Ohio Admin. Code 5160-4-04 - Services provided by an advanced practice registered nurse (APRN)

(A) Definition. "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. The term encompasses a certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nursemidwife (CNM), and certified nurse practitioner (CNP).

(B) Coverage.

(1) Unless a specific exception is noted, all other rules in agency 5160 of the Administrative Code that pertain to services rendered by a physician apply also to services rendered by an APRN.

(2) Payment may be made for For a covered service rendered by an APRN, payment may be made only if the following conditions are met:

(a) The APRN is currently enrolled as an Ohio medicaid provider;

(b)(a) The service is rendered to a an Ohio-medicaid-eligible Ohio recipient individual in a state in which the APRN is licensed or authorized to practice;

(c)(b) The service is within the scope of practice of the APRN's specialty;

(d)(c) The APRN personally rendered the service to an individual patient; and

(e)(d) The service cannot be performed by someone who lacks the skills and training of an APRN.

(3) An APRN employed by or under contract with a physician, group practice, hospital, long-term care facility, or other medicaid provider must not submit a claim for service that would result in duplicate payment.

(C) Claim payment Payment.

(1) Payment for a covered service rendered by a CRNA is made in accordance with rule 5160-4-21 of the Administrative Code.

(2) Payment for a covered service rendered by a CNS, CNM, or CNP is the lesser of the billing provider's submitted charge or the applicable amount from the following list:

(a) For a covered service rendered in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), eighty-five per cent of the medicaid maximum;

(b) For a covered service rendered in a non-hospital setting, one hundred per cent of the medicaid maximum; or

(c) For assistant-at-surgery services provided by a CNS, CNM, or CNP regardless of setting, twenty-five per cent of the medicaid maximum for the covered primary surgical procedure.

(3) Payment for services rendered by a hospital-employed APRN will be made to the hospital.

(4) In the event that payment for a covered service performed by an APRN is issued both to the APRN and to a contracting or supervising provider on behalf of the APRN, one of the issued payments is subject to recovery.

Notes

Ohio Admin. Code 5160-4-04

Effective: 1/1/2022
Five Year Review (FYR) Dates: 10/1/2021 and 01/01/2027
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/24/1983, 04/01/1988, 05/15/1989, 03/01/1994 (Emer.), 05/12/1994, 05/01/1997, 06/01/2002, 01/01/2008, 01/01/2017, 04/01/2018