electronic communication between practitioners regarding a patient without the patient present is not considered telehealth unless the service would allow billing for practitioner to practitioner communication in a non-telehealth setting.

(B) Eligible providers.

(1) The following practitioners are eligible to render services through the use of telehealth:

(a) Physicians as defined in Chapter 4731. of the Revised Code.

(b) Psychologists as defined in Chapter 4732. of the Revised Code.

(c) Physician assistants as defined in Chapter 4730. of the Revised Code.

(d) Clinical nurse specialists, certified nurse-midwives, or certified nurse practitioners as defined in Chapter 4723. of the Revised Code.

(e) Licensed independent social workers, licensed independent marriage and family therapists, or licensed professional clinical counselors as defined in Chapter 4757. of the Revised Code.

(f) Licensed independent chemical dependency counselors as defined in Chapter 4758. of the Revised Code.

(g) Supervised practitioners, trainees, residents, and interns as defined in rules 5160-4-02 and 5160-8-05 of the Administrative Code.

(h) Audiologists, speech-language pathologists, speech-language pathology aides, audiology aides, and individuals holding a conditional license as defined in Chapter 4753. of the Revised Code.

(i) Occupational and physical therapists and occupational and physical therapist assistants as defined in Chapter 4755. of the Revised Code.

(j) Home health and hospice aides.

(k) Private duty registered nurses or licensed practical nurses in a home health or hospice setting.

(l) Dentists as defined in Chapter 4715. of the Revised Code.

(m) Medicaid school program (MSP) practitioners as described in Chapter 5160-35 of the Administrative Code.

(n) Dietitians as defined in Chapter 4759. of the Revised Code.

(o) Behavioral health practitioners as defined in rule 5160-27-01 of the Administrative Code.

(p) Optometrists as defined in Chapter 4725. of the Revised Code.

(q) Pharmacists as defined in Chapter 4729. of the Revised Code.

(r) Other practitioners if specifically authorized in rule promulgated under agency 5160 of the Administrative Code.

(2) The following provider types are eligible to bill for services rendered through the use of telehealth.

(a) Any practitioner identified in paragraph (B)(1) of this rule, except for the following dependent practitioners:

(i) Supervised practitioners, trainees, residents, and interns as defined in rules 5160-4-02 and 5160-8-05 of the Administrative Code, except as provided in rule 5160-4-02.3 of the Administrative Code;

(ii) Occupational therapist assistants as defined in section 4755.04 of the Revised Code;

(iii) Physical therapist assistants as defined in section 4755.40 of the Revised Code;

(iv) Speech-language pathology aides, audiology aides, and individuals holding a conditional license as defined in Chapter 4753. of the Revised Code.

(b) A professional medical group.

(c) A professional dental group.

(d) A federally qualified health center (FQHC) or rural health clinic (RHC) as defined in Chapter 5160-28 of the Administrative Code.

(e) Ambulatory health care clinics (AHCC) as defined in Chapter 5160-13 of the Administrative Code.

(f) Outpatient hospitals on behalf of licensed psychologists and independent practitioners not eligible to separately bill when practicing in an outpatient hospital setting.

(g) Medicaid school program (MSP) providers as defined in Chapter 5160-35 of the Administrative Code.

(h) Private duty nurses.

(i) Home health and hospice agencies.

(j) Behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code.

(k) Hospitals operating an outpatient hospital behavioral health program in accordance with rule 5160-2-76 of the Administrative Code.

(C) Provider responsibilities when providing services through telehealth.

(1) It is the responsibility of the practitioner to deliver telehealth services in accordance with all state and federal laws including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and any HIPAA related directives from the office for civil rights (OCR) at the department of health and human services (HHS) issued during the COVID-19 national public health emergency and 42 C.F.R. part 2 (January 1, 2020).

(2) It is the responsibility of the practitioner to deliver telehealth services in accordance with rules set forth by their respective licensing board and accepted standards of clinical practice.

(3) The practitioner site is responsible for maintaining documentation in accordance with paragraph (C)(1) of this rule for the health care service delivered through the use of telehealth and to document the specific telehealth modality used.

(4) For practitioners who render services to an individual through telehealth for a period longer than twelve consecutive months, the telehealth practice or practitioner is expected to conduct at least one in-person annual visit or refer the individual to a practitioner or their usual source of clinical care that is not an emergency department for an in-person annual visit.

(D) Payment may be made only for the following medically necessary health care services identified in appendix A to this rule when delivered through the use of telehealth from the practitioner site:

(1) When provided by a patient centered medical home as defined in rule 5160-19-01 of the Administrative Code or behavioral health provider as defined in rule 5160-27-01 of the Administrative Code, evaluation and management of a new patient described as "office or other outpatient visit" with medical decision making not to exceed moderate complexity.

(2) Evaluation and management of an established patient described as "office or other outpatient visit" with medical decision making not to exceed moderate complexity.

(3) Inpatient or office consultation for a new or established patient when providing the same quality and timeliness of care to the patient other than by telehealth is not possible, as documented in the medical record.

(4) Mental health or substance use disorder services described as "psychiatric diagnostic evaluation" or "psychotherapy."

(5) Remote evaluation of recorded video or images submitted by an established patient.

(6) Virtual check-in by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient.

(7) Online digital evaluation and management service for an established patient.

(8) Remote patient monitoring.

(9) Audiology, speech-language pathology, physical therapy, and occupational therapy services, including services provided in the home health setting.

(10) Medical nutrition services.

(11) Lactation counseling services.

(12) Psychological and neuropsychological testing.

(13) Smoking and tobacco use cessation counseling.

(14) Developmental test administration.

(15) Limited or periodic oral evaluation.

(16) Hospice services.

(17) Private duty nursing services.

(18) State plan home health services.

(19) Dialysis related services.

(20) Services under the specialized recovery services (SRS) program as defined in rule 5160-43-01 of the Administrative Code.

(21) Notwithstanding paragraph (D)(2) of this rule, behavioral health services covered under Chapter 5160-27 of the Administrative Code.

(22) Optometry services.

(23) Pregnancy education services.

(24) Diabetic self-management training (DSMT) services.

(25) Other services if specifically authorized in rule promulgated under agency 5160 of the Administrative Code.

(E) Submission and payment of telehealth claims.

(1) The practitioner site may submit either a professional or institutional claim for health care services delivered through the use of telehealth. For any professional claim submitted for health care services utilizing telehealth to be paid, it is the responsibility of the provider to follow ODM billing guidelines found on the ODM website: www.medicaid.ohio.gov.

(2) An institutional (facility) claim may be submitted by an outpatient hospital for telehealth services provided by licensed psychologists and independent practitioners not eligible to separately bill when practicing in an outpatient hospital setting. Other telehealth services provided in a hospital setting may be billed in accordance with rule 5160-2-02 of the Administrative Code.

(3) Medicaid-covered services may be provided through telehealth, as appropriate, if otherwise payable under the medicaid school program as defined in Chapter 5160-35 of the Administrative Code.

(4) Except for services billed by behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code and FQHC and RHC services defined in rules 5160-28-03.1 and 5160-28-03.3 of the Administrative Code, the payment amount for a health care service delivered through the use of telehealth is the lesser of the submitted charge or the maximum amount shown in appendix DD to rule 5160-1-60 of the Administrative Code for the date of service.

(5) For a covered telehealth service that is also an FQHC or RHC service, the face-to-face requirement is waived and payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(6) Individuals who meet the definition of inmate in a penal facility or a public institution as defined in rule 5160:1-1-03 of the Administrative Code are not eligible for telehealth services under this rule.

(7) For telehealth services billed by behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code, payment is made in accordance with Chapter 5160-27 of the Administrative Code.

(8) Unless stated otherwise in the billing guidelines, professional claims submitted for health care services provided through the use of telehealth have to include:

(a) A "GT" modifier;

(b) A place of service code that reflects the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth.

(c) A modifier as identified in appendix B to this rule if the physical location of the patient is one of the following locations:

(i) The patient's home (including homeless shelter, assisted living facility, group home, and temporary lodging);

(ii) School;

(iii) Inpatient hospital;

(iv) Outpatient hospital;

(v) Nursing facility;

(vi) Intermediate care facility for individuals with an intellectual disability.

Last updated July 15, 2022 at 9:52 AM

Supplemental Information

Authorized By: 5164.02, 5164.95
Amplifies: 5164.02, 5164.95
Five Year Review Date: 11/15/2025
Rule 5160-1-19 | Submission of medicaid claims.
 

(A) Unless otherwise directed by the Ohio department of medicaid (ODM), paper claims will not be accepted. Except as otherwise provided in section 5164.46 of the Revised Code or a state agency's interagency agreement, claims are to be submitted directly to ODM through one of the following formats:

(1) Electronic data interchange (EDI), in accordance with rule 5160-1-20 of the Administrative Code.

(2) The ODM provider web portal; or

(3) Pharmacy point-of-sale.

(B) Claims should be submitted pursuant to the national correct coding initiative and according to the coding standards set forth in the following guides:

(1) The healthcare common procedure coding system;

(2) The current procedural terminology codebook;

(3) The current dental terminology codebook; or

(4) The international classification of diseases handbooks.

(C) Claims for items and services that necessitate a rendering or supervising provider, order, prescription, referral, or certification will be denied if:

(1) They do not include the national provider identifier (NPI) and the legal name of the rendering, supervising, ordering, prescribing, referring, or certifying provider; and

(2) The provider does not have an active medicaid provider agreement.

(D) Timely filing:

(1) Claims are timely if received by ODM within:

(a) Three hundred sixty-five days of the actual date the service was provided.

(b) Three hundred sixty-five days from the date of discharge for inpatient hospital claims.

(c) Three hundred sixty-five days from the date of service or inpatient hospital discharge, as applicable, for denied claims that are re-submitted for payment.

(2) Provider-reported underpaid claims should be adjusted within three hundred sixty-five days from the date of service or inpatient hospital discharge, as applicable.

(E) Exceptions to timely filing are:

(1) Claims submitted via the "automatic medicare crossover process" (the automatic process of medicare electronically submitting a claim to ODM following medicare adjudication and payment of a claim for a dually eligible individual) are not subject to timely filing provisions in this rule.

(2) Claims for wraparound payment for a federally qualified health center (FQHC) or rural health center (RHC) are timely if submitted to ODM within one hundred eighty days from the date the claim was paid.

(3) Claims submitted to ODM after three hundred sixty-five days of the date of service or discharge, as applicable, due to a delay in eligibility determination or a state hearing decision regarding eligibility are timely if received by ODM within one hundred eighty days of the notice of eligibility determination or state hearing decision to be considered for payment.

(4) Claims submitted to ODM after three hundred sixty-five days of the date of service or discharge, as applicable, due to a reversal of payment by a third party payer are timely if the adjusted claim is received within one hundred eighty days of the recovery of funds to be considered for payment.

(5) Any claim delayed in submission to, or adjudicated by ODM, due to an action or decision by ODM, at the discretion of ODM, may be reimbursed after three hundred sixty-five days from the date of service or inpatient hospital discharge.

(F) In instances of conflict of claim payment between two providers, ODM may adjust or void a claim as appropriate after notification to the providers.

(G) Overpaid claims.

(1) When a provider identifies an overpayment, the provider will submit an electronic adjustment to ODM within sixty days of discovery to return the overpayment.

(2) When ODM identifies an overpayment, ODM will notify the provider of the overpayment. The provider has sixty days to correct the overpayment. If the provider fails to correct an identified overpayment within sixty days, ODM will make the adjustment from subsequent payments to the provider or void the claim as appropriate. If an ODM adjustment is not possible, ODM will issue an invoice to the provider for the overpaid amount. The provider has sixty days from the date of the invoice to seek reconsideration or remit payment to ODM. If the provider fails to remit the full payment due the unpaid balance will be certified to the Ohio attorney general for collection.

(3) ODM will pursue collections by invoice for overpayments that result in a credit balance owed to ODM that remain outstanding for more than forty-five days.

(4) Appeal rights may be exercised in accordance with Chapter 5160-70 of the Administrative Code. All ODM recoverable amounts are subject to the application of interest in accordance with rule 5160-1-25 of the Administrative Code.

(H) ODM forms that are necessary for a claim to be processed should only be submitted through the ODM provider web portal unless otherwise permitted by ODM.

(I) Claim adjustments should only be submitted through EDI or the ODM provider web portal.

(J) ODM will only process refund checks from providers for an invoice for a claim overpayment, a letter of collection of an outstanding overpayment, audit, or review, or other circumstance deemed appropriate by ODM.

Last updated February 1, 2023 at 8:53 AM

Supplemental Information

Authorized By: 5164.02, 5164.46
Amplifies: 5162.03, 5164.02, 5164.70, 5164.46
Five Year Review Date: 2/1/2028
Prior Effective Dates: 10/1/1983, 2/1/1984, 7/1/1985 (Emer.), 8/1/1986, 10/1/1987, 7/1/2003, 1/1/2004, 3/28/2005, 7/1/2005, 12/30/2005 (Emer.), 12/31/2007 (Emer.), 3/30/2008, 12/31/2009 (Emer.), 3/31/2010, 8/2/2011
Rule 5160-1-20 | Electronic data interchange (EDI) trading partner enrollment and testing.
 

(A) For purposes of this rule, the following definitions apply:

(1) "Covered entity" has the same meaning as in 45 C.F.R. 160.103 (as in effect on October 1, 2021).

(2) "Electronic data interchange (EDI) transactions" are transactions developed by standards development organizations recognized by the federal centers for medicare and medicaid services (CMS) and adopted by the Ohio department of medicaid (ODM). The different EDI transactions are as follows:

(a) "American national standards institute (ANSI) X12 270 eligibility, coverage, or benefit inquiry" is a transaction used to inquire about the eligibility, benefits or coverage under a subscriber's health care policy.

(b) "ANSI X12 271 eligibility, coverage, or benefit information response" is a transaction used to communicate information about, or changes to, eligibility, benefits, or coverage.

(c) "ANSI X12 274 provider information" is a transaction used to exchange demographic and educational or professional qualifications about health care providers between providers, provider networks, or any other entity that maintains or verifies health care provider information.

(d) "ANSI X12 275 patient information" is a transaction used to communicate individual patient information requests and patient information (either solicited or unsolicited) between separate care entities in a variety of settings.

(e) "ANSI X12 276 health care claim status request" is a transaction used to request the status of a health care claim.

(f) "ANSI X12 277 health care claim status notification" is a transaction used to respond to a request regarding the status of a health care claim.

(g) "ANSI X12 278 health care services review information request and response" is a transaction used to transmit health care service information for the purpose of referral, certification, authorization, notification, or reporting the outcome of a health care services review.

(h) "ANSI X12 820 premium payment" is a transaction used to make a payment or send a remittance advice.

(i) "ANSI X12 834 monthly member roster or enrollment and disenrollment in a health plan" is a transaction used to establish communication between the sponsor of the insurance product and the payer.

(j) "ANSI X12 835 health care claims payment and remittance advice" or "835 remittance advice" is a transaction used to make a payment or send an explanation of benefits remittance advice.

(k) "ANSI X12 837 health care claim" is a transaction used to submit health care claim billing or encounter information, or both, from providers (institutional, professional, or dental) of health care services to payers, either directly or via clearinghouses.

(3) "Trading partner" is a covered entity as defined in 42 C.F.R. 160.103 (as in effect October 1, 2021) that submits, receives, routes, or translates EDI transactions directly related to the administration or provision of medical assistance provided under a public assistance program.

(B) Responsibilities of trading partners.

(1) To enroll as an EDI trading partner with ODM under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and be issued a trading partner number, a covered entity completes and submits to ODM the following:

(a) The electronic trading partner form available at https://medicaid.ohio.gov.

(b) The ODM form 06306 "Designation of an 835 or 834-820 Trading Partner" (rev. 4/2017). This form is submitted only if the trading partner will be receiving the 835 remittance advice on behalf of its clients.

(c) A trading partner agreement. Trading partner agreements are to be signed by an authorized representative of the trading partner.

(2) Once the medicaid trading partner number is assigned, the trading partner submits EDI transactions for the testing process in accordance with paragraph (C) of this rule.

(C) Testing criteria for trading partners.

(1) All trading partners are to abide by all ODM testing criteria as outlined in paragraph (C)(2) of this rule and in the trading partner enrollment and testing information guide available at www.medicaid.ohio.gov.

(2) The testing criteria to be met is as follows:

(a) Trading partners are to submit three files per the following transaction types and pass testing: 837 (professional, institutional, dental), 270 (eligibility), and 276 (claim status inquiry).

(b) Trading partners are to test the transaction types they will be submitting in production.

(c) For batch transactions, each file is to contain a minimum of fifty claims, claim status inquiries, or eligibility inquiries.

(d) For real-time transactions of types 270 and 276, provide at least three real-time submissions for each transaction type.

(e) All EDI files are to completely pass X12 integrity testing, HIPAA syntax, and HIPAA situation testing. Trading partners are expected to modify their EDI files in accordance with new federally mandated HIPAA standards.

(f) During testing, trading partners may submit one claim file per day, per 837 transaction (one professional, one institutional, and one dental), one eligibility inquiry, and one claim status inquiry per day. Multiple tests per day are accepted for real-time transactions of types 270 and 276.

(D) Passing criteria for transactions tested.

(1) Files containing the 270 eligibility transaction are considered passing when a successful 271 response is received without error codes 73 (invalid or missing subscriber) or 75 (subscriber not found).

(2) Files containing the 275 patient information transaction are considered passing when a successful 999 response is received.

(3) Files containing the 276 claim status transaction are considered passing when a valid 277 response is received with the requested claim information.

(4) Files containing the 278 service request transaction are considered passing when a valid 278 response is received without error codes 04 (authorized quantity exceeded) or 79 (invalid participant identification).

(5) Files containing the 837 health care claim transaction are considered passing when at least ninety per cent of the claims are in paid status after test adjudication.

(E) Trading partners that are not actively submitting and receiving 837 health care claim transaction sets but who are actively submitting and receiving 270/271 and 276/277 transaction sets are to provide, in a manner specified by ODM, a report of all providers by national provider identifier (NPI) that the trading partner represents. The first report is due at the time of initiating a trading partner agreement with ODM. Subsequent reports are due quarterly based on the calendar year, no later than January first, April first, July first and October first. If the necessary reports are not submitted, the trading partner agreement will be denied or terminated, as applicable.

(F) If a trading partner does not submit or receive EDI transactions for a period of two years or longer, ODM may terminate the trading partner agreement without notice.

(G) Trading partners are responsible for any breach of information and will be held fully liable for any and all costs related to such a breach.

Last updated December 1, 2022 at 10:40 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 12/1/2027
Prior Effective Dates: 1/1/2004, 5/23/2007, 12/11/2011
Rule 5160-1-25 | Interest on overpayments made to medicaid providers.
 

(A) Except for medicaid contracting managed care plans (MCPs), and nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICF/IID) rate recalculations performed in accordance with sections 5165.41 and 5124.41 of the Revised Code, any provider of services or goods contracting with the Ohio department of medicaid (ODM) pursuant to Title XIX of the Social Security Act who, without intent, obtains payment from the medicaid program in excess of the amount to which the provider is entitled becomes liable for payment of interest charged in accordance with this rule on the amount of the overpayment. The interest rate charged is the average bank prime rate in effect on the first day of the calendar quarter during which the provider receives notice of the excess payment, as determined in accordance with section 5164.60 of the Revised Code. Interest payments shall be calculated on the basis of simple interest.

(B) Interest payments shall be charged on a daily basis for the period from the date the payment was made to the date upon which repayment is received by the state.

(C) The "date payment was made" shall mean the following:

(1) For any reasonable cost basis, prospective payment basis, or other cost-related rate final settlement issued by ODM, the "date payment was made" shall be ten days from the date the final settlement is received by the provider as shown by the U.S. postal service return receipt slip, with a notice of rights to appeal pursuant to Chapter 119. of the Revised Code.

(2) For audits conducted in accordance with rule 5160-1-27 of the Administrative Code, the "date payment was made" shall be the latest date a warrant or electronic funds transfer (EFT) was issued to pay an item included in the random sample.

(3) For post-payment reviews conducted in accordance with rule 5160-1-27 of the Administrative Code, the "date payment was made" shall be the latest date a warrant or EFT was issued in payment of a claim that is included in the review.

(D) The "date upon which repayment is received by the state" shall mean the following:

(1) In the case of repayment by check or EFT, the "date upon which repayment is received by the state" shall be the date the repayment is date-stamped by ODM, the date the repayment is deposited as certified mail with the U.S. postal service, or the date the EFT is deposited in the state's account.

(2) In the case of repayment by one or more offsets implemented by the ODM claims adjustment unit against future claims payments owed to the provider, the "date upon which repayment is received by the state" shall be the date on which the total amount of the overpayment is fully recovered.

(E) ODM may waive interest when voluntary repayment is made by a provider before any notification by ODM that an overpayment has occurred.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.60
Five Year Review Date: 9/4/2019
Prior Effective Dates: 5/30/2002
Rule 5160-1-27 | Review of provider records.
 

(A) As specified in Chapter 5160-1 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, frequency, extent, duration, and delivery setting of services provided to medicaid recipients, and to document significant business transactions. Medicaid providers are required to provide such records and documentation to the Ohio department of medicaid (ODM) or its designee, the secretary of the federal department of health and human services, or the state medicaid fraud control unit upon request.

(B) For purposes of this rule, the following definitions apply:

(1) "Audit" means a postpayment examination, made in consideration of generally accepted auditing standards, of a medicaid provider's records and documentation to determine program compliance, the extent and validity of services paid for under the medicaid program and to identify any inappropriate payments. The department shall have the authority to use statistical methods to conduct audits and to determine the amount of overpayment. An audit may result in a final adjudication order by the department.

(2) "Hold and Review" means a process of prepayment review of a medicaid provider's claims, including client records, medical records, or other supporting documentation, for determination of appropriate claims payment or reimbursement.

(a) Hold and review administered by ODM will be done in accordance with rule 5160-1-27.1 of the Administrative Code.

(b) Hold and review administered by state agencies other than ODM will be done in accordance with rule 5160-1-27.2 of the Administrative Code.

(3) "Review" means a post-payment examination of a medicaid provider's paid claims to determine program compliance, validity of payments and identification of recovery of overpayments under the medicaid program. Review also means special projects or analysis to determine quality of care, compliance with accepted standards of care, and general program compliance. A review may result in an educational letter, a request for a corrective action plan subject to department approval, and/or recovery of inappropriate paid claims due to non-program compliance.

(4) "Notice of operational deficiency" means a written notice issued by the department that identifies provider conduct, treatment or practices that are determined by the department not to be in the best interests of the consumer or the medicaid program and/or are noncompliant with the regulations governing the medicaid program and that must be corrected. The notice states the nature of the deficiency, the time period that the provider has to correct the deficiency and the person within the department the provider is to contact to verify that the deficiency has been corrected.

(C) Records, documentation and information must be available regarding any services for which payment has been or will be claimed to determine that payment has been or will be made in accordance with applicable federal and state requirements. For the purposes of this rule, an invoice constitutes a business transaction but does not constitute a record which is documentation of a medical service.

(D) Various methods of audit and review will be utilized in all cases of suspected fraud, waste and abuse, in accordance with rule 5160-1-29 of the Administrative Code. If fraud, waste and abuse are apparent, the department will take action to gain compliance and recoup inappropriate payments.

(E) The provider must maintain all records as stipulated in this rule and rule 5160-1-17.2 or Chapter 5160-3 of the Administrative Code, as applicable.

(F) All records, documentation and/or information requested in accordance with paragraph (B) of this rule shall be submitted to the department or its designee, in an appropriate manner as determined by the department. Records subject to audit and review must be produced at no cost to the department.

(1) Records subject to audit and review must be made available for examination in the time period described in rule 5160-1-17.2 of the Administrative Code, or as determined by the department or its designee. Failure to supply requested records, documentation and/or information as indicated in this rule will result in no payment for outstanding services.

(2) In all situations, the department has the authority to conduct an on-site visit with the provider at the provider's location for the examination or collection of records, and/or for compliance verification. Upon such occasions, as deemed necessary by the department or its designee, a member of the provider's staff is to be assigned to assist in collecting the information. Upon request from the department, the provider will photocopy or make the applicable records available for photocopying.

(3) Services billed to and reimbursed by the department, which are not validated in the recipients' records, are subject to recoupment through the audit and review process described in this rule.

Supplemental Information

Authorized By: 5164.02, 5166.02, 5162.10
Amplifies: 5164.02, 5166.02, 5162.10
Five Year Review Date: 9/3/2020
Prior Effective Dates: 4/7/1977, 7/1/1980, 10/1/1984, 7/1/1990, 9/1/2007
Rule 5160-1-27.1 | Hold and review process.
 

(A) "Hold and Review" is defined in accordance with rule 5160-1-27 of the Administrative Code.

(1) Hold and review without prior notification.

(a) The Ohio department of medicaid (ODM) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons:

(i) In response to allegations of fraud or other willful misrepresentation of claims submission; or

(ii) When a provider has been indicted for a criminal offense.

(b) ODM shall notify the provider in writing within ten business days that the provider's claims have been, and will continue to be, subject to hold and review.

(2) Hold and review with prior notification.

(a) ODM may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, with prior notice to the provider under the following circumstances:

(i) When the information is used to complement or follow up a provider certification or other quality review process;

(ii) Upon request from the office of the attorney general, the office of inspector general or the auditor of state;

(iii) A medicaid provider's agreement has been proposed for termination for reasons other than those stated in paragraph (A) of this rule; or

(iv) For reasons otherwise necessary to assure the basic integrity of claims submission and payment.

(b) ODM will notify the provider in writing within ten business days before the effective start date of the hold and review.

(B) Review of the medicaid provider's claims and documentation for the hold and review process is subject to the provisions of rule 5160-1-27 of the Administrative Code.

(C) The hold and review may be applied without regard to date of service.

(D) Failure by ODM to notify a provider of a hold and review shall not impede the agency from taking actions under this rule.

(E) The notice from ODM shall:

(1) State the general reasons for the withholding of the medicaid provider's claims payments, but need not disclose any specific information concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation;

(2) State the effective date ODM implements the hold and review process;

(3) State the types of services and claims, in whole or in part, that will be subject to the hold and review process;

(4) Identify the documentation required to be submitted to ODM by the provider:

(5) Inform the provider of the right to submit evidence for consideration to ODM;

(6) State the contact at ODM for questions regarding the hold and review process.

(F) Except for medicaid providers required to submit medical claims to ODM electronically, all claims from providers placed on hold and review must be submitted in non-electronic (paper) format.

(G) Providers who must submit medical claims electronically must submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by ODM.

(H) ODM may, if appropriate, send copies of the notice to local, state and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment.

(I) ODM has one hundred twenty days from the date each claim for payment is received to review the claim and make a determination whether or not to do one of the following:

(1) Forward the claim for adjudication;

(2) Forward the claim for denial; or

(3) Issue a "Notice of Operation Deficiency."

(J) The hold and review process is not subject to Chapter 119. of the Revised Code or any other appeal.

Supplemental Information

Authorized By: 5164.02, 5166.02, 5162.10
Amplifies: 5164.02, 5166.02, 5162.10
Five Year Review Date: 9/3/2020
Prior Effective Dates: 9/1/2007
Rule 5160-1-27.2 | Medicaid hold and review process for medicaid claims paid through state agencies other than the Ohio department of medicaid.
 

(A) "Medicaid administrative agency" means a state agency other than the Ohio department of medicaid that:

(1) Administers a component of the medicaid program under the terms of a contract with ODM under section 5162.35 of the Revised Code; and

(2) Pays claims for medicaid services or reimburses local entities for claims paid for medicaid services.

(B) "Hold and Review" is defined in accordance with rule 5160-1-27 of the Administrative Code.

(C) Hold and review may be initiated by ODM or a medicaid administrative agency for the following reasons:

(1) When the information is used to complement or follow-up a provider or certification or other quality review process;

(2) In response to allegations of fraud or willful misrepresentation of claims submission;

(3) Upon the request of the office of the attorney general, the office of inspector general, or the auditor of state;

(4) When a provider's medicaid provider agreement is subject to termination;

(5) When a provider has been indicted for a criminal offense; or

(6) For reasons otherwise necessary to assure the basic integrity of claims submission and payment.

(D) The hold and review may be applied without regard to date of service.

(E) Hold and review initiated by medicaid administrative agencies.

(1) The medicaid administrative agency shall have formal written approval from ODM to initiate a hold and review process.

(2) The medicaid administrative agency may recruit the assistance of local governmental entities to review records subject to hold and review.

(3) The medicaid administrative agency may initiate hold and review without prior notification to the provider when the medicaid administrative agency receives a request to initiate hold and review from the office of the attorney general, the office of inspector general, the auditor of state, or ODM.

(4) When the medicaid administrative agency initiates hold and review without prior notification to the provider, the medicaid administrative agency shall provide written notice to the provider, including a copy of ODM written approval within ten business days of initiating a hold and review.

(5) The medicaid administrative agency may initiate hold and review with prior notification to the provider for any purpose contained in paragraph (C) of this rule. The medicaid administrative agency shall notify the provider at least ten business days prior to subjecting the provider's claims to hold and review.

(6) For claims payment that the medicaid administrative agency pays directly to the medicaid provider, the medicaid administrative agency may subject the medicaid provider's claim(s) payment, in part or in whole, to hold and review.

(7) For reimbursements the medicaid administrative agency makes to local entities for claims that the local entity pays to the medicaid provider directly, the medicaid administrative agency:

(a) May require the local entity to hold the medicaid provider's claim(s) payment for claims subject to hold and review;

(b) May deny reimbursement to the local entity for the claims on which the hold and review was requested after allowing the local entity a reasonable time to comply; and

(c) Shall not deny reimbursement to the local entity for claims that the local entity paid prior to the request.

(8) A failure by the medicaid administrative agency to notify a provider of a hold and review process shall not impede the agency from taking actions under this rule.

(9) Review of the medicaid provider's claims and documentation for hold and review is subject to the provisions of rule 5160-1-27 of the Administrative Code.

(10) The notice from the medicaid administrative agency shall:

(a) State the general reasons for subjecting the medicaid provider's claims to hold and review, but need not disclose any specific information concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation;

(b) State the date the medicaid administrative agency implements the hold and review;

(c) State the types of services and claims that are subject to hold and review;

(d) Identify the documentation required to submit to the medicaid administrative agency;

(e) Inform the provider of the right to submit evidence for consideration to the medicaid administrative agency; and

(f) State the contact at the medicaid administrative agency for questions regarding the hold and review and where to send the requested documentation.

(11) The medicaid administrative agency shall send copies of the notice to all local, state, and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment.

(12) Providers who submit medical claims electronically may be required under this rule to submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by the medicaid administrative agency.

(13) The medicaid administrative agency has one hundred twenty days from the date each claim for payment is received to review the claim and make a determination whether or not to do one of the following:

(a) Forward the claim for adjudication;

(b) Forward the claim for denial; or

(c) Issue a "Notice of Operation Deficiency."

(F) Hold and review process initiated by ODM.

(1) ODM may require a medicaid administrative agency to initiate a hold and review described in this rule or to cooperate in a hold and review initiated by ODM under rule 5160-1-27.1 of the Administrative Code.

(2) In cooperating with a request from ODM to initiate a hold and review, medicaid administrative agencies shall:

(a) Comply with the provider notification requirements of this rule; and

(b) Suspend payment or reimbursement of the claims that are subject to hold and review; and

(c) Require local entities to suspend payment for the claims subject to hold and review; and

(d) Obtain provider records, including client records, medical records, and other supporting documentation that ODM requests as part of the review from local entities and providers; and

(e) Participate in the review of records and other supporting documentation when requested by ODM; and

(f) Provide any other information requested by ODM in order to assure accurate tracking and timely resolution of the claims subject to hold and review.

(3) For claims associated with alcohol and drug addiction services, ODM shall rely on the Ohio department mental health and addiction services to obtain and review provider records, including client records and medical records, as necessary to assure the special confidentiality of these records required by 42 C.F.R., part 2 as amended through October 1, 2006.

(4) After requesting a hold and review and allowing the medicaid administrative agency a reasonable time to comply, ODM may stop drawing from the centers for medicare and medicaid services, and passing to the other agency, the federal match associated with the claims that are subject to the review. ODM will not withhold federal match for claims that other agencies or local entities paid prior to the ODM request.

(G) For purposes of determining whether time limits for the submission of claims have been met for claims subjected to hold and review, the date of claims submission shall be the date that the medicaid administrative agency received the original claim from the provider.

(H) The hold and review process is not subject to Chapter 119. of the Revised Code or any other appeal.

Supplemental Information

Authorized By: 5164.02, 5166.02, 5162.10
Amplifies: 5164.02, 5166.02, 5162.10, 5162.35
Five Year Review Date: 9/3/2020
Prior Effective Dates: 9/1/2007
Rule 5160-1-29 | Medicaid fraud, waste, and abuse.
 

(A) For purposes of this rule, the following definitions apply:

(1) "Abuse" has the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1, 2023).

(2) "Fraud" has the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1, 2023).

(3) "Waste" means any preventable act such as inappropriate utilization of services or misuse of resources that results in unnecessary expenditures to the medicaid program.

(B) The Ohio department of medicaid (ODM) will have in effect a program to prevent and detect fraud, waste, and abuse in the medicaid program. Where cases of suspected fraud to obtain payment from the medicaid program are detected, providers will be subject to a review by ODM and the case will be referred to the attorney general's medicaid fraud control unit or the appropriate enforcement officials. If waste and abuse are suspected or apparent, ODM, the office of the attorney general, or both will take action to gain compliance and recoup inappropriate or excess payments in accordance with rule 5160-1-27 or 5160-26-06 of the Administrative Code.

(C) Cases of provider fraud, waste, and abuse may include, but are not limited to, the following:

(1) A pattern of duplicate billing by a provider to obtain reimbursement to which the provider is not entitled.

(2) Misrepresentation as to services provided, quantity provided, date of service, who performed the service or to whom services were provided.

(3) Billing for services not provided.

(4) A pattern of billing, certifying, prescribing, or ordering services that are not medically necessary or reimbursable in accordance with rule 5160-1-01 of the Administrative Code, not clinically proven and effective, and not consistent with medicaid program rules and regulations.

(5) Differing charges for the same services to medicaid versus non-medicaid recipients. For inpatient hospital services billed by hospitals reimbursed on a prospective payment basis, ODM will not pay, in the aggregate, more than the provider's customary and prevailing charges for comparable services.

(6) Violation of a provider agreement by requesting or obtaining additional payment for covered medicaid services from the recipient or the recipient's family, other than medicaid co-payments as designated in rule 5160-1-09 of the Administrative Code, or from other providers.

(7) Collusive activities involving the medicaid program between a medicaid provider and any person or business entity.

(8) Misrepresentation of cost report data so as to maximize reimbursement or misrepresent gains or losses.

(9) Billing for services that are outside the current license limitations, scope of practice, or specific practice parameters of the person supplying the service.

(10) Misrepresenting by commission or omission any information on the provider enrollment and revalidation application, provider agreement, or any documentation supplied by the provider to ODM.

(11) Ordering excessive quantities of medical supplies, drugs and biologicals, or other services.

(12) Any action which would constitute a violation of the False Claims Act (October 1, 2023), 31 U.S.C. 3729-3733.

(13) Non-compliance with the service definitions, activities, coverage, and limitations as listed in the applicable provisions in agency 5160 of the Administrative Code.

(D) ODM will not pay for services prescribed, ordered, or rendered by a provider, when those services were prescribed, ordered, or rendered by that provider after the date the provider was terminated under the medicaid program in accordance with rule 5160-1-17.6 of the Administrative Code.

(E) In instances when a provider suspects that there may be fraud, waste, or abuse by a recipient, the provider should contact the local county department of job and family services (CDJFS). Cases of recipient fraud, waste, and abuse may include, but are not limited to:

(1) Alteration, sale, or lending of the medicaid card to others for securing medical services, or other related criminal activities.

(2) Receiving excessive medical visits and services.

(3) Obtaining services not personally needed and used by the recipient.

(4) Any action to falsely obtain medicaid eligibility as described in section 2913.401 of the Revised Code.

(F) Providers will assume responsibility for the business practices of employees. In accordance with rule 5160-1-17.2 of the Administrative Code, the Ohio medicaid provider agreement states that each provider will comply with the terms of the provider agreement, Revised Code, Administrative Code, and federal statutes and rules. Providers will take the necessary time to thoroughly acquaint themselves and their employees with all rules relative to their participation in the medicaid program. Ignorance of medicaid program rules will not be an acceptable justification for violation of the provider agreement, relevant statutes, or rules.

Last updated July 18, 2024 at 8:52 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/18/2029
Prior Effective Dates: 7/1/1980
Rule 5160-1-31 | Prior authorization.
 

(A) Reimbursement for certain items or services covered under the medicaid program is dependent on obtaining prior authorization from the Ohio department of medicaid (ODM), its designee, or a medicaid managed care entity (MCE). Prior authorization requests have to be approved by ODM, its designee, or MCE before the services are rendered or the items are delivered unless the services or items meet the provisions stated in section 5160.34 of the Revised Code or paragraph (D) of this rule.

(B) Except as authorized under section 5160.34 of the Revised Code, prior authorization requests submitted via paper cannot be processed. All other prior authorization requests should be submitted pursuant to the instructions located at www.medicaid.ohio.gov.

(C) For services or items requiring prior authorization, only those approved in the prior authorization determination will be eligible for reimbursement.

(D) The following exceptions to prior authorization apply:

(1) In situations where the provider considers a delay in providing services or an item requiring prior authorization to be detrimental to the health of the medicaid recipient, the services or item may be rendered or delivered and approval for reimbursement sought after the fact.

(2) In cases of emergency, for prescribed drugs requiring prior authorization, the prescribed drug may be rendered without prior authorization in accordance with rule 5160-9-03 of the Administrative Code.

(3) In the discretion of and as instructed by ODM, a retroactive prior authorization may be sought.

(E) A medicaid provider may request a reconsideration of an adverse prior authorization determination in accordance with section 5160.34 of the Revised Code. A reconsideration of an adverse prior authorization determination rendered by an MCE or transplant consortium should be submitted and addressed in accordance with their respective processes for reconsideration. A reconsideration of an adverse prior authorization determination rendered by ODM or its designee should be submitted and addressed in the following manner:

(1) The request for reconsideration has to be received by ODM or its designee within sixty calendar days of the notification to the provider of an adverse determination. A valid request for reconsideration should be submitted pursuant to the instructions located at www.medicaid.ohio.gov and include the following:

(a) Medicaid recipient's name and medicaid number;

(b) Name of requested service or item and billing code;

(c) Date of service or item request;

(d) Clinical documentation supporting medical necessity for the service or item;

(e) A reference to any relevant federal or state law or regulation, if applicable;

(f) An explanation outlining the reason for reconsideration, including supportive information not previously submitted as necessary; and

(g) If applicable, an indication of whether the service or item qualifies as "urgent care services" as defined in section 5160.34 of the Revised Code.

(2) ODM or its designee will make a standard reconsideration determination within ten calendar days of receipt. If an expedited review is requested because the service or item qualifies as urgent care services, the reconsideration determination will be made no later than forty-eight hours after receipt.

(3) The review of the reconsideration will be conducted by a clinical peer appointed or contracted by ODM or its designee.

(4) The provider reconsideration process afforded under this rule does not interfere with the medicaid recipient's right to appeal in accordance with division 5101:6 of the Administrative Code.

Last updated July 2, 2024 at 9:38 AM

Supplemental Information

Authorized By: 5160.02, 5160.34
Amplifies: 5160.34
Five Year Review Date: 6/30/2029
Prior Effective Dates: 12/21/1977, 5/30/2002, 8/11/2005, 8/2/2011, 6/12/2020 (Emer.)
Rule 5160-1-32 | Medicaid: safeguarding and releasing information.
 

(A) "Safeguarded information" includes but is not limited to the following types of information about individual medicaid applicants, enrollees, or former recipients:

(1) Names and addresses;

(2) Social security numbers;

(3) Medical services provided;

(4) Social and economic conditions or circumstances;

(5) Agency evaluation of personal information;

(6) Medical data, including diagnosis and past history of disease or disability;

(7) Any information received in connection with the identification of third party coverage; and

(8) Any information received for verifying income eligibility and amount of medical assistance payments. Income information received from the social security administration (SSA) or the internal revenue service (IRS) should be safeguarded according to the regulations of the agency that furnished the data.

(B) For the purpose of this rule, "administrative agency" means the Ohio department of medicaid (ODM) or an agent of ODM to determine eligibility or maintain records for a medical assistance program. The administrative agency has the following responsibilities:

(1) Implementing administrative, physical and technical safeguards in accordance with 45 C.F.R. 164.308, 45 C.F.R. 164.310, and 45 C.F.R. 164.312 (as in effect on October 1, 2023).

(2) Following the safeguarding guidelines for protecting federal tax information (FTI) described in the most current version of IRS publication 1075 (rev. 11/2021).

(3) Safeguarding information received or maintained about an individual connected with the administration of the medicaid program in accordance with section 1902(a)(7) of the Social Security Act (as in effect on October 1, 2023).

(4) Publicizing provisions governing the confidential nature of information about individuals, including the legal sanctions imposed for improper disclosure and use, in accordance with 42 C.F.R. 431.304 (as in effect October 1, 2023).

(5) Providing copies of the publicized provisions to individuals and to other persons and agencies to whom information is disclosed, in accordance with 42 C.F.R. 431.304 (as in effect October 1, 2023).

(6) Protecting the types of safeguarded information referenced in 42 C.F.R. 431.305 (as in effect October 1, 2023).

(7) Maintaining confidentiality and safeguarding psychiatric hospitalization records, mental health or addiction treatment records, rehabilitation and correction records, or other sensitive records in accordance with section 5122.31 of the Revised Code.

(8) Refraining from publishing names of individuals in accordance with 42 C.F.R. 431.306(c) (as in effect October 1, 2023).

(C) Release of information. The administrative agency has the following responsibilities:

(1) Obtaining permission from an individual or authorized representative before releasing information, unless that information is used to verify income or eligibility, in accordance with 42 C.F.R. 431.306(d) (as in effect on October 1, 2023).

(2) Applying policies to all requests for information from outside sources, including governmental bodies, courts of law, or law enforcement officials, except as provided in sections 5160.45 to 5160.48 of the Revised Code.

(3) Establishing criteria specifying the conditions for release and use of information about individuals. The information has to be restricted to persons or agency representatives who are subject to standards of confidentiality that are comparable to those of the agency in accordance with 42 C.F.R. 431.306(a) and (b) (as in effect on October 1, 2023).

(4) Limiting disclosures of protected health information (PHI) for individuals applying for, or participating in, a medical assistance program to purposes related to payment, treatment, or health care operations. For any other purposes, disclosures of information about the health care of an individual, health care provided to an individual, or payment for the provision of health care for an individual has to include an authorization or waiver of authorization from an institutional review board or privacy board compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in accordance with 45 C.F.R. 164.508 and 45 C.F.R. 164.512(i) (as in effect October 1, 2023).

(5) Releasing information as permitted by and in accordance with section 5160.45 of the Revised Code.

Last updated November 1, 2024 at 8:01 AM

Supplemental Information

Authorized By: 5162.02, 5160.48
Amplifies: 5160.45, 5160.48
Five Year Review Date: 11/1/2029
Prior Effective Dates: 10/1/2013
Rule 5160-1-32.1 | Standard authorization form.
 

(A) In accordance with section 3798.10 of the Revised Code, a standardized authorization form that meets all requirements specified in 45 C.F.R. 164.508 and, where applicable, 42 C.F.R Part 2 as in effect on October 1, 2018, for the use and disclosure of protected health information is found in appendix A to this rule.

(B) If the standardized authorization form is properly executed, and adequately identifies the individual identified in section I of the form found in appendix A to this rule, by either an individual or the individual's personal representative, it shall be accepted by any person or governmental entity in this state as valid authorization for the use or disclosure of the individual's protected health information to the persons or governmental entities specified in the form. Please use the instructions found in appendix B to this rule to assist with completing the standard authorization form.

(C) A person or governmental entity is not precluded from accepting as valid authorization for the use or disclosure of protected health information a form other than the form prescribed in paragraph (A) of this rule if the other form meets all requirements specified in 45 C.F.R. 164.508 and, if applicable, 42 C.F.R Part 2 as in effect on October 1, 2018.

(D) Nothing in this rule shall require obtaining authorization or use of the form found in appendix A to this rule when use or disclosure of the information is required or permitted without such authorization by 45 C.F.R. Chapter A, Subchapter C and, if applicable, 42 C.F.R. Part 2 as in effect on October 1, 2018.

(E) The standard authorization form must be accepted state-wide thirty days post effective date.

Appendix A

Appendix B

View Appendix

Last updated October 16, 2024 at 2:34 PM

Supplemental Information

Authorized By: 5162.02, 5164.02, 3798.10
Amplifies: 3798.10
Five Year Review Date: 1/3/2024
Rule 5160-1-33 | Medicaid: authorized representatives.
 

(A) Designation of an authorized representative.

(1) ) An individual may designate any person or organization to serve as that individual's authorized representative. Any person serving as an authorized representative must be at least eighteen years or older.

(2) Authority for a person or organization to act on behalf of the individual accorded under state law, including but not limited to, a court order establishing legal guardianship, must be treated as a written designation by the individual of authorized representation.

(3) The designation of an authorized representative must be in writing, and must identify what duties the individual is authorizing the representative to perform.

(4) If the designated authorized representative is unwilling or unable to accept the responsibility of being an authorized representative, the authorized representative must inform the administrative agency and the individual of the refusal or withdrawal.

(B) The authorized representative:

(1) Must present proper identification, if requested by the administrative agency, prior to the disclosure of medicaid information to the authorized representative.

(2) Must agree to maintain or be legally bound to maintain the confidentiality of any information regarding the individual provided by the administrative agency.

(3) Will receive copies of notices and correspondence sent to the individual by the administrative agency.

(4) Stands in the place of the individual. Any responsibility of the individual is a responsibility of the authorized representative. Any action taken by the authorized representative or failure to act will be accepted as the action or lack of action of the individual.

(5) Shares all responsibilities set out in rule 5160:1-2-08 of the Administrative Code.

(C) The administrative agency may contact the individual to clarify or verify information provided by an authorized representative if the authorized representative provides information that seems contradictory, unclear, or unrealistic.

(D) The administrative agency may choose not to contact the authorized representative if the administrative agency believes that the authorized representative might endanger the individual in a situation of domestic violence, abuse, or neglect in accordance with 45 C.F.R. 164.502(g)(5) (as in effect October 1, 2015).

(E) If the authorized representative is a provider or staff member or volunteer of an organization, the authorized representative must affirm that he or she will adhere to the regulations in 42 C.F.R. Part 431 Subpart F (as in effect October 1, 2015), 42 C.F.R. 447.10 (as in effect October 1, 2015), 45 C.F.R. 155.260(f) (as in effect October 1, 2015), as well as other relevant state and federal laws concerning conflicts of interest and confidentiality of information.

(F) The power to act as authorized representative is valid until the individual notifies the administrative agency that the authorized representative is no longer authorized to act on his or her behalf, or the authorized representative informs the administrative agency the he or she no longer is acting in such capacity, or there is a change in the legal authority upon which the authorized representative's authority was based. Such notice should include the applicant or authorized representative's signature as appropriate.

(G) Assistance from persons or organizations who are not authorized representatives.

(1) A person or organization may accompany and assist an individual with portions of the application, verification, or redetermination process without being an individual's authorized representative.

(2) The administrative agency must not reveal confidential information or send notices or correspondence to a person or organization who is assisting an individual, unless the person or organization is designated as an authorized representative.

(3) A person or organization who is assisting an individual must provide accurate information to the administrative agency, to the best of his or her knowledge, regardless of whether the person or organization is an authorized representative.

Supplemental Information

Authorized By: 5162.03, 5163.02
Amplifies: 5162.03, 5163.02, 2913.401
Five Year Review Date: 1/13/2022
Prior Effective Dates: 10/1/2013
Rule 5160-1-39 | Verification of home care service provision to home care dependent adults.
 

(A) Home care service providers, as defined in this paragraph, must have a system as follows.

(1) Definitions.

(a) "Home care dependent adult" means a consumer who:

(i) Resides in a private home or other non-institutional, unlicensed living arrangement without a parent or guardian present;

(ii) Requires, due to health and safety needs, regularly scheduled home care services to remain in the home or other living arrangement; and,

(iii) Is sixty years of age or older, or is at least twenty-one years of age but less than sixty years of age, and has a physical disability or mental impairment.

(b) "Home care service provider" is:

(i) A medicare certified home health agency or other accredited agency in accordance with Chapter 5160-12 of the Administrative Code that provides service in the home to the home care dependent adult; or

(ii) A medicare certified hospice provider in accordance with Chapter 5160-56 of the Administrative Code that provides services to the terminally ill.

(c) "Life-threatening condition" means a health condition that will place the consumer at risk of permanent impairment if the home care service is not provided.

(d) "Mental impairment" means a consumer has a diminished capacity of judgment such that if the consumer were left alone, it would place the consumer at risk of permanent impairment.

(e) "Physical disability" means a consumer's physical condition of severe functional limitations.

(2) A home care service provider, who provides home care services to a home care dependent adult, must have a system which effectively monitors the delivery of services by its employee(s). The system must include:

(a) A mechanism to verify whether their employees are present (e.g., at the beginning and end of a visit) at the location and time where services are to be provided for home care dependent adults who have a mental impairment or life-threatening condition;

(b) Verification of whether the provider's employees have provided the services at the proper location and time at the end of each working day for all other home care dependent adults not addressed in paragraph (A)(2)(a) of this rule. (e.g., adults age sixty or older, or adults that are at least twenty-one years of age but less than sixty years of age and have a physical disability); and,

(c) Implementation of a protocol for scheduling substitute employees when the monitoring system identifies that an employee has failed to provide home care services at the proper location and time. The protocol must include a standard for determining the length of time that may elapse without jeopardizing the health and safety of the home care dependent adult.

(3) For the information obtained through the monitoring system in accordance with paragraph (A)(2) of this rule, the home care service provider must have procedures in place to:

(a) Maintain records;

(b) Compile annual reports which must include the rate at which home care services were provided at the proper location and time;

(c) Conduct random checks of the accuracy of the monitoring system. For purposes of conducting these checks, a random check is considered to be a check of not more than five per cent or less than one per cent of the home care visits the provider's employees make to different home care dependent adults within a particular work shift; and,

(d) Retain records in accordance with rule 5160-1-17.2 of the Administrative Code.

(B) Home care service providers, as defined in paragraph (A) of this rule and as defined by the department of developmental disabilities or department of aging, shall demonstrate their verification system of home care service provision in accordance with section 121.36 of the Revised Code and paragraph (A) of this rule by:

(1) Participating in periodic compliance reviews; and/or,

(2) Furnishing upon request to Ohio department of medicaid (ODM), its designee or the medicaid fraud control unit any records related to the provisions outlined in section 121.36 of the Revised Code.

Supplemental Information

Authorized By: 5164.02, 5166.02, 121.36
Amplifies: 5164.02, 5166.02, 121.36
Five Year Review Date: 7/3/2020
Prior Effective Dates: 9/26/2004
Rule 5160-1-42 | Provider credentialing.
 

In accordance with the federal credentialing standards found in 42 CFR 422.204, "provider selection and credentialing" (as in effect on October 1, 2021), this rule details the credentialing and recredentialing process for medicaid providers.

(A) For purposes of this rule, the following definitions apply.

(1) "Council for affordable quality healthcare (CAQH)" is a non-profit organization which created a process allowing ODM to use a single, uniform application for credentialing. This end-to-end process simplifies data collection, primary source verification, and sanctions monitoring, to support ODM's credentialing needs.

(2) "Credentialing" means an evaluation of the qualifications of health care providers that seek contracts or participation agreements with ODM.

(3) "Credentialing committee" means the group of individuals appointed by ODM for provider and facility review, as well as reconsidering providers and facilities initially denied by credentialing as described in paragraph (K) of this rule.

(4) "Delegate" means a hospital group or physician hospital organization formed by a hospital and group of physicians granted the authority by ODM to credential its health care providers who require credentialing.

(5) "Delegation" means the act of ODM granting another health care entity the authority to credential its health care providers who require credentialing.

(6) "Designee" means a third party with whom ODM has contracted to complete certain credentialing related administrative tasks and information gathering tasks required to fulfill credentialing and re-credentialing for those providers whose credentialing is not completed through the process of delegation; and

(7) "Eligible provider" has the same meaning as a person or entity who is an eligible provider as defined in rule 5160-1-17 of the Administrative Code who is enrolled with ODM.

(B) Credentialing by ODM is mandatory for the following practitioners:

(1) Physicians as defined in Chapter 4731. of the Revised Code;

(2) Psychologists as defined in Chapter 4732. of the Revised Code;

(3) Physician assistant as defined in Chapter 4730. of the Revised Code;

(4) Dentists as defined in Chapter 4715. of the Revised Code;

(5) Optometrists as defined in Chapter 4725. of the Revised Code;

(6) Pharmacists as defined in Chapter 4729. of the Revised Code;

(7) Chiropractors as defined in Chapter 4734. of the Revised Code;

(8) Acupuncturists as defined in Chapter 4762. of the Revised Code;

(9) Clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner as defined in Chapter 4723. of the Revised Code;

(10) Licensed independent social worker, licensed independent marriage and family therapist, or licensed professional clinical counselor as defined in Chapter 4757. of the Revised Code;

(11) Licensed independent chemical dependency counselor as defined in Chapter 4758. of the Revised Code;

(12) Certified Ohio behavior analysts as defined in Chapter 4783. of the Revised Code;

(13) Audiologists as defined in Chapter 4753. of the Revised Code;

(14) Occupational therapist as defined in Chapter 4755. of the Revised Code;

(15) Physical therapist as defined in Chapter 4755. of the Revised Code;

(16) Speech-language pathologist as defined in Chapter 4753. of the Revised Code; and

(17) Dietitians as defined in Chapter 4759. of the Revised Code.

(C) Credentialing by ODM is mandatory for the following facilities:

(1) Nursing facilities as defined in Chapter 5165. of the Revised Code;

(2) Hospitals as defined in Chapter 3727. of the Revised Code;

(3) Hospice as defined in Chapter 3721. of the Revised Code;

(4) Home health agencies as defined in rule 3701-60-01 of the Administrative Code;

(5) Ambulatory surgical facilities as defined in section 3702.30 of the Revised Code;

(6) Community mental health services providers as defined in Chapter 5119. of the Revised Code;

(7) Community addiction services providers as defined in Chapter 5119. of the Revised Code;

(8) End stage renal disease (ESRD) treatment centers as described in rule 3701-83-23.1 of the Administrative Code;

(9) Radiology centers as described in rule 3701-83-51 of the Administrative Code; and

(10) Residential facility as defined in Chapter 5119. of the Revised Code.

(D) Credentialing by ODM is not mandatory for the following practitioners:

(1) Health care professionals who are permitted to provide services only under the direct supervision of an independently enrolled practitioner as defined in rule 5160-4-02 of the Administrative Code;

(2) Hospital-based health care professionals who provide services "incidental-to" a hospital service and are not independently enrolled;

(3) Health care professionals who are designated as current residents, interns, or fellows as defined in Chapter 5160-4 of the Administrative Code; and

(4) Moonlighting residents as defined in 42 CFR 415.208 (as in effect on October 1, 2021).

(E) Those providers listed in paragraph (B) of this rule will provide ODM or ODM's credentialing designee the following information for initial credentialing verification:

(1) Access to the standard provider credentialing application form used by the council for affordable quality healthcare (CAQH) in accordance with section 3963.05 of the Revised Code within one-hundred-eighty days prior to credentialing date;

(2) Active provider licensing information;

(3) Board certification, if applicable;

(4) Education;

(5) Clinical privileges, if applicable;

(6) Medical malpractice insurance;

(7) Drug enforcement administration (DEA) certification, if applicable;

(8) National practitioner data bank information regarding malpractice and clinical privilege actions;

(9) Sanctions or limitations on licensure;

(10) Eligibility for participation in medicare and medicaid, if applicable; and

(11) Minimum five-year work history. The five-year timeframe begins with date of initial licensure. If the provider has been licensed for less than five years, available work history should be provided.

(F) The facilities listed in paragraph (C) of this rule will provide ODM or ODM's credentialing designee access to the following information for initial credentialing verification:

(1) The Ohio department of insurance (ODI) form INS5036, revision date February of 2021, found at https://insurance.ohio.gov/static/Forms/Documents/INS5036.pdf;

(2) Active provider licensing information;

(3) Certification through an accrediting body or a site visit completed by a state designated agency;

(4) Eligibility for participation in medicare and medicaid, if applicable;

(5) Verification of good standing with applicable state and federal bodies; and

(6) Active malpractice insurance.

(G) Prerequisites for becoming a delegate as defined in paragraph (A)(4) of this rule are the following:

(1) Maintain an active, valid delegation contract approved by the credentialing committee;

(2) The delegate has to complete a pre-delegation audit prior to their becoming an active delegate;

(3) The delegate has to adhere to the standards set forth in the delegated contract, including the time frames and content for reporting, duties assigned, necessary processes and procedures, and collaborating of a yearly audit;

(4) The delegate has to have their own credentialing committee, with decision making capabilities, and delegation contract monitoring;

(5) The delegate has to report any additions, changes, and terminations in a timely manner including both credentialed and non-credentialed practitioners and facilities;

(6) Delegates will be audited by ODM every twelve months; and

(7) Practitioners with a delegated group understand they are still expected to update their information in the provider data system, and to revalidate according to their ODM determined schedule.

(H) Every thirty-six months, those providers listed in paragraph (B) of this rule will provide ODM or ODM's credentialing designee information listed in paragraphs (E)(1) to (E)(10) of this rule for recredentialing.

(I) Every thirty-six months, facilities listed in paragraph (C) of this rule will provide ODM or ODM's credentialing designee the information listed in paragraphs (F)(1) to (F)(6) of this rule for recredentialing verification.

(J) The following information may be requested by the state or its designee from providers or facilities as listed in paragraph (B) or (C) of this rule at any time during the credentialing or recredentialing process:

(1) Demographic information;

(2) Information missing in CAQH;

(3) Verification of certifying board names;

(4) Explanation for work history gaps;

(5) Updates regarding expired information;

(6) Verification of specialty information;

(7) Information regarding previous sanctions or affirmative responses to CAQH disclosure questions; and

(8) Continuing education (CE) prerequisites as required by the provider's state licensing board.

(K) ODM will establish and utilize a credentialing committee for provider and facility review and appeals when the credentialing prerequisites specified in paragraph (K)(1) of this rule are under review. The credentialing committee will follow the process described in this paragraph when a provider or facility is found to be non-compliant with the credentialing prerequisites.

(1) Providers or facilities that fail to meet the following prerequisites, have a discrepancy, or negative findings with the information provided in paragraph (E) or (F) of this rule, are subject to review by the state established credentialing committee. Prerequisites are the following:

(a) Previous licensing board sanctions;

(b) Previous clinical actions taken by a medical group or hospital;

(c) Affirmative responses to CAQH disclosure questions, with the exception of the following CAQH questions:

(i) To your knowledge, has information pertaining to you ever been reported to the national practitioner data bank (NPDB) or healthcare integrity and protection data bank (HIPDB)?

(ii) Have you had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past ten years? And if yes, provide information for each case.

(d) Excessive malpractice claims within the past ten years, as defined by the credentialing committee;

(e) Inappropriate training or education for disclosed provider specialty;

(f) Previous medicare or medicaid disbarments or actions;

(g) Site visit non-compliance;

(h) Previous DEA actions;

(i) Material misrepresentation or omission concerning professional credentials; and

(j) Prior criminal history in accordance with rule 5160-1-17.8 of the Administrative Code.

(2) The following individuals will participate in the ODM credentialing committee as determined by ODM. Voting members are expected to attend no less than seventy-five per cent of all meetings held to maintain voting rights, and sign non-discrimination and conflict of interest forms.

(a) Committee chair;

(b) Community-based peers of providers requiring credentialing as defined in paragraph (B) of this rule;

(c) Managed care organization representatives;

(d) Medical directors; and

(e) Staff from ODM and ODM's designee.

(3) The credentialing committee members will carry out the following responsibilities:

(a) Review the credentials of practitioners;

(b) Review and approve sanctions monitoring;

(c) Review and approve delegated audits, contracts, and agreements; and

(d) Review and approve credentialing reports from ODM and ODM's designee.

(4) When a provider or facility is denied by the credentialing committee, the following process will occur.

(a) The provider or facility is sent a denial letter by ODM outlining the unmet credentialing prerequisites or negative findings under review, and their appeal rights and instructions for proceeding;

(b) The provider or facility will have no more than thirty calendar days to appeal to the credentialing committee;

(c) The appellant provides the credentialing committee with supplemental information which supports its appeal of the decision;

(d) Appeal decision is rendered by the credentialing committee; and

(e) Credentialing committee decisions on appeals are final, and those providers and facilities denied by the credentialing committee are not subject to reconsideration as found in paragraph (D) of rule 5160-70-02 of the Administrative Code. The practitioners denied by the credentialing committee are denied ODM enrollment.

(L) Providers and facilities who do not have any negative findings regarding the information needed for initial credentialing verification or recredentialing listed in paragraph (E) or (F) of this rule and meet the prerequisites listed in paragraph (K)(1) of this rule are considered to have a clean file and have met the requirements for credentialing with ODM. Providers and facilities with clean files and no negative findings will not meet with the credentialing committee unless otherwise determined by ODM and ODM's designee. Clean files for initial credentialing and recredentialing will have a final review by ODM's medical director.

Last updated October 3, 2022 at 8:44 AM

Supplemental Information

Authorized By: 5164.02; 5164.32
Amplifies: 5162.03; 5164.02; 5164.32
Five Year Review Date: 10/1/2027
Rule 5160-1-42.1 | Delegated credentialing.
 

(A) The Ohio department of medicaid (ODM) authorizes eligible provider delegates to perform credentialing activities on behalf of individual providers in accordance with rule 5160-1-42 of the Administrative Code.

(B) "Delegate" and "Delegation" have the same meaning as in rule 5160-1-42 of the Administrative Code.

(C) Entities seeking delegation will be expected to meet the following criteria to become an authorized delegate and to maintain delegate status:

(1) Be an eligible provider as defined in rule 5160-1-17 of the Administrative Code:

(2) Participate with home-state agency that administers titles XIX (medicaid), XXI (children's health insurance program - CHIP), or XVIII (medicare) of the Social Security Act;

(3) Be based in Ohio or a contiguous state;

(4) Have at least fifty Ohio medicaid enrolled and active affiliated individual providers;

(5) Submit to the credentialing department a request in writing; and

(6) Complete a pre-delegation audit conducted by ODM to include review of the following information maintained by the delegate:

(a) Credentialing policies and procedures;

(b) Sample of practitioner credentialing files;

(c) Credentialing meeting minutes; and

(d) Ongoing sanctions monitoring.

(D) ODM has the right to deny or terminate delegation status. Denial or termination of delegation status does not afford hearing rights.

(E) Delegated credentialing of facilities is not permissible under the ODM delegated credentialing agreement.

Last updated January 3, 2023 at 9:21 AM

Supplemental Information

Authorized By: 5164.02, 5164.32
Amplifies: 5162.03, 5164.02, 5164.32
Five Year Review Date: 1/1/2028
Rule 5160-1-60 | Medicaid payment.
 

(A) The medicaid payment for a covered procedure, service, or supply constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments as defined in rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the Administrative Code, however, precludes a provider from requesting payment, collecting, or waiving the collection of medicare copayments from a medicaid recipient for medicare part D services. Medicaid recipient liability provisions set forth in rule 5160-1-13.1 of the Administrative Code do not apply to medicare part D services.

(B) Providers are expected to submit their usual and customary charge (the amount charged to the general public) on all claims. The medicaid payment amount for a covered service, procedure, or supply is the lesser of the submitted charge or the established medicaid maximum. Medicaid maximum payment amounts for many existing services, procedures, and supplies, particularly services rendered by practitioners of the healing arts, are set forth in the appendix to this rule. The initial maximum payment amount for a covered procedure, service, or supply represented by a new procedure code that takes effect at the beginning of a calendar year is established in accordance with paragraph (J) of this rule. Specific payment amounts or payment formulas set forth in other rules in agency 5160 of the Administrative Code supersede corresponding entries in the appendix to this rule.

(C) Pursuant to rule 5160-1-08 of the Administrative Code, providers are expected to take reasonable measures to determine any third-party resource available to a medicaid recipient and to file a claim with that third party when required to do so under rule 5160-1-08 of the Administrative Code. When there is a third-party payer, medicaid payment for a covered procedure, service, or supply is the lesser of two amounts:

(1) The provider's submitted charge; or

(2) The medicaid maximum payment amount less the sum of all third-party payments and any applicable medicaid copayment (unless the difference is zero or less, in which case medicaid will make no further payment).

(D) For services that are subject to a copayment pursuant to rule 5160-1-09 of the Administrative Code, the total medicaid maximum payment amount is reduced by the total medicaid copayment. The provider may collect from the medicaid recipient or bill the medicaid recipient for the total medicaid copayment, which is determined in accordance with the relevant rule of the Administrative Code.

(E) For dates of service on or after August 1, 2017, the rates for the facility services provided by an ASC are addressed in rule 5160-22-01 of the Administrative Code.

(F) Except as otherwise permitted by federal statute or regulation, the medicaid maximum payment amounts described in this rule must not exceed the established maximum medicare allowed amounts for the same procedures, services, or supplies.

(G) Medicaid payment is not allowed for non-covered procedures, services, and supplies nor for covered procedures, services, or supplies that are denied by the department as a result of a prepayment review, utilization review, or prior authorization process. (Chapter 5160-2 of the Administrative Code describes how these provisions are applied to inpatient and outpatient hospital services.)

(H) Every submitted claim must include the most appropriate code representing each procedure, service, or supply provided.

(I) "Site differential" is a difference in medicaid payment based on the place in which the service is provided. When a covered service is subject to a site differential, the payment amount is the lesser of the provider's submitted charge or the applicable maximum facility payment amount or maximum non-facility payment amount.

(1) The maximum facility payment amount applies to a service provided at one of the following sites:

(a) A hospital (inpatient hospital, outpatient hospital, emergency department, or inpatient psychiatric facility);

(b) A skilled nursing facility; or

(c) An ambulatory surgery center (ASC).

(2) The maximum non-facility payment amount applies to a service provided at any other site.

(J) Additional information about the coverage of and payment for certain procedures is shown in the 'prof/tech split' and 'PC/TC indicator' columns of the appendix to this rule.

(1) A 'prof/tech split' entry indicates that the procedure is made up of both a professional and a technical component for the time period shown. The indicator denotes the relative proportions of the medicaid maximum payment amount allocated to the professional and technical components. For example, the indicator C means that the medicaid maximum payment amounts for the professional component and for the technical component are, respectively, forty per cent and sixty per cent of the medicaid maximum payment amount for the total procedure. There are thirteen such indicators:

(a) C: Forty per cent / sixty per cent;

(b) D: Eighty per cent / twenty per cent;

(c) F: Ten per cent / ninety per cent;

(d) G: Twenty per cent / eighty per cent;

(e) H: Twenty-five per cent / seventy-five per cent;

(f) I: Thirty per cent / seventy per cent;

(g) J: Thirty-five per cent / sixty-five per cent;

(h) K: Fifty per cent / fifty per cent;

(i) L: Sixty per cent / forty per cent;

(j) M: Seventy per cent / thirty per cent;

(k) O: One hundred per cent / zero per cent;

(l) P: Seventy-five per cent / twenty-five per cent; and

(m) Q: Ninety per cent / ten per cent.

(2) A numeric 'PC/TC indicator' entry shows the degree to which a procedure is professional or technical in nature or has a professional or technical component; these numeric values are defined by the centers for medicare and medicaid services (CMS), http://www.cms.gov. A lowercase alphabetic 'PC/TC indicator' entry indicates a medicaid payment restriction based on the location in which the procedure is performed (a place-of-service restriction). Meanings of these numeric and alphabetic indicators are summarized in the appendix to this rule.

(K) The department may set payment limits based on the characteristics of an individual procedure, service, or supply or the relationships between procedures, services, or supplies. For example, payment may be disallowed for a procedure if it is incompatible with another procedure or another procedure makes it redundant. In configuring its claim-processing system, the department may define its own limits, adopt limits established by an authoritative source, or modify limits established by an authoritative source. The maximum payment amounts for specimen collection and diagnostic testing for COVID-19 are set at the Ohio medicare rate.

(L) The "Healthcare Common Procedure Coding System (HCPCS)" is a numeric and alphanumeric code set maintained and distributed by CMS for the uniform designation of certain medical procedures and related services. Level one of HCPCS consists of "Current Procedural Terminology (CPT)," a comprehensive listing of medical terms and codes published by the American medical association (AMA), http://www.ama-assn.org, for the uniform designation of diagnostic and therapeutic procedures in surgery, medicine, and the medical specialties. When the department initially establishes coverage for a procedure, service, or supply the initial maximum payment amount is set at eighty per cent of the medicare allowed amount. If no medicare allowed amount is available the initial medicaid maximum payment amount is set at the unweighted average of the current maximum payment amounts for comparable procedures, services, or supplies. For convenience, a list of such initial maximum payment amounts is posted on the department's web site, http://medicaid.ohio.gov.

View Appendix

Last updated October 1, 2024 at 9:22 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/1/2027
Prior Effective Dates: 7/10/1983, 10/1/1983 (Emer.), 5/9/1986 (Emer.), 7/30/1986 (Emer.), 10/25/1986, 6/23/1988, 10/1/1988, 1/13/1989 (Emer.), 5/1/1990, 4/1/1992 (Emer.), 7/1/1992, 7/31/1992 (Emer.), 4/1/1993, 12/30/1993 (Emer.), 2/1/1996 (Emer.), 4/4/1996, 3/19/1998, 7/1/1998, 12/31/1998 (Emer.), 3/31/1999, 12/31/1999 (Emer.), 3/20/2000, 3/30/2001, 11/14/2002, 3/24/2003, 9/25/2003, 12/8/2003, 1/2/2004 (Emer.), 11/1/2004 (Emer.), 9/1/2005, 10/15/2006, 12/29/2006 (Emer.), 12/31/2007 (Emer.), 11/13/2008, 12/31/2008 (Emer.), 12/24/2009, 12/31/2009 (Emer.), 2/1/2010 (Emer.), 3/31/2010, 12/6/2010, 9/1/2011, 3/29/2012, 12/31/2012 (Emer.), 9/1/2013, 3/27/2014, 1/1/2016, 1/1/2019, 7/1/2019, 1/1/2020, 6/12/2020 (Emer.), 1/1/2022
Rule 5160-1-60.2 | Direct reimbursement for out-of-pocket expenses incurred for medicaid covered services during approved eligibility periods.
 

(A) For purposes of this rule:

(1) "Applicant for reimbursement" is:

(a) An individual who has been determined eligible for a retroactive eligibility period in accordance with rule 5160:1-2-01 of the Administrative Code, and who is seeking reimbursement for medical expenses for which the individual paid for during this approved time period; or

(b) An individual who, as a result of an eligibility determination or state hearing decision, now has effective dates of eligibility and is seeking reimbursement for medical expenses for which the individual paid during this approved time period; or

(c) An individual who has been erroneously charged a medicaid co-pay for services eligible for a co-pay in accordance with rule 5160-1-09 of the Administrative Code, and who is seeking reimbursement of the co-pay amount incurred during the time period when the individual should not have been subject to a co-pay and for which the individual paid; or

(d) A person not legally obligated to pay for an individual's medical bills, but who does, in fact, contribute payment toward the individual's medical bills incurred during the approved eligibility period.

(2) "Effective dates of eligibility" means the period described in rule 5160:1-2-01 of the Administrative Code.

(3) "Medicaid covered service" is a service or product that meets all the following criteria:

(a) Medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(b) Delivered by an eligible provider who qualifies for one of the following:

(i) A medicaid provider agreement as described in rule 5160-1-17.12 of the Administrative Code; or

(ii) An approved contract or single case agreement with a medicaid managed care entity (MCE);

(c) A reimbursable medical service as defined in rule 5160-1-02 of the Administrative Code.

(d) A physician service as defined in Chapter 5160-4 of the Administrative Code, or a dental service as defined in Chapter 5160-5 of the Administrative Code.

(4) "Payer" is the Ohio department of medicaid (ODM), an MCE contracted with ODM, or any entity ODM designates with the authority to issue direct reimbursements.

(5) "Retroactive eligibility period" means the period described in rule 5160:1-2-01 of the Administrative Code.

(B) For any application for reimbursement, the payer will make direct reimbursement, including applicable co-pays, in accordance with 42 C.F.R. 447.25 only if all of the following are met:

(1) The individual has an eligibility period as defined in paragraph (A)(2) or (A)(5) of this rule and the date on which the individual received the medicaid covered service was within the period of eligibility;

(2) The service was a medicaid covered service, and the service was not a nursing facility service included in the nursing facility's per diem rate;

(3) The applicant for reimbursement contacts the provider and requests reimbursement, and the provider either does not agree to reimburse the applicant or does agree to reimburse the applicant but does not do so within ninety days;

(4) Within ninety days from the date the provider does not agree or fails to reimburse the applicant, the applicant requests direct reimbursement from the appropriate payer;

(5) Within ninety days from the date the applicant asks the payer for direct reimbursement described in paragraph (B)(4) of this rule, the applicant provides the following documentation to the payer:

(a) Written verification of a bill from the provider which specifies the medicaid covered services provided;

(b) Written verification that the individual paid the provider;

(c) Any other documentation that may be requested by the payer, including proof that the provider did not agree to reimburse the applicant, or did agree to reimburse the applicant but did not do so within ninety days of the request, as specified in paragraph (B)(4) of this rule;

(d) The name, address, and phone number of the provider who rendered the medicaid covered services to the individual and the name of the billing provider; and

(e) The name, address and phone number of any third party that paid or was liable to pay for any portion of the medicaid covered service.

(6) Requests for direct reimbursement will qualify for reimbursement consideration only if submitted to the payer within three hundred sixty-five days of the date of service or hospital discharge, or within one hundred eighty days of the notice of state hearing decision or eligibility determination;

(7) Reimbursement from a third party as defined in section 5160.35 of the Revised Code is not available;

(8) The request is not for reimbursement of medicare part A out-of-pocket expenses.

(C) Within ninety days of meeting the conditions specified in paragraph (B) of this rule, the payer will process the request for reimbursement. Applicants for reimbursement who receive an approval for reimbursement will be reimbursed either the amount of their out-of-pocket medical expenses or the co-pay charges, whichever is applicable, but in no event will the reimbursement exceed the medicaid maximum allowed amount identified in rule 5160-1-60 of the Administrative Code.

(D) The bills identified as satisfying a person's spenddown obligation or paid to the county to meet medicaid eligibility are not reimbursable by the medicaid program.

(E) All notice and hearing provisions set forth in division 5101:6 of the Administrative Code apply to determinations made under this rule.

Last updated September 17, 2024 at 3:18 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2027
Rule 5160-1-60.4 | By-report procedures, services, and supplies.
 

(A) The term "by-report" identifies a covered procedure, service, or supply for which no single maximum payment amount has been established and for which payment is not determined by prior authorization. Claims for by-report procedures, services, and supplies are reviewed manually by the department or its designee. The purpose of the review is to determine whether the procedure code for the by-report procedure, service, or supply reported on the claim is the most appropriate and, if so, to establish a maximum payment amount for the procedure, service, or supply on a case-by-case basis. Information must be submitted on or with the claim (e.g., supporting documents such as operative reports, clinical assessments, or other medical records) to identify the particular by-report procedure, service, or supply.

(B) By-report procedures, services, and supplies are so indicated in the relevant rule in agency 5160 of the Administrative Code or in its associated payment schedule.

(C) A non-covered procedure, service, or supply that is reported on a claim with a by-report procedure code is non-covered.

(D) A claim for a by-report procedure, service, or supply will not be reviewed further and may be denied under either of the following conditions:

(1) Information submitted on or with the claim does not sufficiently identify the by-report procedure, service, or supply, and additional documentation requested by the reviewer is not supplied; or

(2) The procedure, service, or supply can be reported appropriately with a different procedure code for which a specific maximum payment amount has been established.

(E) When a claim has been denied because a different procedure code adequately describes a procedure, service, or supply, the provider may submit a new claim with the appropriate code. The new claim must not be submitted for by-report consideration.

Last updated September 17, 2024 at 3:18 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2023
Prior Effective Dates: 12/21/1977, 12/30/1977, 4/1/1988
Rule 5160-1-61 | Non-covered services.
 

(A) The following services are entirely excluded from coverage:

(1) A service that is experimental in nature and is not performed in accordance with standards of medical practice;

(2) A service that is related to forensic studies;

(3) An autopsy service;

(4) A service for the treatment of infertility;

(5) An abortion that does not meet the criteria for coverage set forth in rule 5160-17-01 of the Administrative Code;

(6) A service that does not meet the criteria for coverage set forth in any other rule in agency 5160 of the Administrative Code;

(7) A service pertaining to a pregnancy that is a result of a contract for surrogacy services, under which a woman agrees to become pregnant for the purpose of carrying and giving birth to a child she will not raise but instead will relinquish to the other contracting party; and

(8) Assisted suicide and other measures taken actively with the specific intent of causing or hastening death.

(B) In accordance with Division CC, Title II, Section 210 of the Consolidated Appropriations Act, 2021 (Pub. L. No. 116-260), payment may be made for routine patient costs associated with participation in a qualifying clinical trial involving an experimental procedure.

(C) Neither the withholding or withdrawing of treatment nor the provision of palliative care constitutes assisted suicide, even if the measure may increase the likelihood of death, so long as the measure is not taken for the specific purpose of causing death.

Last updated March 22, 2024 at 10:32 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2027
Prior Effective Dates: 10/1/1987, 3/9/2002, 3/27/2006, 1/1/2017
Rule 5160-1-70 | Relocated provisions concerning episode based payments.
 

Provisions concerning episode based payments are set forth in rule 5160-19-04 of the Administrative Code.

Supplemental Information

Authorized By: 5162.05, 5164.02, 5167.02
Amplifies: 5164.02, 5164.03
Five Year Review Date: 4/29/2021
Prior Effective Dates: 12/31/2015 (Emer.)
Rule 5160-1-71 | Relocated provisions concerning patient centered medical homes (PCMH) and eligible providers.
 

Provisions concerning patient centered medical homes (PCMH) and eligible providers are set forth in rule 5160-19-01 of the Administrative Code. The PCMH rules implement the Ohio department of medicaid's comprehensive primary care (CPC) program and CPC for kids programs.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/17/2025
Prior Effective Dates: 10/1/2016, 1/1/2018, 10/1/2018
Rule 5160-1-72 | Relocated provisions concerning patient centered medical homes (PCMH) and payments.
 

Provisions concerning patient centered medical homes (PCMH) and payments are set forth in rule 5160-19-02 of the Administrative Code. The PCMH rules implement the Ohio department of medicaid's comprehensive primary care (CPC) program and CPC for kids programs.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/17/2025
Prior Effective Dates: 10/1/2016
Rule 5160-1-73 | Behavioral health care coordination.
 

(A) For the purpose of this rule, the following definitions apply.

(1) "Attributed individual" is the Ohio medicaid covered individual for whom a qualified behavioral health entity eligible under this rule has accountability for providing behavioral health care coordination.

(2) "Attribution" is the process through which medicaid covered individuals are assigned to a specific qualified behavioral health entity. The Ohio department of medicaid (ODM) is responsible for attributing eligible individuals.

(3) "Behavioral health care coordination" (BHCC) is an evidence-based comprehensive care coordination model that connects qualified behavioral health entities with an assigned panel of eligible members with high-need behavioral health conditions.

(4) "Comprehensive primary care initiative" (CPC) is the ODM implementation of a patient-centered medical home (PCMH) model as established through rules 5160-1-71 and 5160-1-72 of the Administrative Code.

(5) "Consolidated clinical document architecture" (C-CDA) is an implementation guide developed and maintained by "Health Level Seven International" (HL7) which specifies a library of templates and prescribes their use for a set of specific document types for the purpose of electronic exchange of health care information.

(6) "Eligible member" is the medicaid covered individual who meets the diagnosis and service utilization criteria that enables them to receive BHCC from a qualified behavioral health entity to which they have been attributed.

(7) "Fast healthcare interoperability resources" (FHIR) is a standard developed by HL7 for exchanging healthcare information electronically.

(8) "Healthcare effectiveness data and information set" (HEDIS) is a tool developed by the national center for quality care (NCQA) to measure performance on dimensions of care and service.

(9) "Medication-assisted treatment" (MAT) is the combined provision of behavioral therapy and medications for the treatment of substance use disorders. All medications must be approved by the United States food and drug administration (FDA) for the treatment of a substance use disorder.

(10) "National quality forum" (NQF) refers to the performance measures endorsed by the national quality forum.

(11) "Performance and quality improvement" (PQI) refers to the standards developed by the council on accreditation (COA) that measure effective quality improvement plans.

(12) "Primary care practice" (PCP) is a practice led by primary care practitioners who comprehensively manage the health needs of individuals.

(13) "Qualified behavioral health entity" (QBHE) is the participating entity which has attributed individuals and is responsible for the BHCC activities.

(B) A QBHE must:

(1) Meet the certification requirements set forth in paragraph (A)(1) of rule 5160-27-01 of the Administrative Code and in calendar year 2017 or later have provided both mental health and substance use disorder treatment services under the same ownership; or

(2) Meet the requirements stated in paragraph (G)(2)(a) of rule 5160-2-75 of the Administrative Code if an outpatient hospital provider; and

(3) Within ninety calendar days of approval to participate as a QBHE, have an active provider contract with each medicaid managed care plan (MCP);

(4) Submit an application to become a QBHE. ODM reserves the right to deny any QBHE enrollment application it determines is not in compliance with the requirements of this rule. A QBHE may seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code to challenge a decision by ODM to deny a QBHE enrollment application;

(5) At the time of submitting an enrollment application to become a QBHE, have at least one practitioner from each of the following categories affiliated with the entity:

(a) A practitioner with prescribing authority in the state of Ohio;

(b) A registered nurse or licensed practical nurse; and

(c) An other licensed professional as described in rule 5160-8-05 of the Administrative Code.

(6) For the practitioner types defined in paragraph (B)(5) of this rule, continue to have such practitioners affiliated with the participating QBHE at all times to maintain eligibility as a QBHE.

(7) Demonstrate an organizational commitment to integration of physical and behavioral health care at the date of application to become a QBHE. The entity must meet one of the following:

(a) Have an ownership or membership interest in a primary care organization where primary care services are fully integrated and embedded;

(b) Enter into a written integrated care agreement such as a contract or memorandum of understanding with a primary care provider; or

(c) Achieve implementation of primary physical health care standards by a national accrediting entity as an integrated primary care-behavioral health provider, primary care medical home or behavioral health home.

(C) The QBHE must attest to the following at the time of application:

(1) That it has the ability to share, receive, and use electronic data from a variety of sources with other health care providers, ODM, and the MCPs;

(2) That it uses consent forms containing elements necessary to support the full exchange of health information in compliance with all applicable state and federal laws.

(3) That it has the ability to submit prescriptions electronically;

(4) That it implements and actively uses an electronic health record (EHR) in clinical services; and

(5) If QBHE enrolled in the BHCC program prior to July 1, 2019, QBHE will have the ability, within six months of July 1, 2019 service start (January 2020), to send, receive, and use continuity of care records through the use of standard electronic formats such as FHIR and C-CDA. If QBHE enrolled in the BHCC program after July 1, 2019, QBHE will have the standard electronic formats prepared at the time of application.

(D) Eligible individual requirements.

(1) Except for the following populations, all medicaid covered individuals who meet the diagnostic and utilization criteria set forth in this rule will be attributed to a QBHE:

(a) Individuals who have been receiving inpatient care at a hospital or residing in a nursing facility for more than ninety days.

(b) Individuals who are currently receiving another care coordination service that substantially duplicates those activities provided through BHCC.

(2) Eligible individuals who meet the criteria in one of the following groups are eligible for BHCC and will be attributed to a QBHE:

(a) Group 1. Claims utilization in the twelve months preceding attribution identifies at least one of the following diagnostic criteria or diagnoses as identified in appendix A to this rule:

(i) A primary diagnosis of schizophrenia;

(ii) A primary diagnosis of bipolar disorder with psychosis;

(iii) A primary diagnosis of major depression with psychosis;

(iv) A primary diagnosis indicating attempted suicide or self-injury;

(v) A reported condition of homicidal ideation;

(vi) A reported condition of suicidal ideation;

(vii) A primary diagnosis of substance use with pregnancy or one year postpartum; or

(viii) Receipt of an injectable antipsychotic.

(b) Group 2. Claims utilization in the twelve months preceding attribution identifies a combination of the following diagnostic and utilization criteria:

(i) One or more of the following services, service locations or medications for a behavioral-health related condition:

(a) Inpatient hospital visit;

(b) Crisis unit visit;

(c) A nursing facility visit;

(d) A rehabilitation facility visit;

(e) A medication as identified in appendix B to this rule that was administered as a component of MAT for treatment of a substance use disorder; or

(f) For individuals under the age of twenty-two, a therapeutic behavioral group service per diem; and

(ii) One or more of the following primary diagnoses as identified in appendix C to this rule:

(a) Bipolar disorder without psychosis;

(b) Major depression without psychosis;

(c) Post traumatic stress disorder;

(d) Substance use disorder;

(e) Conduct disorder;

(f) Personality disorder;

(g) Psychosis;

(h) Oppositional defiance disorder;

(i) Eating disorder; or

(j) Other depression.

(3) For medicaid covered individuals who do not have sufficient claims history to substantiate the eligibility criteria for BHCC, any provider may make a referral to the MCP to request enrollment in BHCC and attribution to a QBHE. The provider must provide sufficient documentation to demonstrate the individual meets the BHCC eligibility criteria as defined in this rule. Each referral is subject to review and approval by the MCP.

(4) Eligible members who are in foster care and meet the eligibility criteria in paragraph (D)(2) of this rule will be attributed to a QBHE only after the guardian is notified of eligibility by ODM or its designee, and the guardian provides consent for the individual in foster care to receive BHCC.

(5) For eligible members who are also receiving substance use disorder (SUD) residential treatment, the following applies:

(a) The eligible member will be attributed to or maintain attribution with a QBHE during the SUD residential treatment period.

(b) The QBHE will not be eligible for BHCC payments during the eligible member's SUD residential treatment period because BHCC is duplicative of the care coordination responsibilities of the SUD residential treatment program.

(c) The QBHE will immediately re-engage the eligible member for BHCC upon discharge from the SUD residential treatment period.

(6) For eligible members who also meet criteria for assertive community treatment (ACT) or intensive home based treatment (IHBT) as defined in Chapter 5160-27 of the Administrative Code, the following applies:

(a) The eligible member will be attributed to or maintain attribution with a QBHE.

(b) If the QBHE is certified to deliver ACT or IHBT, it shall provide ACT or IHBT in lieu of BHCC as long as ACT or IHBT is medically necessary. When the ACT or IHBT service is no longer medically necessary, the eligible member shall be transitioned to BHCC.

(c) If the QBHE is not an eligible provider of ACT or IHBT, the eligible member may choose to either receive BHCC from the QBHE or opt-out and receive ACT or IHBT from a provider eligible to deliver ACT or IHBT.

(E) Attribution.

(1) At any time, the eligible member may choose a specific QBHE or request to be re-attributed to a different QBHE by submitting a request to the member's MCP.

(2) If no choice has been identified by the eligible member, attribution will be completed using claims utilization data and the member's visit history, provider specialty, and geographic proximity between the member and provider.

(3) Eligible individuals may opt-out of receiving BHCC and may opt-in at any time by making a request to the MCP.

(F) A participating QBHE must perform the following activities as needed for their attributed individuals:

(1) "Outreach and engagement" activities which includes:

(a) Conducting initial outreach and engagement with attributed individuals upon enrollment in the BHCC program;

(b) Leading initial outreach with the attributed individual's PCP to share information regarding the BHCC program participation and care plan development;

(c) Building trust-based relationships to understand the preferences and goals of the attributed individual and begin engaging with the individual's family or social support system;

(d) Leading development of the outreach plan that ensures alignment with the individual's PCP and the MCP to establish a process for information exchange and to identify each stakeholder's role in coordinating care;

(e) Establishing relationships and collaborations with a full spectrum of providers and payers as appropriate; and

(f) Educating other providers and payers about the BHCC program and the value of collaborating to deliver medically necessary services.

(2) "Comprehensive care plan" activities in which the QBHE must:

(a) Within thirty days of the first BHCC activity conducted, begin developing a comprehensive care plan that addresses the individual's behavioral and physical health needs;

(b) Act as the lead for creating and maintaining the comprehensive care plan, including leading outreach to the PCP to incorporate inputs for physical health components in the comprehensive care plan; and

(c) Develop the behavioral health components of the comprehensive care plan.

(G) "Ongoing maintenance" activities must be performed by the QBHE including, but not limited to, the following:

(1) Relationship maintenance activities in which the QBHE must, as a primary contact for communication about behavioral health and physical health needs of the attributed individual, conduct regular check-ins, educational activities and additional intensive support as needed which include the following:

(a) Directing individual and family education on behavioral health, including self-care and adherence to the comprehensive care plan; and

(b) Conducting follow ups with the individual on behavioral health care and updating, as appropriate, the comprehensive care plan, CPC practice, or PCP.

(2) "Individual engagement and access to appropriate care" activities in which the QBHE must:

(a) Improve access to appropriate care by addressing barriers such as assistance with scheduling appointments or connecting the attributed individual to transportation;

(b) Lead scheduling with guidance from the CPC practice or PCP and work with the attributed individual to reduce barriers to attendance for appointments;

(c) Lead follow-ups with the CPC practice or PCP to understand implications from ambulatory or acute encounters such as treatment adherence;

(d) Engage directly with the attributed individual's health care providers as well as community resources to support care and make necessary updates to the comprehensive care plan;

(e) Be accountable for referral decision support and scheduling for behavioral health care in both inpatient and outpatient settings; and

(f) Stabilize crises by gathering information from the attributed individual, CPC practice or PCP, social support systems, and other medical providers and formulating a response for immediate intervention or stabilization.

(3) "Engaging supportive services" activities in which the QBHE must facilitate access to needed community services such as housing or vocational services.

(4) "Population health management" activities in which the QBHE must use appropriate data to identify high-risk individuals and utilize the appropriate resources to deliver specialized interventions.

(5) "Individual transition" activities in which the QBHE must:

(a) Ensure the attributed individual's successful transition between providers or sites of care including triaging the individual to medically necessary services not available at the attributed QBHE;

(b) Lead outreach to the CPC practice or PCP after major behavioral health events such as an inpatient stay and discuss implications for physical healthcare;

(c) Follow up with the CPC practice or PCP following major physical health related events and discuss implications for behavioral health care as well as transition needs of the attributed individual such as transportation and medications; and

(d) Monitor the attributed individual's admission and discharges related to behavioral health treatment by establishing relationships with hospitals and hospital emergency departments.

(H) An enrolled QBHE will be evaluated based upon its population of attributed individuals meeting the identified thresholds for the following HEDIS, NQF, and PQI measures, as applicable, quarterly and at the end of each calendar year by ODM or the MCP. More detailed information regarding these requirements can be found on the ODM website, www.medicaid.ohio.gov.

(1) Adult body mass index (BMI) assessment;

(2) Controlling high blood pressure;

(3) Comprehensive diabetes care; eye exam (retinal) performed;

(4) Comprehensive diabetes care; HbA1c poor control (greater than nine per cent);

(5) Comprehensive diabetes care; HbA1c testing;

(6) Tobacco use; screening and cessation;

(7) Follow-up within seven days after hospitalization for mental illness;

(8) Follow-up within seven days after an emergency department visit for mental illness;

(9) Follow-up within seven days after an emergency department visit for alcohol or other drug dependence;

(10) Antidepressant medication management;

(11) Initiation and engagement of alcohol and other drug dependence treatment;

(12) Adherence to antipsychotic medications for individuals with schizophrenia;

(13) Metabolic monitoring for children and adolescents on antipsychotics;

(14) Use of multiple concurrent antipsychotics in children and adolescents;

(15) Emergency department visits;

(16) Behavioral health-related inpatient admissions;

(17) Inpatient discharges;

(18) All-cause readmissions;

(19) Adolescent well-care visits;

(20) Weight assessment and counseling for nutrition and physical activity for children and adolescents including BMI documentation;

(21) Per cent of live births weighing less than two thousand five hundred grams;

(22) Prenatal care including timeliness of care;

(23) Postpartum care;

(24) Use of opioids at high dosage (greater than eighty morphine equivalent dose per day); and

(25) Rate of opioid-related emergency department visits per one-thousand member months.

(I) Additional requirements for enrolled QBHEs.

(1) The QBHE must assign at least one individual who serves as the point of contact for the MCP and ODM or its designee to discuss performance of BHCC quality measures.

(2) The QBHE must identify a care team that includes the following roles:

(a) Case manager to lead the care coordination relationship and serve as the primary point of contact for the individual and their family.

(b) Registered nurse or licensed practical nurse to consult and coordinate with the eligible member's other medical providers.

(c) Program administrative contact to act as the single point of contact to fulfill records requests and perform other administrative activities.

(3) The QBHE must maintain records that meet the requirements set forth in rule 5160-1-17.2 of the Administrative Code.

(4) For eligible members or attributed individuals who opt-out of the BHCC program, the QBHE must document in the medical record the circumstances regarding the individual's decision and notify the member's MCP of this decision by no later than the end of the following business day.

(5) If a participating QBHE chooses to terminate its designation as a QBHE, it must provide notice to ODM and the MCPs in accordance with rule 5160-26-05 of the Administrative Code.

(J) Reimbursement.

(1) QBHEs are authorized under this rule to provide the identified BHCC activities on a monthly basis to attributed individuals and obtain a monthly payment rate as found in appendix D to this rule for each calendar month the BHCC specific activities are performed.

(2) To be eligible for payment under this rule, BHCC activities must be separate and distinct from other medicaid-covered services provided within the same calendar month.

(3) If the member is attributed prior to July 1, 2019, the QBHE may begin submitting claims for BHCC for dates of service in July 2019 no earlier than August 1, 2019. If the member is attributed after July 1, 2019 for the first program year, the QBHE may begin submitting claims for BHCC in the calendar month following the month in which the eligible member was attributed to the QBHE. QBHEs will not be reimbursed for BHCC services prior to July 1, 2019.

(4) The BHCC activities performed must be identified on claims for BHCC using the procedure codes and modifiers identified in appendix D to this rule.

(5) The QBHE may bill for BHCC once per calendar month per attributed individual when the following requirements are met:

(a) For the initial payment, the QBHE may submit a claim for the BHCC service if it has completed, at a minimum, the activity requirements set forth in paragraphs (F)(1)(a) to (F)(1)(c) of this rule and begin developing the comprehensive care plan as specified in paragraph (F)(2) of this rule.

(b) For ongoing payment, the QBHE may submit a claim for BHCC if it has completed in the same calendar month, at least one of the activity requirements set forth in paragraph (F) or (G) of this rule. Other activities stated in paragraphs (F) and (G) of this rule must be provided as needed.

(c) At least one activity is performed every month that involves contact with the attributed individual.

(6) For attributed individuals in the BHCC program, payments for community psychiatric supportive treatment (CPST) and targeted case management as described in Chapter 5160-27 of the Administrative Code will not be made as these are considered duplicative of the BHCC program activities.

(K) Penalties.

(1) The QBHE must continue to meet all requirements as defined in this rule. If these requirements are not met upon evaluation, payment under this rule is subject to termination.

(2) A QBHE may seek reconsideration pursuant to rule 5160-70-02 of the Administrative Code to challenge decisions by ODM to terminate payments described in this rule.

View Appendix

Supplemental Information

Authorized By: 5162.02, 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 1/10/2024
Rule 5160-1-80 | Substitute practitioners (locum tenens).
 

(A) Definitions.

(1) "Practitioner," for purposes of this rule, is a collective term for the following professionals:

(a) Doctor of medicine or osteopathy;

(b) Advanced practice registered nurse;

(c) Dentist;

(d) Optometrist;

(e) Podiatrist; or

(f) Chiropractor.

(2) "Regular practitioner" is a practitioner enrolled in the Ohio medicaid program who regularly takes care of an individual's health care needs.

(3) "Substitute practitioner" is a practitioner who generally does not maintain an individual practice and who works in place of a regular practitioner when the regular practitioner is absent;

(B) Coverage and limitations. Payment may be made for services rendered by a substitute practitioner only when the following conditions are met:

(1) Both the regular practitioner and the substitute practitioner are professionals listed in paragraph (A)(1) of this rule;

(2) The regular practitioner is expected to be absent for a period of not longer than sixty days unless there are extenuating circumstances (e.g., active duty in the armed forces, pregnancy, extended illness);

(3) The substitute practitioner has the status of an independent contractor rather than of an employee;

(4) The substitute practitioner meets the applicable provider screening requirements described in rule 5160-1-17.8 of the Administrative Code;

(5) The substitute practitioner has not been sanctioned under medicare, medicaid, or Title XX and is not otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries; and

(6) The substitute practitioner receives payment from the regular practitioner as a fixed amount per diem or on a similar fee-for-time basis.

Last updated October 2, 2023 at 8:23 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/1/2028
Prior Effective Dates: 10/1/2018
Rule 5160-1-97 | One-time medicaid provider relief payments.
 

The department of medicaid (ODM) will make relief payments available to Ohio medicaid hospitals defined in paragraph (A) of this rule, as authorized under Section 270.15 of Amended Substitute House Bill 45 of the 134th General Assembly:

(A) ODM will make available a one-time lump sum payment to the following hospital types:

(1) "Critical access hospitals," as defined in rule 5160-2-05 of the Administrative Code.

(2) "Rural hospitals," as defined in rule 5160-2-05 of the Administrative Code.

(B) The payment will be established in the following manner:

(1) The total sum to be made available to all eligible Ohio medicaid hospitals as defined in paragraph (A) of this rule is sixty-two million dollars less the amount described in paragraph (B)(2) of this rule.

(2) Any hospital located in a county in the Northwest region as defined in the appendix of rule 5160-2-05 of the Administrative Code with a population of less than forty-two thousand residents and less than three hundred square land miles according to the United States census bureau (July 1, 2021) will qualify for an additional payment of two million one hundred thousand dollars.

(3) No individual hospital will receive a total calculated payment that exceeds three million dollars.

(4) For each hospital, the value of the final one-time payment will be calculated as follows:

(a) Base payment data to be utilized for establishing provider payment amounts are fee-for-service (FFS) payments for state fiscal year 2022 and reflected in the ODM management information technology system (MITS) on January 31, 2023.

(b) Each payment is the product of the ratio of each hospital's total FFS payments to the total FFS payments for all eligible hospitals as defined in paragraph (A) of this rule, multiplied by the amount listed in paragraph (B)(1) of this rule.

(c) For each hospital, if the total calculated payment in paragraph (B)(4)(b) of this rule exceeds the amount described in paragraph (B)(3) of this rule, the hospital's payment amount is limited to the amount defined in (B)(3) of this rule.

(d) For hospitals with a payment amount limited as described in paragraph (B)(4)(c) of this rule:

(i) Subtract the amount calculated in paragraph (B)(4)(c) of this rule from the amount determined in paragraph (B)(4)(b) of this rule then sum these amounts for these hospitals.

(ii) Distribute the sum of the amounts determined in paragraph (B)(4)(d)(i) of this rule, to all hospitals that have not exceeded the payment amount calculated in paragraph (B)(3) of this rule, using the same methodology described in paragraph (B)(4)(b) of this rule until all remaining funds from the amount calculated in paragraph (B)(4)(d)(i) of this rule are expended.

(5) If a hospital's calculated payment amount in paragraph (B)(4)(b) of this rule is less than four thousand dollars, no payment will be made to that hospital.

Last updated May 30, 2023 at 8:24 AM

Supplemental Information

Authorized By: 5160.02, 5164.02
Amplifies: 5160.02, 5164.02
Five Year Review Date: 5/27/2028
Prior Effective Dates: 6/17/2022 (Emer.)
Rule 5160-1-98 | Deposits to the health care/medicaid support and recoveries fund for program support.
 

(A) The Ohio department of medicaid (ODM) will deposit a portion of the intergovernmental transfers (IGT) that are paid under any state directed payment (SDP) program as authorized under 42 CFR 438.6(c) effective as of October 1, 2022 and are subject to Section 333.360 of Amended Substitute House Bill 33 of the 135th General Assembly, to the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code.

(B) On or after the effective date of this rule and for each year thereafter:

(1) Pursuant to paragraph (A) of this rule, each provider eligible to receive a directed SDP program payment will submit to ODM an additional IGT which is to be four per cent of the hospital's computed IGT amount.

(2) In subsequent SDP program years, ODM may establish a rate higher or lower than the rate described in paragraph (B)(1) of this rule as approved by the medicaid director.

Last updated September 27, 2024 at 2:39 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03 and 5162.52
Five Year Review Date: 4/15/2029