Ohio Admin. Code 5160-12-07 - Reimbursement: exceptions
Home healthcircumstances outside the provider's
control result in any of the exceptions set forth in this rule
. The provider shall maintain written documentation that
includes the date, the time (if available), the content of the communication,
the contact name, and the contact information (e.g., telephone number, fax
number, email address, or mailing address).
(A) Requirements of paragraphs (D)(2) of rule
5101:3-12-01
5160-12-01 and (C
E )(2) of rule
5101:3-12-02
5160-12-02 of the Administrative Code
do
are not
have to be met if either paragraph (A)(1), (A)(2), or (A)(3) of this
rule
due to any of the following
applies:
(1)
Services are not identified on the all services plan when the
consumer
individual is enrolled in
on an
ODJFS
Ohio
department of medicaid (ODM) -administered waiver, and the provider has
documented attempts to work with the case manager and the case manager's
supervisors to identify the services on the all services plan. Documentation
shall include written proof of the provider's attempts to obtain the all
services plan that identifies the services. This exception does not extend to
instances in which the provider disagrees with the amounts of service
identified on the all services plan.
(2) Services are not documented on the
services
service plan or individual
service plan when the consumer
individual is enrolled in
on an
Ohio department of aging ( ODA)
- or
ODMR/DD
department
of developmental disabilities (DODD) -administered waiver, and the
provider has documented attempts to work with the case manager and the case
manager's supervisors to identify the services on the
services
service plan. Documentation shall include written
proof of the provider's attempts to obtain the services
service plan
that identifies the services. This exception does not extend to instances in
which the provider disagrees with the amounts of service identified on the
services
service plan.
(3) The provider verified and documented
before providing services that either:
paragraph (A)(3)(a) or (A)(3)(b) of this rule
applies.
(a) The
consumer
individual was not enrolled in
on a home and
community-based services (HCBS) waiver at the initiation of services and every
six months thereafter.
,
And
and the case manager cannot produce documentation
that the provider was notified that the consumer
individual had become enrolled
in
on an HCBS
waiver.
;
or
(b) The
consumer
individual was not enrolled in
on
an
a
HBCS
HCBS
waiver and subsequently, at any point during, the delivery of services, the provider became
aware of the consumer's
individual's enrollment and the provider notified
the case manager and requested that the services be identified on the plan. And
the case manager cannot produce documentation that the provider was notified
that the consumer
individual had become enrolled
in
on
an
a HCBS
waiver.
(B)
Requirements of paragraphs (F
H ) of rule 5101:3-12-05
5160-12-05 and (F
H ) of rule
5101:3-12-06
5160-12-06 of the Administrative Code
do
are not
have to be met if either paragraph (B)(1) or (B)(2) of this rule
due to either of the following
applies.
:
(1) The provider has written documentation
from a facility/home (i.e., an adult foster home, adult family home, adult
group home, residential care facility, community
alternative home, or other facility) stating that the facility/home is
not responsible for providing the same or similar home health or PDN services
to the consumer
individual; or
.
(2)
Home health and/or PDN services provided to the consumer
individual
enrolled in
on the assisted living HCBS waiver in accordance with
rule 5101:3-1-06
5160-1-06 and Chapter 173-39 of the Administrative
Code do not constitute a duplication of services.
(C)
For services to
be reimbursed by Ohio medicaid or its designee, the provider shall document all
efforts to meet the requirements set forth in Chapter 5160-12 of the
Administrative Code which includes maintaining a written record of the
provider's effort to obtain missing information from case managers and other
service related professionals. Provider documentation must include the date and
time of each contact and attempted contact, contact's information (i.e.,
contact's title, telephone number, fax number, email address, and/or mailing
address), and the nature of the provider's communication with the
contact.
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162..03, 5164.02, 5164.77
Prior Effective Dates: 08/02/2007
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