Ohio Admin. Code 4123-6-37.2 - Payment of hospital outpatient services
Unless an MCO has negotiated a different payment rate with a
hospital pursuant to rule
4123-6-10 of the Administrative
Code, reimbursement for hospital outpatient services with a date of service of
May 1, 2023
BWC will use the medicare integrated outpatient code editor and medicare medically unlikely edits in effect as implemented by the materials specified in paragraph (A)(9) of this rule and table 8 of the appendix to this rule to process bills for hospital outpatient services under this rule; however, BWC will not apply the outpatient code edits identified in table 1 of the appendix to this rule.
BWC will not apply the annual medicare outpatient prospective payment system outlier, hold harmless, and exempt cancer hospital reconciliation processes to payments for hospital outpatient services under this rule.
For purposes of this rule, hospitals are identified as critical access hospitals, rural sole community hospitals, essential access community hospitals and exempt cancer hospitals based on the hospitals' designation in the medicare outpatient provider specific file in effect implemented by the materials specified in paragraph (A)(10) of this rule.
For purposes of this rule, the following hospitals are recognized as "children's hospitals": nationwide children's hospital (Columbus), Cincinnati children's hospital medical center, shriners hospital for children (Cincinnati), university hospitals rainbow babies and children's hospital (Cleveland), Toledo children's hospital, children's hospital medical center of Akron, and children's medical center of Dayton.
Reimbursement for any hospital outpatient services identified in table 6 of the appendix to this rule will be determined using the medicare outpatient prospective payment system methodology as set forth in this paragraph, applying the status indicator and ambulatory payment classification specified for the service in table 6 of the appendix to this rule.
In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare outpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule, other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907(d) as amended as of the effective date of this rule, the "applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.
Except as otherwise provided in paragraphs (A)(2)(b)(ii) and (A)(2)(b)(iii) of this rule, hospital outpatient services reimbursed via fee schedule under the medicare outpatient prospective payment system will be reimbursed under the applicable medicare fee schedule in effect as implemented by the materials specified in paragraph (A)(10) of this rule, plus the add-on payments set forth in paragraph (A)(4) of this rule, if applicable.
The following services will be reimbursed the lesser of the charges billed by the hospital for the allowed services rendered, the applicable fee schedule rates set forth in tables 2, 3, 4 and 5 of the appendix to this rule, or the rate the MCO contracted or negotiated with the hospital:
Notwithstanding any other reimbursement methodology set forth in this rule, critical access hospitals will be reimbursed at one hundred one per cent of reasonable cost for all payable line items.
Reimbursement for outpatient services provided by hospitals and
distinct-part units of hospitals that do not participate in the medicare
program will be calculated in accordance with the methodologies set forth in
this rule, using the applicable FY23
A QHP or self-insuring employer may reimburse hospital outpatient services at:
The bureau may request information from any facility billing
the bureau for services as a provider-based facility as may be necessary to
establish whether the facility meets the criteria for provider-based status
under 42 C.F.R.
413.65 as published in the October 1,
2022
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 09/01/2007, 01/01/2011, 04/01/2011, 04/01/2012, 04/01/2013, 05/05/2014, 05/01/2015, 05/01/2016,05/01/2017, 05/01/2018, 05/01/2019, 05/16/2020,05/06/2021, 05/01/2022, 05/01/2023, 09/01/2023
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
Unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement for hospital outpatient services with a date of service of May 1, 2023
BWC will use the medicare integrated outpatient code editor and medicare medically unlikely edits in effect as implemented by the materials specified in paragraph (A)(9) of this rule and table 8 of the appendix to this rule to process bills for hospital outpatient services under this rule; however, BWC will not apply the outpatient code edits identified in table 1 of the appendix to this rule.
BWC will not apply the annual medicare outpatient prospective payment system outlier, hold harmless, and exempt cancer hospital reconciliation processes to payments for hospital outpatient services under this rule.
For purposes of this rule, hospitals are identified as critical access hospitals, rural sole community hospitals, essential access community hospitals and exempt cancer hospitals based on the hospitals' designation in the medicare outpatient provider specific file in effect implemented by the materials specified in paragraph (A)(10) of this rule.
For purposes of this rule, the following hospitals are recognized as "children's hospitals": nationwide children's hospital (Columbus), Cincinnati children's hospital medical center, shriners hospital for children (Cincinnati), university hospitals rainbow babies and children's hospital (Cleveland), Toledo children's hospital, children's hospital medical center of Akron, and children's medical center of Dayton.
Reimbursement for any hospital outpatient services identified in table 6 of the appendix to this rule will be determined using the medicare outpatient prospective payment system methodology as set forth in this paragraph, applying the status indicator and ambulatory payment classification specified for the service in table 6 of the appendix to this rule.
In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare outpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule, other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907(d) as amended as of the effective date of this rule, the "applicable medicare reimbursement rate for the hospital outpatient service under the medicare outpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.
Except as otherwise provided in paragraphs (A)(2)(b)(ii) and (A)(2)(b)(iii) of this rule, hospital outpatient services reimbursed via fee schedule under the medicare outpatient prospective payment system will be reimbursed under the applicable medicare fee schedule in effect as implemented by the materials specified in paragraph (A)(10) of this rule, plus the add-on payments set forth in paragraph (A)(4) of this rule, if applicable.
The following services will be reimbursed the lesser of the charges billed by the hospital for the allowed services rendered, the applicable fee schedule rates set forth in tables 2, 3, 4 and 5 of the appendix to this rule, or the rate the MCO contracted or negotiated with the hospital:
Notwithstanding any other reimbursement methodology set forth in this rule, critical access hospitals will be reimbursed at one hundred one per cent of reasonable cost for all payable line items.
Reimbursement for outpatient services provided by hospitals and distinct-part units of hospitals that do not participate in the medicare program will be calculated in accordance with the methodologies set forth in this rule, using the applicable FY23
A QHP or self-insuring employer may reimburse hospital outpatient services at:
The bureau may request information from any facility billing the bureau for services as a provider-based facility as may be necessary to establish whether the facility meets the criteria for provider-based status under 42 C.F.R. 413.65 as published in the October 1, 2022
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 09/01/2007, 01/01/2011, 04/01/2011, 04/01/2012, 04/01/2013, 05/05/2014, 05/01/2015, 05/01/2016,05/01/2017, 05/01/2018, 05/01/2019, 05/16/2020,05/06/2021, 05/01/2022, 05/01/2023, 09/01/2023