Ohio Administrative Code › Title 3901 - Department of Insurance › Chapter 3901-8 - Health Insurance › Section 3901-8-03 - Standardized health claim form rule

Current through all regulations passed and filed through July 1, 2024
(A) Purpose
The purpose of this rule is to standardize the forms used in
				the billing and reimbursement of health care, reduce the number of forms
				utilized, increase efficiency in the reimbursement of health care through
				standardization and encourage the use of electronic data interchange of health
				care expenses and reimbursement.
(B) Authority
This rule is promulgated pursuant to the authority vested in
				the superintendent under sections
				3901.041,
				
									
										3901.21 and
				3902.22
									 of the Revised
				Code.
(C) Definitions
As used in this rule
(1) "CDT codes" means the most current dental
			 terminology and codes prescribed by the American dental association.
(2) "Claim" means any request submitted to a
			 third-party payer for benefits or proceeds under a benefit plan or contract on
			 a standardized health claim form as described in paragraph (E)(3) or (E)(4) of
			 this rule.
(3) "CPT codes" means
			 the most current procedural terminology and codes as published by the American
			 medical association (AMA).
(4) "CMS" means the centers for medicare and
			 medicaid services of the U.S. department of health and human services formerly
			 known as the federal health care financing administration of the U.S.
			 department of health and human services .
(5) "CMS 
									form 1450" means
			 the health insurance claim form published by CMS for use by institutional care
			 practitioners. For purposes of this rule, the CMS form 1450 includes the UB-04
			 form and its successors.
(6) "CMS
			 
									form
			 1500" means the health insurance claim form published by CMS for use by health
			 care practitioners. For purposes of this rule, the CMS
			 
									form
			 1500 
									includes successor forms as approved by CMS.
(7) "HCPCS" means CMS's common
			 procedure coding system which is based upon the AMA's most current CPT
			 publication.
(a) "HCPCS
			 
										level 1
			 codes" means the AMA's CPT codes with the exception of anesthesiology
			 services;
(b) "HCPCS
			 
										level 2
			 codes" means the codes for physician and non-physician services which are not
			 included in the most current CPT publication;
(c) "HCPCS 
										level 3 codes"
			 means the codes for services needed by individual contractors or state agencies
			 to process claims. They are used for items and services not having the
			 frequency of use, geographic distribution, or general applicability needed to
			 justify a code assignment at a higher level.
(8) "Health care practitioner" means:
(a) A chiropractor licensed under Chapter
			 4734. of the Revised Code;
(b) A
			 corporation or partnership of health care practitioners defined in this
			 rule;
(c) A dentist licensed under
			 Chapter 4715. of the Revised Code;
(d) A dietitian licensed under Chapter 4759.
			 of the Revised Code;
(e) A nurse
			 licensed under Chapter 4723. of the Revised Code;
(f) An optometrist licensed under Chapter
			 4725. of the Revised Code;
(g) A
			 physician as defined under section
			 4730.01 of the Revised
			 Code;
(h) A podiatrist licensed
			 under Chapter 4731. of the Revised Code;
(i) A psychologist licensed under Chapter
			 4732. of the Revised Code; or
(j) A therapist, including speech, physical,
			 respiratory and occupational therapists licensed under Chapter 4753., 4755. or
			 4761. of the Revised Code.
(9) "
									ICD-10-CM
			 codes" means the disease codes in the most current international classification
			 of diseases, clinical modifications published by the U.S. department of health
			 and human services.
(10) "Institutional care practitioner" means:
(a) A hospice licensed under Chapter 3712. of
			 the Revised Code;
(b) A hospital as
			 defined under section
			 3727.01 of the Revised Code;
			 or
(c)
										
										A
			 home or residential facility licensed under Chapters 3721. and
			 
										5119.
			 of the Revised Code.
(11) "J400 form" means the uniform dental
			 claim form approved by the American dental association for use by dentists. For
			 purposes of this rule, the J400 form 
									includes its
			 successors.
(12) "Medicare" means
			 Title XVIII of the federal Social Security Act (
			 42 U.S.C.
			 1395 ).
(13) "NCPDP universal claim form" means the
			 form adopted for use by the national council for prescription drug programs,
			 including 
									forms PUCFCC and PUCF2PT.
									
									For purposes of this rule, the NCPDP universal claim
			 form includes its successors.
(14) "Other provider" means a supplier of
			 health care services or supplies not meeting the definition of health care
			 practitioner or institutional care practitioner, including but not limited to a
			 pharmacist, physician assistant, nurse aide, or supplier of durable medical
			 equipment.
(15) "Third-party payer"
			 is as defined in section
			 3901.38 of the Revised
			 Code.