Current through all regulations passed and filed through September 16, 2024
Home health, RN assessment, RN
consultation, and private duty nursing (PDN) service providers may be
reimbursed when any of the exceptions set forth in this rule
apply through no fault of the provider:
(A) Requirements of paragraphs (D)(2) of rule
5160-12-01 and (E)(2) of rule
5160-12-02 of the Administrative Code
are not
met
due to any of the following:
(1)
Services are not identified on the all services plan when the
individual is enrolled
on an
Ohio
department of medicaid (ODM)-administered waiver, and the provider has
documented attempts to work with the case manager and the case manager's
supervisors to identify the services on the all services plan. Documentation
shall include written proof of the provider's attempts to obtain the all
services plan that identifies the services. This exception does not extend to
instances in which the provider disagrees with the amounts of service
identified on the all services plan.
(2) Services are not documented on the
service plan or individual
service plan when the
individual is enrolled
on an
Ohio department of aging (ODA) or
department
of developmental disabilities (DODD)-administered waiver, and the
provider has documented attempts to work with the case manager and the case
manager's supervisors to identify the services on the
service plan. Documentation shall include written
proof of the provider's attempts to obtain the
service plan
that identifies the services. This exception does not extend to instances in
which the provider disagrees with the amounts of service identified on the
service plan.
(3) The provider verified and documented
before providing services that either:
(a) The
individual was not enrolled
on a home and
community-based services (HCBS) waiver at the initiation of services and every
six months thereafter,
and the case manager cannot produce documentation
that the provider was notified that the individual had become enrolled
on an HCBS
waiver;
or
(b) The
individual was not enrolled
on
a
HCBS
waiver and subsequently, at any point during the delivery of services, the provider became
aware of the
individual's enrollment and the provider notified
the case manager and requested that the services be identified on the plan. And
the case manager cannot produce documentation that the provider was notified
that the individual had become enrolled
on
a HCBS
waiver.
(B)
Requirements of paragraphs (H) of rule
5160-12-05 and (H) of rule
5160-12-06 of the Administrative Code
are not
met
due to either of the following
:
(1) The provider has written documentation
from a facility/home (i.e., an adult foster home, adult family home, adult
group home, residential care facility, or other facility) stating that the facility/home is
not responsible for providing the same or similar home health or PDN services
to the individual; or
(2)
Home health and/or PDN services provided to the
individual
enrolled
on the assisted living HCBS waiver in accordance with
rule 5160-1-06 and Chapter 173-39 of the Administrative
Code do not constitute a duplication of services.
(C)
For services to
be reimbursed by Ohio medicaid or its designee, the provider shall document all
efforts to meet the requirements set forth in Chapter 5160-12 of the
Administrative Code which includes maintaining a written record of the
provider's effort to obtain missing information from case managers and other
service related professionals. Provider documentation must include the date and
time of each contact and attempted contact, contact's information (i.e.,
contact's title, telephone number, fax number, email address, and/or mailing
address), and the nature of the provider's communication with the
contact.
