Current through all regulations passed and filed through September 16, 2024
(A) The purpose of this rule is to set forth
the provisions for claiming to receive medicaid reimbursement for the provision
of services by medicaid school program (MSP) providers as defined in Chapter
5160-35 of the Administrative Code.
(B) The CPT (common procedural terminology)
and HCPCS (healthcare common procedure coding system) covered services provided
through MSP providers that are allowable for medicaid reimbursement are listed
on the department's website,http://medicaid.ohio.gov and are
provided in accordance with Chapter 5160-35 and rule
5160-8-35
of the
Administrative Code. The following limits apply:
(1) Assessment/evaluation services cannot be
billed more than once per continuous twelve month period.
(2) Re-assessment/re-evaluation services
may be performed not more
frequently than every thirty days nor less frequently than every sixty days;
for developmental services, reevaluation may be performed not more frequently
than every thirty days nor less frequently than every six
months.
(3) Skilled services
cannot be billed for dates of service beyond twelve months of the initial
assessment/evaluation or re-assessment/re-evaluation.
(C) Medically necessary services for
individuals under age twenty-one that go beyond the coverage and limitations
established in this rule will be:
(1) Prior
authorized by the Ohio department of medicaid (ODM) in accordance with rule
5160-1-31 of the Administrative
Code; and
(2) Services defined as
medical assistance in accordance with section 1905(a) of the Social Security
Act, 42 U.S.C. 1396d
(January 1, 2013).
(D)
The following conditions will be met in order to receive medicaid reimbursement
for services provided through the medicaid school program:
(1) The school district
will be
a qualified MSP provider in accordance with rule
5160-35-02 of the Administrative
Code.
(2) The MSP provider
will
submit claims for reimbursement for all direct service costs provided in
accordance with rule
5160-35-05 of the Administrative
Code and paragraph (B)(3) of rule
5160-35-06 of the Administrative
Code for which the MSP provider will submit a cost report seeking cost
reconciliation. Costs for direct services for which a provider has not
submitted an interim claim will not be paid to the provider in any final cost
report settlement.
(3) The MSP
provider will submit claims for only those services for which
it has statutory responsibility to provide to either an eligible child with an
IEP or for assessment/evaluation for a medicaid eligible child for whom they
are trying to determine the appropriateness of developing an individualized
education program (IEP).
(4) The
executive officer of the MSP provider or his/her designee
will
attest to the validity of the non-federal share of expenditures in accordance
with paragraph (G) of this rule.
(5) The service provided through the MSP
provider will be in accordance with rules
5160-35-05 and
5160-35-06 of the Administrative
Code.
(6) The service for which
reimbursement is sought will be one clearly identified in the IEP of an
eligible child, with the exception of the initial assessment/evaluation as
described in paragraph (B)(7) of rule
5160-35-05 of the Administrative
Code.
(7)
The service must be agreed to by the medicaid-covered
individual or the medicaid-covered individual's authorized
representative.
(E)
MSP providers will enroll and submit claims as an ODM
electronic data interchange (EDI) trading partner or contract with an ODM EDI
trading partner for the submission of claims to ODM.
(F) Claims will be
submitted in accordance with rule
5160-1-02 of the Administrative
Code, will only be for services agreed to by the
medicaid-covered individual or the medicaid-covered individual's authorized
representative, and will include the most appropriate code representing each
procedure, service, or supply provided in accordance with rule
5160-1-60 of the Administrative
Code.
(G) When a medicaid
claim is submitted through an EDI trading partner, the claim shall include a
ten character code that is the first item listed in the NTE02 field, and that
is an attestation of whether or not the claim is certified by the executive
officer of the MSP provider or his/her designee as follows:
(1) Attest yes: used if the claim is
certified by the executive officer of the MSP provider or his/her designee to
only include expenditures under the medicaid program under Title XIX of the
Social Security Act (the Act), and as applicable, under the state children's
health insurance program (SCHIP), under Title XXI of the Act, that are
allowable in accordance with applicable implementing federal, state, and local
statutes, regulations, and policies, and the state plan approved by the
secretary of health and human services and in effect at the time of the
submission of this claim; and the expenditures included in the claim are based
on the MSP provider's accounting of actual recorded expenditures; and the
established amount of local public funds were
available and used to match the MSP provider's (local public school district's)
allowable expenditures included in this claim, and such local public funds were
in accordance with all applicable federal
mandates
for the non-federal share match of expenditures; and federal matching funds are
not being claimed in this claim submission to match any expenditure under any
medicaid and/or SCHIP state plan amendment that has not been approved by the
secretary of health and human services effective for the period of this
claim.
(2) Attest nay: used if the
claim is not certified by the executive officer of the MSP provider or his/her
designee to only include expenditures under the medicaid program under Title
XIX of the Social Security Act (the Act), and as applicable, under the state
children's health insurance program (SCHIP), under Title XXI of the Act, that
are allowable in accordance with applicable implementing federal, state, and
local statutes, regulations, and policies, and the state plan approved by the
secretary of health and human services and in effect at the time of the
submission of this claim; and the expenditures included in the claim are based
on the MSP provider's accounting of actual recorded expenditures; and the
mandated amount of local public funds were available
and used to match the MSP provider's (local public school district's) allowable
expenditures included in this claim, and such local public funds were in
accordance with all applicable federal mandates
for the non-federal share match of expenditures; and federal matching funds are
not being claimed in this claim submission to match any expenditure under any
medicaid and/or SCHIP state plan amendment that has not been approved by the
secretary of health and human services effective for the period of this claim.
If attest nay is used, the claim will be denied for payment.
(H) Claim submissions
are
considered for reimbursement only when they are received by ODM within
three-hundred sixty-five days of the actual date the service was
provided.
(I) References to
cartridge tape, paper claim and pharmacy-point-of-sale in rule
5160-1-20 of the Administrative
Code are not applicable to the claim and will not be
allowed.
(J)
MSP reimbursable services will be billed in units of
service, as indicated on ODM's website at http://medicaid.ohio.gov. Service coverage and reimbursement rates are in accordance
with "Healthcare Common Procedure Coding System (HCPS)," the "Current
Procedural Terminology (CPT)" codes, and as listed in appendix to rule
5160-1-60 of the
Administrative.
(K) The following applies to
medicaid reimbursement:
(1) Interim payments.
ODM will
reimburse the MSP provider interim payments. The interim payments
will be
the federal financial participation (FFP) portion of the lesser of the billed
charge (not to exceed the usual and customary charge) or the medicaid maximum
according to the department's procedure code reference files for the particular
services performed.
(2) Cost
reports. Each MSP provider will complete the Ohio department of education (ODE)
developed
MSP school based cost report. The cost report is to be
completed by the MSP provider in compliance with all state and federal
provisions the cost report instructions also developed by ODE. The MSP provider
will
contract with an independent certified public accountant (CPA) firm, the state
auditor, or other entity authorized to conduct audits in the state of Ohio to
perform an agreed upon procedures review of the cost report and document
adjustments to the cost report. Once the agreed upon procedures review is
completed, the reviewed cost report will be
submitted to ODE no later than eighteen months after the end of the cost
reporting period as identified in the cost report instructions. The submitted
cost report will be used by ODE and ODM in the cost reconciliation and final
settlement process. It is possible for ODM or ODE
to conduct
a desk or field audit up to three years after the fiscal year end based on risk
assessment criteria developed by ODM. All cost reports for each fiscal year
prior to the effective date of this rule but not starting earlier than July 1,
2005 will be submitted in accordance with the schedule
developed by ODM in cooperation with ODE and approved by CMS.
(3) Cost report extension. For good cause and
upon written request from the MSP provider, ODE can grant an
extension of the cost report filing deadline. The written request
is to be
submitted to the grants management unit at ODE thirty calendar days before the
cost report submission deadline specified in paragraph (K)(2) of this rule. The
request will include information explaining the facts and
circumstances giving rise to the need for a cost report extension, projected
time line for filing the cost report, and any other information which the MSP
provider would like to have considered. Upon reviewing the written request, ODE
can, at
its sole discretion, request additional information, approve or deny the
extension.
(4) Final cost
settlement and reconciliation. The ODM and /or its designee
will
review the cost reports identify adjustments needed, compare the federal
financial participation (FFP) identified in the cost report against the interim
payments made by ODM to the MSP provider, identify the number of students for
which claims for services were received and paid and determine the
proportionate costs for those students using the costs from the cost report for
the total population of medicaid eligible IEP students, and issue a notice of
intended action pursuant to rule
5160-70-03 of the Administrative
Code that denotes the amount due to or from the MSP provider as a result of the
reconciliation. The MSP provider will have thirty-days from the date of the
notice to request a hearing. If no hearing request is
received, ODM will process the reconciled amount. An overpayment determined as
a result of this annual reconciliation to actual cost
will be
collected from the MSP provider by ODM. An underpayment determined as a result
of this annual reconciliation to actual cost will be paid to
the MSP provider by ODM. Failure by a MSP provider to submit an acceptable cost
report in accordance with paragraphs (K) (2) and (K)(3) of this rule, will
result in full repayment by the MSP provider of the total interim payment
received by the MSP provider for the cost reporting period. In addition,
failure to submit an acceptable cost report will result in possible revocation
of the MSP provider agreement and number.
(5)
Reimbursements
for all covered services as are to be considered
payment in full with limitations as set forth in accordance with rule
5160-1-60 of the Administrative
Code.
(6) The MSP providers
will
comply with all applicable federal and state rules, including but not limited
to 45 C.F.R. Part 92 (December 24, 2013), 45 C.F.R. Part 74 (December 24,
2013), Chapters 5160-1 and 5160-35 of the Administrative Code, CMS Publication
15-1 (found at
www.cms.gov/ manuals),
and the terms and conditions set forth within the provider
agreement.
(L) Records
are to
be maintained and disclosed by providers in accordance with rule
5160-1-27 of the Administrative
Code. Records necessary to fully disclose the extent of services provided and
costs associated with these services will be
maintained for a period of six years from the end of the cost reporting period
based upon those records or until any initiated audit, review, investigation or
other activities are completed and appropriately resolved, whichever is longer.
Records will be made available upon request to ODM, ODE or the
U.S. department of health and human services. Failure to supply requested
records, documentation or information could result in no payment
for outstanding services, recoupment of any reimbursements provided for
services that cannot be validated, termination from the medicaid program and/or
any sanctions available pursuant to section
5162.10 of the Revised
Code.
(M) State monitoring: ODM or
its designee has
the authority to conduct audits, reviews, investigations, or any other
activities necessary to assure a medicaid school program provider, its
subgrantee(s) or subcontractor(s) are compliant with federal and state
mandates. Based on the results of an audit, review,
investigation or other activities, ODM will potentially
seek recoupment of funding related to overpayments, misuse, fraud waste or
abuse or noncompliance with federal or state mandates
from the MSP provider.
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