Ohio Admin. Code 5160-18-01 - Freestanding birth center services
(A)
Definitions.
(1)
"Freestanding birth center (FBC)" has the same meaning
as in
42
U.S.C. 1396d(l) (3)(B)
(October 1, 2016).
(2)
"Independent practitioner" and "non-independent
practitioner" have the same meaning as in rule
5160-4-02
of the Administrative Code.
(3)
"Low-risk
expectant mother" has the same meaning as in rule
3701-83-33
of the Administrative Code.
(B)
Provider
requirements. Payment may be made to a FBC only if it meets the following
criteria:
(1)
It holds a current license to perform FBC services issued by the appropriate
authority in the state in which it is located;
(2)
It is operated in
conformity with rules
3701-83-33
to
3701-83-42
of the Administrative Code; and
(3)
It is neither a
hospital registered under section
3701.07 of the Revised Code nor
an entity that is reviewed as part of a hospital accreditation or certification
program.
(C)
Coverage.
(1)
Facility services. Payment may be made to a FBC either
for covered global obstetrical care (i.e., a bundled combination of antepartum,
delivery, and postpartum services) or for covered discrete antepartum,
delivery, and postpartum services, but not for both.
(2)
Professional
services. Separate payment may be made to an independent practitioner, or to a
FBC on behalf of either an independent practitioner or a non-independent
practitioner, for the performance of the following services:
(a)
Covered global
obstetrical care or covered discrete antepartum, delivery, and postpartum
services, but not both;
(b)
Care of the newborn provided in accordance with rule
3701-83-36
of the Administrative Code;
(c)
A covered
medicine, radiology, clinical laboratory, or evaluation and management
(E&M) service or the administration of a pharmaceutical; or
(d)
The professional
component of a covered service comprising both professional and technical
components.
(D)
Limitations.
(1)
Payment may be made for an antepartum, delivery, or
postpartum service only if it meets the following criteria:
(a)
It is provided to
a low-risk expectant mother;
(b)
It is covered in
accordance with agency 5160 of the Administrative Code;
and
(c)
It is provided in
accordance with rules
3701-83-34
to
3701-83-37
of the Administrative Code.
(2)
Payment will not
be made for a service that is outside a practitioner's scope of
practice.
(3)
Payment will not be made to a FBC (as the rendering
provider) for performing the professional component alone of a covered
service.
(4)
A practitioner and a FBC must not submit a claim for
service that would result in duplicate payment.
(E)
Claim payment.
Payment for a covered item or service in the following list is the lesser of
the submitted charge or the maximum amount established in accordance with the
indicated paragraph of the Administrative Code:
(1)
Laboratory
service - rule
5160-11-09;
(2)
Medical service
or procedure - Chapter 5160-4 of the Administrative Code for which maximum
payment amounts are published in appendix DD to rule
5160-1-60 of the
Administrative Code and coverage and payment policy is set forth in the
following rules of the Administrative Code:
(a)
Physician service
- rule
5160-4-01;
(b)
Physician
assistant (PA) service - rule
5160-4-03;
(c)
Advanced practice
registered nurse (APRN) service - rule
5160-4-04;
(d)
Evaluation and
management (E&M) service - rule
5160-4-06;
(e)
Surgical service
- rule
5160-4-22;
or
(f)
Radiology or imaging service - rule
5160-4-25;
(3)
Immunization, injection or infusion (including trigger-point
injection), skin substitute, or provider-administered pharmaceutical - rule
5160-4-12
of the Administrative Code; or
(4)
Medical supply
item - rule
5160-10-03
of the Administrative Code.
Replaces: 5160-18-01, 5160-4-36
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02, 5164.70
Prior Effective Dates: 01/01/2012
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