Ohio Admin. Code 3701-43-12 - Authorization for payment of diagnostic services
(A) Subject to paragraphs (B) and (C) of this
rule, diagnostic services shall be authorized for applicants determined to be
eligible for diagnostic services pursuant to paragraph (B) of rule
3701-43-11 of the Administrative
Code if all of the following apply:
(1) The
services are included in the applicant's medical application submitted by the
managing physician in accordance with paragraph (A)(2) of rule
3701-43-11 of the Administrative
Code, or additional services have been requested by the applicant's managing
physician or other BCMH provider on forms prescribed by the director;
(2) The services are furnished by
providers, as defined in paragraph (P) of rule
3701-43-01 of the Administrative
Code, who are approved under applicable provisions of this chapter to provide
the specific services requested and the services are furnished within the
period of eligibility for diagnostic services;
(3) The services are deemed necessary by the
director for an assessment of the eligible applicant's condition in accordance
with medical policies and the applicable standards of care as defined in
paragraph (U) of rule
3701-43-01 of the Administrative
Code;
(4) The managing physician
and any provider shall furnish to the director upon request medical reports and
progress records verifying completion of the diagnostic services and indicating
whether the child has a handicapping condition;
(5) The services are rendered in Ohio. The
director may waive this requirement if comparable services are not available in
Ohio or if the director determines that travel to obtain comparable services in
Ohio would present an undue hardship for the applicant; and
(6) Request for authorization of services
must be received within eleven months from date of service to enable payment
for those services to occur in accordance with this chapter.
(B) Notwithstanding paragraph (A)
of this rule and pursuant to division (G) of section
3701.023 of the Revised Code,
the director may deny payment of diagnostic services for an eligible recipient
if payment for the services will be made by a third party payor.
(C) Notwithstanding paragraph (A) of this
rule, in authorizing provision of major services such as surgery or inpatient
hospital stays, the director may limit the authorization for payment of
diagnostic services to a specified type and number of services or to specific
providers based upon the applicant's condition.
(D) The department shall notify the applicant
or his or her parent, guardian or other legal representative, selected
providers of major services, the local health department and the managing
physician of the approval or proposed denial of eligibility and the effective
date of eligibility, if approved. The director shall issue this notification
within sixty days of the date of receipt of the last document necessary to make
the eligibility determination or of the failure to submit timely an application
or requested additional information. A notice of proposed denial of eligibility
shall contain a statement of the reasons for denial and a description of the
reconsideration procedure established by paragraph (B) of rule
3701-43-23 of the Administrative
Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701.022, 3701.023
Prior Effective Dates: 10/3/1992, 12/1/01, 9/1/08
R.C. 119.032 review dates: 05/23/2008 and 09/01/2013
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701.022, 3701.023
Prior Effective Dates: 10/3/1992, 12/1/01
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