Current through all regulations passed and filed through September 16, 2024
(A)
In accordance
with
42 C.F.R.
447.15 (as in effect October 1, 2018), the
medicaid payment for a covered service constitutes payment-in-full. It shall
not be construed as a partial payment even when the payment amount is less than
the provider's charge.
(1)
The provider shall not collect nor bill a medicaid
recipient for any difference between the medicaid payment and the provider's
charge, nor shall the provider ask a medicaid recipient to share in the cost
through a deductible, coinsurance, co-payment, missed appointment fee or other
similar charge, other than medicaid co-payments as defined in rule
5160-1-09 of the Administrative
Code and patient liability as described in Chapter 5160-3 and rule
5160:1-6-07 of the
Administrative Code.
(2)
The provider shall not charge a medicaid recipient a
down payment, refundable or otherwise.
(3)
Should the
individual become eligible for medicaid after the date of service and the
eligibility span includes the date of service, the individual may not be
financially responsible.
(B)
A medicaid
recipient cannot be billed when a medicaid claim has been denied for any of the
following reasons:
(1)
Unacceptable or untimely submission of a
claim;
(2)
Failure to request a prior authorization;
or
(3)
A retroactive finding by a peer review organization
(PRO) that a rendered service was not medically necessary.
(C)
A
provider may bill a medicaid recipient for a medicaid covered service in lieu
of submitting a claim to the Ohio department of medicaid (ODM) only if all of
the following conditions are met:
(1)
The provider explains to the medicaid recipient that
the service is a covered medicaid service and other medicaid providers may
render the service at no cost to the individual;
(2)
Prior to each
date of service for the specific service rendered, the provider notifies the
medicaid recipient in writing that the provider will not submit a claim to ODM
for the service;
(3)
The medicaid recipient agrees to be liable for payment
of the service and signs a written statement to that effect before the service
is rendered; and
(4)
The medicaid covered service is not a prescription for
a controlled substance as defined in section
3719.01 of the Revised
Code.
(D)
Services that are not covered by the medicaid program,
including services requiring prior authorization that have been denied by ODM,
may be billed to a medicaid recipient when the conditions in paragraphs (C)(2)
to (C)(4) of this rule are met.
(E)
Any individual
not covered by medicaid on the date of service is financially responsible for
those services unless the individual qualifies for the hospital care assurance
program (HCAP) in accordance with section
5168.14 of the Revised
Code.
Replaces: 5160-1- 13.1
