Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-58 - MyCare Ohio
Section 5160-58-03 - MyCare Ohio plans: covered services

(a) The MCOP may not deny payment for treatment obtained when a member had an emergency medical condition as defined in rule 5160-26-01 of the Administrative Code.

(b) The MCOP cannot limit what constitutes an emergency medical condition on the basis of diagnoses or symptoms.

(c) The MCOP must cover all emergency services without requiring prior authorization.

(d) The MCOP must cover medicaid-covered services related to the member's emergency medical condition when the member is instructed to go to an emergency facility by a representative of the MCOP including but not limited to the member's primary care provider (PCP) or the MCOP's twenty-four-hour toll-free call-in-system.

(e) The MCOP cannot deny payment of emergency services based on the treating provider, hospital, or fiscal representative not notifying the member's PCP of the visit.

(f) The MCOP must cover emergency services as defined in rule 5160-26-01 of the Administrative Code when the services are delivered by a non-contracting provider of emergency services. Claims for these services cannot be denied regardless of whether the services meet an emergency medical condition as defined in rule 5160-26-01 of the Administrative Code. Such services must be reimbursed by the MCOP at the lesser of billed charges or one hundred per cent of the Ohio medicaid program fee-for-service reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program fee-for-service reimbursement rate) in effect for the date of service. If an inpatient admission results, the MCOP is required to reimburse at this rate only until the member can be transferred to a provider designated by the MCOP. Pursuant to section 5167.10 of the Revised Code, the MCOP may not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM.

(g) The MCOP must cover emergency services until the member is stabilized and can be safely discharged or transferred.

(h) The MCOP must adhere to the judgment of the attending provider when the attending provider requests a member's transfer to another facility or discharge. The MCOP may establish arrangements with hospitals whereby the MCOP may designate one of its contracting providers to assume the attending provider's responsibilities to stabilize, treat and transfer the member.

(i) A member who has had an emergency medical condition may not be held liable for payment of any subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

(a) The MCOP must designate a telephone line to receive provider requests for coverage of post-stabilization care services. The line must be available twenty-four hours a day, seven days a week. The MCOP must document the telephone number and process for obtaining authorization has been provided to each emergency facility in the service area. The MCOP must maintain a record of any request for coverage of post-stabilization care services that is denied including, at a minimum, the time of the provider's request and the time the MCOP communicated the decision in writing to the provider.

(b) At a minimum, post-stabilization care services must be provided and reimbursed in accordance with the following:

(c) The MCOP's financial responsibility for post stabilization care services not pre-approved ends when:

(a) Include the components specified in rule 5160-1-14 of the Administrative Code. All components of exams must be documented and included in the medical record of each healthchek eligible member and made available for the ODM annual external quality review.

(b) Are completed within ninety days of the initial effective date of membership for those children found to have a possible ongoing condition likely to require care management services.