Current through all regulations passed and filed through September 16, 2024
This rule sets forth eligibility
requirements for practitioners, group practices, or organizational providers
enrolling with, and seeking reimbursement from, the Ohio medicaid
program.
(A)
Eligible provider means any practitioner, group
practice, or organization identified by the Ohio department of medicaid (ODM)
as a type of provider eligible to enroll in the medicaid program that:
(1)
Meets the
applicable provider requirements and standards in agency 5160 of the
Administrative Code that address applicable service categories and provider
types covered under the Ohio medicaid program;
(2)
Meets additional
requirements and standards set forth in this rule;
(3)
Meets provider
screening requirements and, when applicable, pays the fee for enrollment as a
provider in the medicaid program in accordance with rule
5160-1-17.8 of the
Administrative Code; and
(4)
Is approved for participation in the medicaid program
by ODM as evidenced by the issuance of both a signed "provider agreement" and
an Ohio medicaid provider number.
(B)
Eligible
practitioners licensed by an Ohio licensing board may enroll as a medicaid
provider in accordance with their active licensure and scope of practice as
determined by the licensing entity.
(C)
A provider can be
assigned a professional group provider type when organized for the purpose of
providing professional services under Chapter 4715., 4723, 4725., 4730., 4731.,
4732., 4734., 4753., 4755., 4757., 4759., or 4762. of the Revised Code, and
meets the requirements in either paragraph (C)(1) or (C)(2) of this rule, and
meets the additional requirements set forth in paragraphs (C)(3) to (C)(5) of
this rule.
(1)
A professional practice that is owned by an individual may
be enrolled as a professional group practice if the practice is formed as an
organizational structure listed in paragraph (C)(3) of this rule, and the owner
or member of the practice possesses a valid license, certificate, or other
legal authorization issued under Chapter 4715., 4723, 4725.,4730., 4731.,
4732., 4734., 4753., 4755., 4757., 4759., or 4762. of the Revised Code, and
also meets the requirements found in paragraph (A)(1) of this rule.
A provider enrolling with the medicaid
program that does not meet the provisions listed in paragraph (C) of this rule
may only be enrolled as an individual provider.
(2)
Any group of two
or more individuals may be enrolled as a professional group practice if the
practice is formed as an organizational structure listed in paragraph (C)(3) of
this rule. ODM recognizes two types of professional group practices, a
professional medical group and a professional dental group.
(a)
A professional
medical group is a group that consists of individual practitioners recognized
by ODM as eligible members. These eligible members include but are not limited
to: physicians, osteopaths, advanced practice nurses, physician assistants,
psychologists, podiatrists, optometrists, chiropractors, licensed independent
social workers, licensed professional clinical counselors, independent marriage
and family counselors, licensed independent chemical dependency counselors,
occupational therapists, physical therapists, speech therapists,
acupuncturists, audiologists, opticians, ocularists, licensed dietitians and
registered dietitian nutritionists. With the exception of an incorporated
individual in accordance with paragraph (C)(3)(b) of this rule, the
professional medical practice must consist of two or more members, of like or
different scopes of practice or licensure.
(b)
A professional
dental group is a group that consists only of dentists. With the exception of
an incorporated individual in accordance with paragraph (C)(3)(b) of this rule,
the practice must consist of two or more dentists.
(c)
An out of state
professional medical group must abide by the requirements stated in rule
5160-1-11 of the Administrative
Code.
(3)
For the purposes of the Ohio medicaid program, a
professional group practice may be organized in accordance with one of the
following organization structures:
(a)
A corporation formed under Chapter 1701. of the Revised
Code.
(b)
A limited liability company formed under Chapter 1705.
of the Revised
Code.
(c)
A non-profit
corporation formed under Chapter 1702. of the Revised Code.
(d)
A professional
association formed under Chapter 1785. of the Revised Code.
(e)
A partnership
formed under Chapters 1776. and 1782. of the Revised Code.
(4)
With
the exception of hospitals, long term care facilities, home health agencies,
hospice programs, and intermediate care facilities, each practitioner employed
by or under contract with a group practice or an organization, including, but
not limited to professional group practices, clinics, federally qualified
health centers, and behavioral health facilities, who also meet the respective
requirements in paragraph (A) of the rule, must have an approved individual
provider agreement with ODM.
(5)
Each
practitioner, employed or under contract with a group practice or an
organization that is actively enrolled as a provider in the Ohio medicaid
program, shall affiliate themselves with their respective group practices or
organizational providers when applying for a provider agreement with ODM.
(D)
Requirements for obtaining and using national provider
identifiers (NPI).
(1)
For the purposes of receiving reimbursement for
services rendered to medicaid recipients, ODM shall require providers and
practitioners enrolling in the medicaid program to obtain a
NPI.
(2)
Providers, and practitioners, whether practicing
independently or employed or under contract with a group practice or
organization, who are identified by the american medical association's national
uniform claim committee with a provider taxonomy number shall obtain a NPI and
shall divulge the NPI to ODM upon enrollment.
(3)
The name and NPI
of the practitioner who furnishes services to medicaid recipients shall be on
claims submitted to ODM for reimbursement. Claims submitted without a NPI will
be denied.
(4)
An organization with components or subparts is
responsible for determining if any components or subpart of its organization
require a separate NPI and, if so, shall obtain it for that component or
subpart.
(E)
As part of the initial medicaid provider application,
an applicant shall include a list of all geographical locations at which it
renders services under its NPI. An existing provider shall submit to ODM any
additions or deletions to the list of locations within thirty calendar days of
the change. An enrolled provider must also notify ODM of any provider
affiliation additions or deletions within thirty days of the change. Failure to
follow the requirements of this paragraph may prevent an applicant from being
enrolled as a medicaid provider or if enrolled, may result in the termination
of a provider agreement as provided for in rule
5160-1-17.6 of the
Administrative Code.
(F)
ODM does not enroll providers located outside of the
United States and its territories.
Replaces: 5160-1-17
