all-inclusive per-visit payment amount (PVPA) is established for each FQHC PPS
service provided at an FQHC or related off-site location and for an RHC PPS
service provided at an RHC or related off-site location.
For all FQHC or
RHC sites that are already enrolled as medicaid providers, ODM establishes new
PVPAs equal to the current PVPAs revised to reflect the latest available
medicare economic index (MEI) percentage. The new PVPAs are established by
October first of each year and are in effect from October first through the
following September thirtieth.
When an enrolled
FQHC or RHC site requests adjustment of a PVPA, ODM may establish a new PVPA
based on a cost report in accordance with rule
of the Administrative Code.
For an FQHC or
RHC site that is enrolling as a new medicaid provider or an FQHC site that is
adding a new FQHC PPS service, ODM establishes an initial PVPA in accordance
with the following procedure:
First, the initial PVPA is set equal to the
corresponding PVPA of other FQHC or RHC sites in the immediate area that are
similar in size, caseload, and scope of services. If no such FQHC or RHC site
exists, then the initial PVPA is set equal to the current PVPA at the
applicable statewide sixtieth percentile for the appropriate FQHC or RHC
classification (FQHC or RHC).
This initial PVPA
remains in effect until a new PVPA is established.
After the initial
PVPA is set, the FQHC or RHC site submits a cost report in accordance with rule
of the Administrative Code. A new PVPA is established on the basis of the cost
report and is revised to reflect any changes in the MEI that have occurred
since the cost report was submitted.
PVPA is revised in accordance with paragraph (A)(1) of this
For an FQHC PPS service only, if no current PVPA at the
applicable statewide sixtieth percentile is available, then the initial PVPA,
P, is obtained by the formula P = M × (S / E), rounded up to the next
M is the greater of two figures:
The current PVPA
for medical services at the applicable statewide sixtieth percentile for FQHC
The current PVPA for medical services at the particular
S is the medicaid maximum payment amount (or the median
of the medicaid maximum payment amounts) for a procedure (or a group of
procedures) typical of the service for which a PVPA is being
E is the medicaid maximum non-facility payment amount
for a midlevel evaluation and management service (office visit) for an
A PVPA based on a
cost report is effective from the first day of the first full calendar month
after ODM has established or adjusted the PVPA through the following September
thirtieth. A PVPA that is established or adjusted before September thirtieth
and becomes effective on or after October first is then further revised to
reflect the applicable MEI. No retroactive establishment or adjustment will be
made for a PVPA.
A PVPA is specific to an FQHC or RHC site. No FQHC or
RHC site may submit claims based on the PVPAs of another FQHC or RHC
Decisions of ODM with respect to the establishment or
adjustment of a PVPA are not subject to Chapter 119. of the Revised Code.
Replaces: 5160-28- 05.1, 5160-28- 05.3
Ohio Admin. Code
Five Year Review (FYR) Dates:
Prior Effective Dates: 10/25/2001, 07/01/2006,