Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-4 - Physician Services
Section 5160-4-04 - Services provided by an advanced practice registered nurse (APRN)
Universal Citation: OH Admin Code 5160-4-04
Current through all regulations passed and filed through March 18, 2024
(A) Definition. "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. The term encompasses a certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nursemidwife (CNM), and certified nurse practitioner (CNP).
(B) Coverage.
(1) Unless a specific exception is noted, all
other rules in agency 5160 of the Administrative Code that pertain to services
rendered by a physician apply also to services rendered by an APRN.
(2)
For a covered service rendered
by an APRN, payment may be made only if the
following conditions are met:
(a) The service is
rendered to
an
Ohio-medicaid-eligible individual in a state in which the APRN
is licensed or authorized to practice;
(b) The service is
within the scope of practice of the APRN's specialty;
(c)
The APRN personally rendered the service to an individual patient;
and
(d) The service cannot
be performed by someone who lacks the skills and training of an APRN.
(C) Payment.
(1) Payment for a covered service rendered by
a CRNA is made in accordance with rule
5160-4-21 of
the Administrative Code.
(2)
Payment for a covered service rendered by a CNS, CNM, or CNP is the lesser of
the billing provider's submitted charge or the applicable amount from the
following list:
(a) For a covered service
rendered in a hospital setting (inpatient hospital, outpatient hospital, or
hospital emergency department), eighty-five per cent of the medicaid
maximum;
(b) For a covered service
rendered in a non-hospital setting, one hundred per cent of the medicaid
maximum; or
(c) For
assistant-at-surgery services provided by a CNS, CNM, or CNP regardless of
setting, twenty-five per cent of the medicaid maximum for the covered primary
surgical procedure.
(3)
Payment for services rendered by a hospital-employed APRN will be made to the
hospital.
(4)
In the event that payment for a covered service
performed by an APRN is issued both to the APRN and to a contracting or
supervising provider on behalf of the APRN, one of the issued payments is
subject to recovery.
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.
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