Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-8 - Therapeutic and Diagnostic Services
Section 5160-8-42 - Lactation consultation services
Universal Citation: OH Admin Code 5160-8-42
Current through all regulations passed and filed through December 16, 2024
(A) Definitions applicable to this rule.
(1)
"Eligible provider" has the same meaning as in rule
5160-1-17 of the Administrative
Code.
(2)
"Lactation consultation" is the development and
implementation of management strategies for complex problems related to
breastfeeding and human lactation.
(3)
"International
Board-Certified Lactation Consultant (IBCLC)" is a professional member of the
healthcare team who has earned and maintains the credential established by the
"International Board of Lactation Consultant Examiners," which attests to
expertise in breastfeeding management and care, including the insight, skills,
and knowledge needed to identify complex breastfeeding problems, to provide
education about breastfeeding, and to facilitate an optimal breastfeeding
experience and environment.
(B) Providers.
(1)
Rendering
providers. The following eligible providers may receive medicaid payment for
rendering a lactation consultation service:
(a)
An
IBCLC;
(b)
An advanced practice registered nurse;
(c)
A physician;
or
(d)
A physician assistant.
(2)
Billing
("pay-to") providers. The following eligible providers may receive medicaid
payment for lactation consultation services on behalf of a rendering
provider:
(a)
The rendering provider;
(b)
A professional
medical group practice;
(c)
A professional dental group practice;
(d)
A
pharmacy;
(e)
A federally qualified health center
(FQHC);
(f)
A rural health clinic (RHC); or
(g)
An ambulatory
health care clinic.
(C) Coverage.
(1)
Payment for a
lactation consultation service is made separately from payment for other
professional services. No separate payment, however, is made for a lactation
consultation service provided in conjunction with nurse home visiting services
(which are addressed in rule
5160-21-05 of the Administrative
Code).
(2)
For a lactation consultation service, the practitioner
order specified in rule
5160-1-17 of the Administrative
Code is waived.
(D) Claim payment.
(1)
Payment for a covered lactation consultation service
provided in a hospital is made in accordance with Chapter 5160-2 of the
Administrative Code.
(2)
Payment for a covered lactation consultation service
provided by an FQHC or RHC is made in accordance with Chapter 5160-28 of the
Administrative Code.
(3)
Payment for a covered lactation consultation service
rendered in other settings is the lesser of the submitted charge or the amount
shown in appendix DD to rule
5160-1-60 of the Administrative
Code.
(4)
Payment for lactation pumps and supplies is made in
accordance with rule
5160-10-25 of the Administrative
Code.
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