Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-26 - Managed Care Plan
Section 5160-26-05.1 - Managed care: provider services
Universal Citation: OH Admin Code 5160-26-05.1
Current through all regulations passed and filed through September 16, 2024
(A) A managed care entity (MCE) must provide the following written information to their contracting providers:
(1) The
MCE's
grievance, appeal and state fair hearing procedures and time frames, including:
(a) The member's right to file grievances and
appeals and the requirements and time frames for filing;
(b) The
MCE's toll-free
telephone number to file oral grievances and appeals;
(c) The member's right to a state fair
hearing, the requirements and time frames for requesting a hearing, and
representation rules at a hearing;
(d) The availability of assistance from the
MCE in
filing any of these actions;
(e)
The member's right to request continuation of benefits during an appeal or a
state hearing and specification that at the discretion of ODM the member may be
liable for the cost of any such continued benefits; and
(f) The provider's rights to participate in
these processes on behalf of the provider's patients and to challenge the
failure of the
MCE to cover a specific service.
(2) The
MCE's
requirements regarding the submission and processing of prior authorization
requests including:
(a) A list of the
benefits, if any, that require prior authorization approval from the
MCE;
(b)
The process and format to be used in submitting such requests;
(c) The time frames in which the
MCE must
respond to such requests;
(d)
Pursuant to the provisions of paragraph (A)(1) of this rule, how the provider
will be notified of the
MCE's decision regarding such requests;
and
(e) Pursuant to the provisions
of paragraph (A)(1) of this rule, the procedures to be followed in appealing
the
MCE's denial of a prior authorization request.
(3) The
MCE's
documentation, legibility, confidentiality, maintenance, and access standards for member medical records;
including a member's right to amend or correct his or her medical record as
specified in
45 C.F.R.
164.526 (October 1,
2021).
(4) The
MCE's
process and requirements for the submission of claims and the appeal of denied
claims.
(5)
The
MCE's policies and procedures regarding what action
the MCE
may take in response to occurrences of undelivered, inappropriate, or substandard health care services, including the
reporting of serious deficiencies to the appropriate authorities.
(6) The mutually
agreed upon policies and procedures between the MCE and the provider that explains the provider's obligation to provide oral
translation, oral interpretation, and sign language services to the
MCE's
members including:
(a) The provider's
responsibility to identify those members who may require such
assistance;
(b) The process the
provider is to follow in arranging for such services to be provided;
(c) Information that members will not be
liable for the costs of such services; and
(d) Specification of whether the
MCE or
the provider will be financially responsible for the costs of providing these
services.
(7) The procedures
that providers are to follow in notifying the
MCE of changes in
their practice, including at a minimum:
(a)
Address and phone numbers;
(b)
Providers included in the practice;
(c) Acceptance of new patients; and
(d) Standard office hours.
(8) Specification of
what service utilization and provider performance data the
MCE will
make available to providers.
(9) Specification of
the healthchek components to be provided to eligible members as specified in
Chapter 5160-14 of the Administrative Code.
(B) In addition to the information in paragraph (A) of this rule, a managed care organization (MCO) has to provide the following written information to providers:
(1)
The MCO's
expectations for primary care providers (PCPs), including triage
obligations.
(2)
A description of the MCO's care coordination and care
management programs, and the role of the provider in those programs,
including:
(a)
The MCO's criteria for determining which members might
benefit from care management;
(b)
The provider's
responsibility in identifying members who may meet the MCO's care management
criteria; and
(c)
The process for the provider to follow in notifying the
MCO when such members are identified.
(3)
The MCO's
expectations regarding the submission and processing of requests for specialist
referrals including:
(a)
A list of the provider types, if any, that need prior
authorization approval from the MCO;
(b)
The process and
format to be used in submitting prior authorization requests;
(c)
How the provider
will be notified of the MCO's decision regarding prior authorization requests;
and
(d)
The procedures to be followed in appealing the MCO's
denial of prior authorization requests.
(C) An MCO must adopt practice guidelines and disseminate the guidelines to all affected providers, and upon request to members and pending members. These guidelines must:
(1) Be based on valid and reliable clinical
evidence or a consensus of health care professionals in the particular
field;
(2) Consider the needs of
the MCO's members;
(3) Be adopted
in consultation with contracting health care professionals; and
(4) Be reviewed and updated periodically, as
appropriate.
(D) The MCE must have staff specifically responsible for resolving individual provider issues, including, but not limited to, problems with claims payment, prior authorizations and referrals. The MCE must provide written information to their contracting providers detailing how to contact these designated staff.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
