Provisions of provider agreements for long term care nursing
facilities are defined in Chapter 5101:3-3
5160-3 of the
Administrative Code. Provisions for provider agreements for medicaid
contracting managed care plans are defined in Chapter
5101:3-26
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 job and family services
medicaid (ODJFS
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
handicap
disability; submit claims only for services actually
performed; and, bill
ODJFS
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
ODJFS
ODM.
ODJFS
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
division-level
agency
5101:3
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
5101:3-1-09
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
based upon those records or until any audit
initiated within the
required six year
record maintenance period is completed.
(E) To furnish to
ODJFS
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
ODJFS
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
12/07/2010) (Title XX), as specified in rule
5101:3-1- 17.3
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
ODJFS
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
job and family services
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
5101:3-1-39
5160-1-39 of the Administrative Code when providing
home care services.
Notes
Ohio Admin. Code
5160-1-17.2
Effective:
9/19/2019
Five Year Review (FYR) Dates:
5/24/2019 and
09/19/2024
Promulgated
Under: 119.03
Statutory
Authority: 5164.02
Rule
Amplifies: 5162.03;
5164.02
Prior
Effective Dates: 04/07/1977, 12/30/1977, 01/01/1979, 03/23/1979, 08/31/1979,
11/01/1979, 07/01/1980, 07/07/1980, 10/01/1987, 01/01/1993, 05/30/2002,
01/01/2004, 09/26/2004, 08/11/2005, 12/30/2005 (Emer.), 03/27/2006,
08/02/2011
