Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-1 - General Provisions
Section 5160-1-11 - Out-of-state coverage
Universal Citation: OH Admin Code 5160-1-11
Current through all regulations passed and filed through September 16, 2024
(A) Out-of-state providers:
(1)
Should be licensed, accredited, or certified by their
respective states to be considered eligible to receive reimbursement for
services provided to Ohio medicaid covered individuals.
(2)
Should meet any
standards applicable to the provision of the service in the state in which the
service is being furnished, as well as those standards set forth in the Ohio
medicaid program and in the Administrative Code.
(3)
Except as
provided in paragraph (A)(4) of this rule, need to enroll as Ohio medicaid
providers in order to obtain payment and follow appropriate billing procedures
in accordance with Chapter 5160-1 of the Administrative Code and Chapter 5160-3
of the Administrative Code for long term care nursing facility
services.
(4)
Who are rendering services to medicaid covered
individuals enrolled in a managed care plan (MCP) are not required to enroll
with the Ohio department of medicaid (ODM) when:
(a)
The out-of-state
provider is not in the MCP's network and is providing services under a single
case agreement; or
(b)
The out-of-state provider is a pharmacy that is
in-network with the MCP under a national contract.
(5)
May have their
out-of-state provider's enrollment application denied by ODM based on the
denial, censure or revocation of their professional license by the applicable
licensing board of any other state, or if the applicable licensing board in
Ohio denies, censures or revokes a professional license even if another state's
licensing board approves the respective provider.
(B) Ohio medicaid covered services will be reimbursed when rendered by out-of-state providers only under the following circumstances:
(1)
The medically
necessary services are not available within the state of Ohio, and the use of
out-of-state providers to perform the services is authorized by the department
or its designee, or authorized in accordance with rule
5160-1-31 of the Administrative
Code; or
(2)
The medical need arose as a result of an emergency, an
accident, or an illness which occurred during a period of time the medicaid
covered individual was temporarily absent from Ohio; or
(3)
The individual's
health would have been endangered if care was postponed until the individual
returned to Ohio or attempted to return to Ohio; or
(4)
The provider
location for the medically necessary service is in a bordering state of Ohio,
and it is the usual practice of residents in that community to utilize
out-of-state providers, so long as the cost of the service does not exceed the
cost of the service if provided by in-state providers; or
(5)
The state
determines on the basis of medical advice, that the needed medical services or
necessary supplementary resources are more readily available in another
state.
Replaces: 5160-1-11
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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