(A) The
director
shall apply the criteria prescribed by this rule in determining whether or not
to authorize the provision of treatment services and goods to recipients,
pursuant to division (E) of section
3701.023 of the Revised Code. An
applicant's
managing physician shall request authorization for provision of
goods or services by submitting an individualized plan of treatment as part of
the medical application for
program eligibility under rule
3701-43-15 of the Administrative
Code.
(B) Requests for
authorization for provision of services or goods to recipients that are not
included in the current individualized plan of treatment may be submitted by
the recipient's managing physician or other BCMH provider to the director
within eleven months of the date of service on forms prescribed by the
director.
(C) The managing
physician and any provider must furnish any information requested by the
director, including but not limited to medical or operative reports, hospital
discharge summaries, evaluation reports, and other descriptions of services,
that is necessary to determine whether the goods or services may be authorized.
The information must be submitted so that it is received by the director within
eleven months of the date of service. The managing physician and any provider
also shall submit any information requested by the director to evaluate the
results achieved by the provision of the goods or services.
(D) Subject to paragraph (E) of this rule,
the
director shall authorize
treatment services or goods if:
(1) The services or goods are included in the
recipient's individualized plan of treatment, submitted by the
recipient's
managing physician, in accordance with paragraph
(B)
(C)(2) of rule
3701-43-15 of the Administrative
Code;
(2) The services or goods
meet the definition of
treatment services or goods, as prescribed by paragraph
(X) of rule
3701-43-01 of the Administrative
Code, with respect to the specific medically eligible or associated condition
for which they are requested;
(3)
The services or goods are furnished by providers, as defined by 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 or goods requested and the goods or services are
furnished after the effective date of the
provider's approval;
(4) The request for authorization and any
additional documentation requested by the director are submitted in compliance
with paragraphs (A), (B), and (C) of this rule; and
(5) The services are rendered or the goods
furnished in Ohio. The director may waive the requirement prescribed by this
paragraph if comparable goods or services are not available in Ohio or if the
director determines that travel to obtain comparable services or goods in Ohio
would present an undue travel or financial hardship for the recipient. In
making determinations under this paragraph, the director may consult with one
or more members of the medical advisory council or with other individuals with
expertise in the area.
(E) In determining whether provision of
requested
treatment services or goods may be authorized, the
director shall
consider whether or not the goods or services are necessary for treatment of
the
recipient's
medically eligible condition, in accordance with the applicable
standards of care and
medical policies. The
director shall not authorize
provision of any goods or services that are not listed in the
standards of care
or
medical policies as being necessary for treatment of the condition or that
are in excess of a limitation contained in the standards or policies.
(1) If a recipient's condition is not
addressed by the standards of care or medical policies, the director may use
the standards of care or medical policies applicable to conditions that are
similar to the recipient's condition to determine which goods or services may
be authorized.
(2) The director may
deny authorization for provision of goods or services for treatment of a
recipient's medically eligible condition if payment for the services or goods
will be made by another governmental or private entity, including the medicaid
program, or if payment could have been made by such an entity and was not made
because of an act or omission by the recipient, parent, guardian or other legal
representative or a provider.
(3)
In accordance with the applicable
medical policies or
standards of care, the
director may authorize provision of goods or services for treatment of a
recipient's physical health impairment which, as an isolated condition, would
not be a
medically eligible condition under rule
3701-43-17 of the Administrative
Code, if the impairment is associated with a
medically eligible condition for
which the
recipient is receiving treatment goods or services authorized under
this rule.
(4) In emergency or
extraordinary circumstances that present an undue risk of significant harm to a
recipient, the director may waive any of the criteria or procedures established
by paragraph (D) or (E) of this rule that would prevent authorization of
requested goods or services.
(5) In
circumstances which present an undue hardship to a recipient, the director may
extend the time requirements of paragraphs (B) and (C) of this rule for a
period not to exceed one hundred fifty days if sufficient justification for the
extension is provided by the managing physician, the recipient, parent,
guardian, or other legal representative, or another recipient
advocate.
(6) The director may deny
authorization for provision of goods or services that otherwise may be
authorized under the applicable medical policies or standards of care upon a
determination that the goods or services are not necessary for treatment of the
particular recipient's condition.
(F) In authorizing provision of major
services or goods such as inpatient or outpatient surgery, inpatient hospital
stays, medications, or durable medical equipment, the director may limit the
provision of the goods or services to a specified provider or providers, based
upon complexity, necessary follow-up care, and other relevant
factors.
(G) Notwithstanding
paragraph (E) of rule
3701-43-01 of the Administrative
Code, provision of
treatment services or goods may be authorized only by a
licensed registered nurse or a
physician employed by the Ohio department of
health.
The department shall notify in writing the applicant, parent,
guardian or other legal representative of the child and the managing physician
of the approval or proposed denial of authorization for provision of goods or
services under this rule. A notice of proposed denial shall include a statement
of the reasons for denial and a description of the reconsideration procedure
under paragraph (B) of rule
3701-43-23 of the Administrative
Code.