Ohio Admin. Code 5160-28-08.1 - Cost-based clinics: submission and payment of FQHC claims
(A)
Claims for services provided to managed care plan (MCP)
enrollees, including requests for prior authorization by an MCP of a federally
qualified health center (FQHC) service, must be submitted in accordance with
Chapter 5160-26 of the Administrative Code.
(B)
In claims
submitted to the department for all other services, an FQHC must include the
following data:
(1)
The designated procedure code for an
encounter;
(2)
The appropriate modifier to specify the FQHC service;
and
(3)
Additional codes representing all procedures performed
during the encounter, along with any required modifiers.
(C)
In
claims submitted to the department for supplemental payment for services
provided to an MCP enrollee, an FQHC must also include the following
data:
(1)
The
name of the MCP that paid for the FQHC service;
(2)
The
identification code of the MCP, assigned by the department;
(3)
The MCP payment
plus amounts received from any other third-party payers; and
(4)
Any other
information, such as an adjustment reason code, that is necessary for the
coordination of benefits.
(D)
The department
must pay a valid claim for supplemental payment within four months. However, no
supplemental payment will be made for a claim that is not submitted to the
department within the limits specified in rule
5160-1-19 of the
Administrative Code.
Replaces: Part of 5160-28-07, 5160-28-11
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 08/09/2001, 10/01/2003, 07/01/2006
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