Ohio Admin. Code 5160-3-39.1 - Nursing facilities (NFs): claim submission

(A) Nursing facilities shall submit claims in accordance with rule 5160-1-19 of the Administrative Code. Additional requirements specific to the submission of long-term care per diem claims are in paragraphs (B) to (E) of this rule.

(B) Additional requirements to be met prior to submitting claims for services included in the per diem.

(1) Individual is a medicaid recipient for the dates of service.

(2) Individual is not in a restricted medicaid coverage period (RMCP).

(3) Preadmission screening and resident review (PASRR) is completed in accordance with rules 5160-3-15, 5160-3-15.1 and 5160-3-15.2 of the Administrative Code.

(4) NF-based level of care is completed in accordance with rules 5160-3-05, 5160-3-06, 5160-3-08, and 5160-3-14 of the Administrative Code.

(C) Per diem claims must be submitted as one claim per calendar month which includes all dates for which a medicaid individual is considered a resident. All dates within the monthly claim are to be identified as those eligible for medicaid reimbursement, per rule 5160-3-16.4 of the Administrative Code, or billed as non-covered days. Any claim for less than the full month is limited to admission, discharge, death, changes in payer, and hospice enrollment that occurs during the month.

(D) If a medicaid recipient in the NF has a patient liability (PL) obligation as determined by the Ohio department of medicaid or its designee, the amount of PL in accordance with rule 5160:1-6-07 of the Administrative Code, is to be reported by the NF on the recipient's monthly claim. The PL will be applied as an offset against the amount medicaid would otherwise reimburse for the claim. If the PL exceeds the amount medicaid would reimburse, the claim will be processed with a payment of zero dollars.

(E) If an individual receives a lump-sum and the county department of job and family services (CDJFS) and recipient determine that the lump-sum is to be applied to past medicaid payments, the NF provider must submit adjustment claims for as many prior months as are necessary to fully offset the amount of the lump-sum.

Replaces: 5160-3-28 and 5160-3-39.1

Notes

Ohio Admin. Code 5160-3-39.1

Effective: 2/1/2023
Five Year Review (FYR) Dates: 02/01/2028
Promulgated Under: 119.03
Statutory Authority: 5165.02
Rule Amplifies: 5165.47
Prior Effective Dates: 07/01/2005, 03/22/2015