Current through all regulations passed and filed through September 16, 2024
(A)
Definitions for
purposes of this rule only:
(1)
A "participating provider" is an active provider who
bills the medicaid program for rendered services, or who is an active provider
who orders, prescribes, refers, or certifies but does not bill the medicaid
program.
(2)
An "ordering or referring only provider" is a provider
who orders, prescribes, refers, or certifies an item or service reported on a
claim, and is not a billing provider in the medicaid program. For example: a
provider orders items or services for the medicaid consumer, such as
prescription drugs, durable medical equipment, prosthetics, orthotics, and
supplies, clinical laboratory services, or imaging services, and may certify
home health services for a medicaid consumer.
(3)
"Physician" or
"supervising physician" means an individual authorized to practice medicine in
Ohio or another state.
(4)
"Other professional" means those providers, other than
physicians, who order, prescribe, refer, or certify an item or service reported
on a claim. Examples include but are not limited to: physician assistant,
clinical nurse specialist, nurse practitioner, clinical psychologist, certified
nurse midwife, clinical social worker, and interns, residents, and
fellows.
(B)
A physician or other professional who is an ordering
or referring only provider of medicaid services must be enrolled as a
participating provider with the medicaid program.
(C)
An ordering or
referring only provider shall be considered limited risk for purposes of
screening, as defined in rule 5101:3-1-17.8 of the Administrative
Code.
(D)
Ordering and referring only providers who are enrolled
with the office shall revalidate in accordance with rule 5101:3-1-17.4 of the
Administrative Code.
(E)
Claims for services that require an order,
prescription, referral, or certification will be denied if they do not include
the following:
(1)
A valid national provider identifier (NPI) and the
legal name of the ordering, prescribing, referring, or certifying provider;
or,
(2)
If the ordering, prescribing, referring, or certifying
provider is not a provider type eligible to participate in Ohio medicaid, a
valid NPI and the legal name of the physician or other professional supervising
the ordering or referring provider.
(F)
This rule does
not apply to services delivered through medicaid managed care
plans.
