Ohio Admin. Code 5160-26-11 - Managed care: non-contracting providers

(A) For the purposes of this rule, the following terms are defined as follows:

(1) "Managed care plan (MCP) non-contracting provider" means any provider with an Ohio department of medicaid (ODM) provider agreement who does not contract with the MCP but delivers health care services to that MCP's members, as described in paragraphs (C) and (D) of this rule.

(2) "MCP non-contracting provider of emergency services" means any person, institution, or entity that does not contract with the MCP but provides emergency services to an MCP member, regardless of whether that provider has an ODM provider agreement.

(B)(A) MCP non Non-contracting providers of emergency services must accept as payment in full from the a MCP managed care organization (MCO) the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of service. Pursuant to section 5167.10 5167.101 of the Revised Code, the MCP MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM.
(C)(B) When ODM has approved an MCP's the MCO's members to be referred to an MCP a non-contracting hospital pursuant to rule 5160-26-03 of the Administrative Code, the MCP non-contracting hospital must provide the service for which the referral was authorized and must accept as payment in full from the MCP MCO one hundred per cent of the current Ohio medicaid program reimbursement rate in effect for the date of service. Pursuant to section 5167.10 5167.101 of the Revised Code, the MCP MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM. MCP non Non-contracting hospitals are exempted from this provision when:
(1) The hospital is located in a county in which eligible individuals were required to enroll in an MCP MCO prior to January 1, 2006;
(2) The hospital is contracted with at least one MCP MCO serving the eligible individuals specified in paragraph (C) (B)(1) of this rule prior to January 1, 2006; and
(3) The hospital remains contracted with at least one MCP MCO serving eligible individuals who are required to enroll in an MCP MCO in the service area where the hospital is located.
(D)(C) MCP non Non-contracting qualified family planning providers (QFPPs) must accept as payment in full from the MCP MCO the lesser of one hundred per cent of the Ohio medicaid program reimbursement rate or billed charges, in effect for the date of service.
(E)(D) An MCP A managed care entity (MCE) non-contracting provider may not bill An MCP the MCE member unless: all of the following conditions are met:
(1) The conditions described in rule 5160-1-13.1 of the Administrative Code are met; and

(1) The member was notified by the provider of the financial liability in advance of service delivery.

(2) The notification by the provider was in writing, specific to the service being rendered, and clearly states that the recipient is financially responsible for the specific service. A general patient liability statement signed by all patients is not sufficient for this purpose.

(3) The notification is dated and signed by the member.

(4)(2) The reason the service is not covered by the MCP MCE is specified and is one of the following:
(a) The service is a benefit exclusion;
(b) The provider is not contracted with the MCP MCE and the MCP MCE has denied approval for the provider to provide the service because the service is available from a contracted provider, at no cost to the member; or
(c) The provider is not contracted with the MCP MCE and has not requested approval to provide the service.
(F)(E) An MCP An MCE non-contracting provider may not bill an MCP a member for a missed appointment.
(G)(F) MCP non Non-contracting providers, including MCP non-contracting providers of emergency services, must contact the twenty-four hour post-stabilization services phone line designated by the MCP MCO to request authorization to provide post-stabilization services in accordance with rule 5160-26-03 of the Administrative Code.
(H)(G) MCP non Non-contracting providers, including MCP non-contracting providers of emergency services, must allow the MCP MCE, ODM, and ODM's designee access to all member medical records for a period not less than ten years from the date of service or until any audit initiated within the ten year period is completed. Access must include copies of the medical records at no cost for the purpose of activities related to the annual external quality review specified by 42.C.F.R. 42 C.F.R.438.358 (October 1, 2017 2021).
(I)(H) When an MCP If the MCE elects to impose member co-payments in accordance with rule 5160-26-12 of the Administrative Code, applicable co-payments shall also apply to services rendered by MCP non-contracting providers. When an MCP If the MCE has not elected to impose co-payments in accordance with rule 5160-26-12 of the Administrative Code, MCP non-contracting providers are not permitted to impose co-payments on MCP MCE members.

Notes

Ohio Admin. Code 5160-26-11
Effective: 7/18/2022
Five Year Review (FYR) Dates: 1/1/2023
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.03, 5167.10, 5167.20, 5167.201
Prior Effective Dates: 07/20/2001, 07/01/2003, 01/01/2006, 06/01/2006, 01/01/2007, 01/01/2008, 07/01/2013, 02/01/2015, 01/01/2018

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