Current through all regulations passed and filed through September 16, 2024
(A)
Unless otherwise
directed by the Ohio department of medicaid (ODM), paper claims will not be
accepted. Except as otherwise provided in section
5164.46 of the Revised Code or a
state agency's interagency agreement, claims are to be submitted directly to
ODM through one of the following formats:
(1)
Electronic data
interchange (EDI), in accordance with rule
5160-1-20 of the Administrative
Code.
(2)
The ODM provider web portal; or
(3)
Pharmacy
point-of-sale.
(B)
Claims should be submitted pursuant to the national
correct coding initiative and according to the coding standards set forth in
the following guides:
(1)
The healthcare common procedure coding
system;
(2)
The current procedural terminology
codebook;
(3)
The current dental terminology codebook;
or
(4)
The international classification of diseases
handbooks.
(C)
Claims for items and services that necessitate a
rendering or supervising provider, order, prescription, referral, or
certification will be denied if:
(1)
They do not include the national provider identifier
(NPI) and the legal name of the rendering, supervising, ordering, prescribing,
referring, or certifying provider; and
(2)
The provider does
not have an active medicaid provider agreement.
(D)
Timely
filing:
(1)
Claims are timely if received by ODM within:
(a)
Three hundred
sixty-five days of the actual date the service was provided.
(b)
Three hundred
sixty-five days from the date of discharge for inpatient hospital
claims.
(c)
Three hundred sixty-five days from the date of service
or inpatient hospital discharge, as applicable, for denied claims that are
re-submitted for payment.
(2)
Provider-reported
underpaid claims should be adjusted within three hundred sixty-five days from
the date of service or inpatient hospital discharge, as
applicable.
(E)
Exceptions to timely filing are:
(1)
Claims submitted
via the "automatic medicare crossover process" (the automatic process of
medicare electronically submitting a claim to ODM following medicare
adjudication and payment of a claim for a dually eligible individual) are not
subject to timely filing provisions in this rule.
(2)
Claims for
wraparound payment for a federally qualified health center (FQHC) or rural
health center (RHC) are timely if submitted to ODM within one hundred eighty
days from the date the claim was paid.
(3)
Claims submitted
to ODM after three hundred sixty-five days of the date of service or discharge,
as applicable, due to a delay in eligibility determination or a state hearing
decision regarding eligibility are timely if received by ODM within one hundred
eighty days of the notice of eligibility determination or state hearing
decision to be considered for payment.
(4)
Claims submitted
to ODM after three hundred sixty-five days of the date of service or discharge,
as applicable, due to a reversal of payment by a third party payer are timely
if the adjusted claim is received within one hundred eighty days of the
recovery of funds to be considered for payment.
(5)
Any claim delayed
in submission to, or adjudicated by ODM, due to an action or decision by ODM,
at the discretion of ODM, may be reimbursed after three hundred sixty-five days
from the date of service or inpatient hospital
discharge.
(F)
In instances of conflict of claim payment between two
providers, ODM may adjust or void a claim as appropriate after notification to
the providers.
(G)
Overpaid claims.
(1)
When a provider
identifies an overpayment, the provider will submit an electronic adjustment to
ODM within sixty days of discovery to return the overpayment.
(2)
When ODM
identifies an overpayment, ODM will notify the provider of the overpayment. The
provider has sixty days to correct the overpayment. If the provider fails to
correct an identified overpayment within sixty days, ODM will make the
adjustment from subsequent payments to the provider or void the claim as
appropriate. If an ODM adjustment is not possible, ODM will issue an invoice to
the provider for the overpaid amount. The provider has sixty days from the date
of the invoice to seek reconsideration or remit payment to ODM.
If the provider fails to remit the full
payment due the unpaid balance will be certified to the Ohio attorney general
for collection.
(3)
ODM will pursue collections by invoice for overpayments
that result in a credit balance owed to ODM that remain outstanding for more
than forty-five days.
(4)
Appeal rights may be exercised in accordance with
Chapter 5160-70 of the Administrative Code. All ODM recoverable amounts are
subject to the application of interest in accordance with rule
5160-1-25 of the Administrative
Code.
(H)
ODM forms that are necessary for a claim to be
processed should only be submitted through the ODM provider web portal unless
otherwise permitted by ODM.
(I)
Claim adjustments
should only be submitted through EDI or the ODM provider web
portal.
(J)
ODM will only process refund checks from providers for
an invoice for a claim overpayment, a letter of collection of an outstanding
overpayment, audit, or review, or other circumstance deemed appropriate by
ODM.
Replaces: 5160-1-19
