Current through all regulations passed and filed through September 16, 2024
(A)
Reimbursement for
certain items or services covered under the medicaid program is dependent on
obtaining prior authorization from the Ohio department of medicaid (ODM), its
designee, or a medicaid managed care entity (MCE). Prior authorization requests
have to be approved by ODM, its designee, or MCE before the services are
rendered or the items are delivered unless the services or items meet the
provisions stated in section
5160.34 of the Revised Code or
paragraph (D) of this rule.
(B)
Except as
authorized under section
5160.34 of the Revised Code,
prior authorization requests submitted via paper cannot be processed. All other
prior authorization requests should be submitted pursuant to the instructions
located at
www.medicaid.ohio.gov.
(C)
For services or items requiring prior authorization,
only those approved in the prior authorization determination will be eligible
for reimbursement.
(D)
The following exceptions to prior authorization
apply:
(1)
In
situations where the provider considers a delay in providing services or an
item requiring prior authorization to be detrimental to the health of the
medicaid recipient, the services or item may be rendered or delivered and
approval for reimbursement sought after the fact.
(2)
In cases of
emergency, for prescribed drugs requiring prior authorization, the prescribed
drug may be rendered without prior authorization in accordance with rule
5160-9-03 of the Administrative
Code.
(3)
In the discretion of and as instructed by ODM, a
retroactive prior authorization may be sought.
(E)
A medicaid
provider may request a reconsideration of an adverse prior authorization
determination in accordance with section
5160.34 of the Revised Code. A
reconsideration of an adverse prior authorization determination rendered by an
MCE or transplant consortium should be submitted and addressed in accordance
with their respective processes for reconsideration. A reconsideration of an
adverse prior authorization determination rendered by ODM or its designee
should be submitted and addressed in the following manner:
(1)
The request for
reconsideration has to be received by ODM or its designee within sixty calendar
days of the notification to the provider of an adverse determination. A valid
request for reconsideration should be submitted pursuant to the instructions
located at
www.medicaid.ohio.gov
and include the following:
(a)
Medicaid
recipient's name and medicaid number;
(b)
Name of requested
service or item and billing code;
(c)
Date of service
or item request;
(d)
Clinical documentation supporting medical necessity for
the service or item;
(e)
A reference to any relevant federal or state law or
regulation, if applicable;
(f)
An explanation
outlining the reason for reconsideration, including supportive information not
previously submitted as necessary; and
(g)
If applicable, an
indication of whether the service or item qualifies as "urgent care services"
as defined in section
5160.34 of the Revised
Code.
(2)
ODM or its designee will make a standard
reconsideration determination within ten calendar days of receipt. If an
expedited review is requested because the service or item qualifies as urgent
care services, the reconsideration determination will be made no later than
forty-eight hours after receipt.
(3)
The review of the
reconsideration will be conducted by a clinical peer appointed or contracted by
ODM or its designee.
(4)
The provider reconsideration process afforded under
this rule does not interfere with the medicaid recipient's right to appeal in
accordance with division 5101:6 of the Administrative Code.
Replaces: 5160-1-31
