Ohio Admin. Code 5160-1-31 - Prior authorization [except for services provided through medicaid contracting managed care plans (MCPs)]
Current through all regulations passed and filed through March 11, 2022
(1) Prior authorization for
transplantation services must be obtained by the hospital before the service is
rendered in accordance with rule 5101:3-2-07.1 of the Administrative
(2) In addition to services
requiring prior authorization, some hospital inpatient and outpatient services
may require pre-certification in accordance with rules
(3) Prior authorization for out of
state coverage will be made in accordance with rule
(4) Prior authorization for
long-term care outlier services will be made in accordance with rules
5101:3-3-54.1 , 5101:3-3-54.5 , and 5101:3-3-87.1 of the Administrative
(5) Prior authorization for pharmacy
services will be made in accordance with Chapter 5101:3-9 of the Administrative
(B) Completed prior authorization
forms and any necessary supporting documentation should be mailed or faxed to
the location listed at the bottom of the request form. A duplicate copy of each
request must be retained in the providers records. Telephone requests for prior
authorization will only be accepted for pharmacy services.
(1) The following forms must be used
when requesting prior authorization:
(a) Requests for authorization of
medical services, supplies, equipment or transportation services must be
submitted on the JFS 03142 "Prior Authorization" form (rev. 2/2003).
(b) Requests for the authorization
of dental services must be submitted on the JFS 03612 "Prior Authorization for
Dental Services" form (rev. 3/2003).
(c) Requests for the authorization
of medically necessary transport must be submitted on the JFS 03452
"Practitioner Certification of Medical Necessity for Ambulette Transportation"
form (rev. 07/2003) and must accompany form JFS 03142.
(2) Requests for prior authorization
submitted to ODJFS or its designee must include correct HCPCS or CPT code(s)
for that date of service in accordance with rule 5101:3-1-19.3 of the
(3) When a request for prior
authorization does not include documentation required for review of medical
necessity, the request will be denied. The provider may submit a new request
with the required documentation.
(G) Reimbursement for a prior
authorized service or item is contingent upon:
(1) The consumer being eligible for
medicaid at the time the service is rendered.
(2) The provider renders services in
accordance with the rules contained in Chapters 5101:3-2 to 5101:3-56 of the
(3) The reduction of benefits by
third-party payers, including medicare, have been properly applied to the
request for payment from ODJFS.
(4) ODJFS's timely filing
limitations for claims have not been violated in accordance with rule
5101:3-1-19.3 of the Administrative Code.
(5) The determination of medical
necessity by ODJFS or its designee has been met in accordance with rule
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 7/1/91 (Emer), 9/30/91, 5/30/02, 8/11/05
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§ 5160-1-31. Prior authorization [except for services provided through medicaid contracting managed care plans (MCPs)]
(A) Reimbursement for some items and/or services covered under the medicaid program is available only upon obtaining prior authorization from the Ohio department of job and family services (ODJFS). Prior authorization must be obtained from ODJFS or its designee by the provider before the services are rendered or the items delivered,unless the services meet the provisions in paragraph (F) of this rule. .
(B) Services, supplies or prescription drugs that require prior authorization by the department are identified in Chapters 5101:3-2 to 5101:3-56 of the Administrative Code.
(C) All prior authorization requests must be submitted through the medicaid information technology system (MITS) web portal. Paper prior authorization requests will be returned to the provider unprocessed.
(D) When the prior authorization request has been processed by ODJFS or its designee, the provider will receive notification indicating the decision for each service, supply or prescription drug. Only those services, supplies or prescription drugs approved in the prior authorization notice will be reimbursed.
(E) When a request for prior authorization has been approved, the notification will include a prior authorization (PA) number. In order for the provider to be reimbursed, the provider must use the assigned PA number when submitting the claim for payment.
(F) In situations where the provider considers a delay in providing services, supplies or prescription drugs requiring prior authorization to be detrimental to the health of the consumer, the services, supplies or prescription drugs may be rendered or delivered and approval for reimbursement sought after the fact.
(G) When a request for prior authorization is denied, ODJFS or its designee will issue a notice of medical determination and a right to a state hearing to the consumer. A copy of this denial notice will be sent to the county department of job and family services to be filed in the consumer's case record. Providers will also be notified of the denial.(Effective: 08/02/2011 R.C. 119.032 review dates: 09/20/2010 and 08/01/2016 Promulgated Under: 119.03 Statutory Authority: 5111.02 Rule Amplifies: 5111.01, 5111.02 Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 7/1/91 (Emer), 9/30/91, 5/30/02, 8/11/05 )