The following claims for services
rendered to medicaid consumers are exempt from this rule:
(1) Claims for services provided through
medicaid managed care plans must be submitted in accordance with Chapter
5101:3-26 of the Administrative Code; and
(2) Claims submitted by nursing facility
providers must be submitted in accordance with rules 5101:3-1-05, 5101:3-1-08,
and 5101:3-3-39.1 of the Administrative Code.
by a provider or type of provider required by the office of medical assistance
to submit claims in a format other than the electronic claims submission
formats provided in paragraph (B) of this rule.
All other claims, except for a state
agency that has an interagency agreement with
the office of medical
to submit claims in a different format, must be
submitted to the
through one of the following formats:
Electronic data interchange (EDI) in
accordance with standards established under the Health Insurance Portability
and Accountability Act (HIPAA) of 1996. EDI formats for claims submission
(a) The "837 Health Care Claim
Professional" (837P) electronic format;
(b) The "837 Health Care Claim Institutional"
(837I) electronic format; or
The "837 Health Care Claim Dental" (837D) electronic format.
The medicaid information
technology system (MITS) web portal; or
(4) Hard copy paper claim, with the
exception of paragraphs (C)(1) and (C)(2) of this rule, in accordance with
standards developed by the national uniform billing committee, the national
uniform claim committee or the American dental association. Paper claim formats
(a) The "CMS 1500" professional
claim format (rev. 8/2005);
(b) The "UB-04" institutional claim
format (rev. 5/2007); or
(c) The "American Dental
Association" claim format (rev. 2006).
(C) The following claims must be
submitted for payment in either the EDI format or through the MITS web
(1) Medicare crossover claims in
accordance with rule 5101:3-1-05oftheAdministrativeCode; or
(2) Claims that indicate other third
party insurance plan information in accordance with rule
Claims must be submitted pursuant to the national correct coding initiative and
coding standards set forth in the following guides and described in
healthcare common procedure coding system;
(2) The current procedure terminology
(3) The current dental
terminology codebook; or
international classification of diseases codebook.
Timely filing limitations.
Claims other than inpatient
hospital claims must be received by
hundred sixty-five days of the actual date the service was provided.
(b) Inpatient hospital claims must be
received within three hundred sixty-five days from the date of
beyond three hundred sixty-five days from the actual date of service or
hospital discharge will be denied except when the provisions of paragraph
this rule apply.
of this rule, the date of receipt is the date
internal control number.
Re-submission of denied claims.
Claims denied by the
may be re-submitted for payment and must be received by the later of the
(i) Three hundred sixty-five
days from the actual date or service; or
(ii) One hundred eighty days from the date
the claim denied, even if this date is beyond three hundred sixty five days
from the original date of service.
(b) Resubmitted claims received beyond seven
hundred thirty days from the actual date of service or hospital discharge will
with prior payment by medicare or another insurance plan must be received
within one hundred eighty days from the date medicare or the insurance plan
paid the claim.
timely filing requirements.
submission of a claim is delayed due to the pendency of an administrative
hearing decision by
the Ohio department of job and family services
or an eligibility determination by a county department of job and
family services (CDJFS), the claim must be received within one hundred eighty
days from the date of the administrative hearing decision by ODJFS or the
eligibility determination by the CDJFS. Documentation showing the date of
service and the administrative hearing decision or eligibility determination
must be submitted with the claim. In no case shall a delay in processing
eligibility information at the CDJFS (as required in rule 5101:1-38-01.2 of the
Administrative Code) be a basis for denial of payment under this
When a claim can not
be submitted to
within three hundred sixty five days of the actual
date of service due to coordination of benefits delays with medicare and/or
other third party payers, the claim must be received by
within one hundred eighty days from the date medicare or the other insurance
plan paid the claim.
claim has been submitted and denied and is later found to meet the provisions
rule, the claim may be resubmitted with documentation attached to support the
delay in submission.
(1) Adjustments to underpaid claims
must be submitted within one hundred eighty days from the date medicaid paid
overpaid claims must be submitted, and overpayments refunded, to
within sixty days of discovery.
Overpayments are recoverable by
at the time of discovery. Appeal rights under
Chapter 119. of the Revised Code may be exercised to the extent provided in
accordance with rule 5101:3-1-57 of the Administrative Code. All recoverable
amounts are subject to the application of interest in accordance with rule
5101:3-1-25 of the Administrative Code.
collections by invoice for overpayments that result in a credit balance due to
and remain outstanding for more than sixty
may be submitted through the EDI format or through the MITS web
no longer accept paper adjustment forms, except in cases where
determines a paper adjustment must be used for a claim to be
no longer process refund checks from providers for claim overpayments, except
when an invoice or letter for collection of an outstanding overpayment has been
sent to the provider for an
audit or review.
Claims that require a specific
form to accompany the claim (for example, a claim
for a hysterectomy service must have a hysterectomy consent form accompany the
claim) may be submitted through the web portal, regular mail, or EDI format.
(1) Claims submitted via EDI shall be
consistent with the Health Insurance Portability and Accountability Act of 1996
supporting documentation shall be submitted with the designated electronic data
management system (EDMS) cover sheet.
submitting EDI transactions.
partners must enroll and receive an
trading partner number in order to submit EDI transactions.
To become an active trading partner with
trading partners must abide by all
requirements, including the completing of a ninety per cent pass rate for each
transaction type tested.
authorized trading partners that are actively submitting and receiving 837
health care claim transaction sets may submit and receive the 270/271 and the
276/277 transaction sets.
Ohio Admin. Code
119.032 review dates:
Effective Dates: 6/1/78, 6/3/83, 8/1/83 (Emer), 10/1/83, 2/1/84, 10/1/84,
7/1/85 (Emer), 7/11/85 (Emer), 9/30/85, 8/1/86, 10/1/87, 2/1/88, 5/1/89,
7/1/90, 7/1/02, 7/1/03, 10/16/03 (Emer), 1/1/04, 11/15/04, 12/30/04 (Emer),
4/1/05, 3/28/05, 7/1/05, 12/30/05 (Emer), 3/27/06, 12/29/06 (Emer), 3/29/07,
5/23/07, 12/31/07 (Emer), 3/30/08, 12/31/08 (Emer), 3/31/09, 12/31/09 (Emer),
2/1/10, 3/31/10, 8/2/11