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


Ohio Admin. Code 5160-28-08.1
Effective: 10/1/2016
Five Year Review (FYR) Dates: 10/01/2021
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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