Current through all regulations passed and filed through September 16, 2024
This rule describes general principles
regarding reimbursement of services by medicaid. Reimbursement may be subject
to additional administrative criteria as described in agency 5160 of the
Administrative Code.
(A)
A medical service is reimbursable if:
(1)
The service is
determined medically necessary as defined in rule
5160-1-01 of the Administrative
Code.
(2)
The service is agreed to by the medicaid-covered
individual or the medicaid-covered individual's authorized
representative.
(3)
The service is rendered to a medicaid-covered
individual as defined in division 5160:1 of the Administrative
Code.
(4)
The service is provided within the limits of the
medicaid-covered individual's medicaid benefit package.
(5)
The service is
provided within the scope of practice of the rendering provider as defined by
applicable federal, state, and local laws and regulations.
(6)
The service is
rendered by a provider assigned to or selected by the medicaid-covered
individual or medicaid-covered individual's authorized representative, with the
exception of medicaid-covered individuals enrolled in the coordinated services
program as defined in Chapter 5160-20 of the Administrative
Code.
(7)
The service is rendered by an eligible provider or
panel provider for managed care plan participating provider.
(B)
Special conditions regarding medicaid reimbursement.
(1)
If a service is
charged to medicaid at a rate greater than the provider's usual and customary
charge to other patients for comparable services, the provider will be
reimbursed at the provider's usual and customary charge or medicaid permitted
reimbursement rate, whichever is lower.
(2)
Inpatient and
outpatient hospital services billed by hospitals reimbursed on a prospective
payment basis, as defined in Chapter 5160-2 of the Administrative Code, will
not be paid, in the aggregate, more than the provider's customary and
prevailing charges for comparable services.
(3)
Medicaid will not
provide reimbursement for a provider-preventable condition as defined in
42 CFR
447.26 (as in effect on October 1, 2018). The
prohibition on provider-preventable conditions shall not result in a loss of
access to care or services for medicaid-covered individuals.
(C)
Additional reimbursement principles are applicable to the
following:
(1)
Services delivered through the medicaid managed plans as
described in Chapter 5160-26 of the Administrative Code.
(2)
Habilitation
services as defined in
42 USC
1396n(c)(5) (as in effect on
October 1, 2018) and permitted in agency 5160 of the Administrative
Code.
(D)
Commingling is prohibited. For the purposes of this
rule commingling occurs when the sharing of office space, staff (employed or
contracted), supplies, equipment, or other resources with an on-site practice
or provider organization owned or operated by the same provider, physician, or
non-physician practitioners results in one or both of the following:
(1)
Duplicate
medicaid reimbursement for services performed; or
(2)
A provider
selectively choosing a higher reimbursement rate for the services
performed.
Replaces: 5160-1-02
