Ohio Admin. Code 3701-43-09 - Criteria and procedures for payment of providers
(A) The director
shall pay providers for diagnostic services and for treatment services and
goods furnished to recipients in accordance with this rule.
(B) The director shall pay only for services
or goods that have been authorized to be provided under the applicable
provisions of this chapter.
(C) A
provider shall submit a request for payment on a form prescribed by the
director and containing at least the name and identification number of the
applicant or recipient to whom the services or goods were provided, the
provider's identification number, a description of the goods or services
provided and the amount of the charges for the goods or services. The request
for payment shall be submitted so that it is received by the director no later
than twelve months after the last date on which goods or services included in
the request were furnished.
(D) If
the request for payment does not contain sufficient information for the
director to determine whether payment may be made, the director shall deny the
request. The director shall notify the provider within thirty days after
receipt of a request for payment that the request has been denied and of any
additional or corrected information necessary to process the request.
Additional information may include, but is not limited to, reports,
descriptions of the types or amounts of goods or services provided, the amount
of charges for the goods or services and information concerning submission of
claims for third-party benefits. The provider may resubmit the request for
payment but shall not resubmit the request so that it is received by the
director more than twenty-four months after the last date on which goods or
services included in the request were furnished.
(E) A provider shall submit claims for
medicaid benefits and for all other third-party benefits which may provide
payment for the services rendered or goods supplied and shall make all
reasonable efforts to assist the recipient to whom the goods or services were
provided and the recipient's parent, guardian or other legal representative to
submit claims for third-party benefits and any information necessary for
processing the claims. The claims for third-party benefits shall have been
submitted no less than sixty days before a request for payment is submitted to
the director under this rule.
(1) If any
payment is made for the goods or services by the medicaid program, the director
shall not make payment under this rule. If the recipient of the goods or
services giving rise to the request for payment is a medicaid recipient at the
time that the services or goods were furnished, the director shall not make
payment under this rule until after the medicaid program has denied payment for
the goods or services.
(2) If
payment is received by the provider through third-party benefits, other than
medicaid program benefits, for the goods or services, the director shall
subtract the amount of the third-party benefits from the amount determined
under paragraph (F) of this rule and shall pay the difference to the provider.
(3) If a provider receives payment
from the medicaid program or through other third-party benefits of at least the
amount determined under paragraph (F) of this rule from the program for goods
or services authorized to be provided by the director under the applicable
provisions of this chapter, the provider shall not seek payment of any
additional amount from the recipient, recipient's parent, guardian or other
legal representative.
(F) If the director determines that a request
for payment meets the criteria prescribed by this rule, the director shall pay
the provider within sixty days after receipt of all necessary information.
Subject to paragraph (E)(2) of this rule, the director shall pay:
(1) For inpatient hospital care, outpatient
care and for all other medical assistance furnished by hospitals to recipients
in accordance with reasonable cost principles for reimbursement under the
medicare program established under Title XVIII of the Social Security Act, 79
Stat. 291 (1965),
42 U.S.C.
1395 (1965).
(2) Providers of good or services other than
inpatient or outpatient hospital care in accordance with the fee schedules set
forth in the operational manual.
The director shall notify the provider in writing of the amount paid and, if the amount paid is less than the charges, of the reconsideration procedure established by paragraph (B) of rule 3701-43-23 of the Administrative Code.
(3)
For pharmaceuticals, the pharmaceutical shall be
approved by the medicaid program and be necessary to treat an eligible
condition as specified in rule
3701-43-17 of the Administrative
Code. The director may deny approval for certain pharmaceuticals when the
director determines that there are other therapeutic equivalents available
within the drug class and on the basis of costs, medical efficacy, operational
guidelines and other factors, the denial is determined to be in the best
interest of the program.
(G) The director shall deny payment if the
provider fails to meet any of the deadlines established by this rule or if the
request for payment does not meet the criteria for payment prescribed by this
rule. The director shall notify the provider in writing of the denial of a
request for payment and the reasons for denial of the request for payment
within thirty days of:
(1) Receipt of
information verifying that the request for payment does not meet the criteria
prescribed by this rule; or
(2)
The provider's failure to comply with a deadline established by this rule.
Notes
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701.023
Prior Effective Dates: 1/2/1989, 10/19/98, 2/14/00, 12/1/01, 1/29/07, 9/1/08, 10/8/10
Promulgated Under: 119.03
Statutory Authority: 3 701.021
Rule Amplifies: 3701.021, 3701.023
Prior Effective Dates: 1/2/1989, 10/19/98, 2/14/00, 12/1/01, 1/29/07, 9/1/08
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