Ohio Administrative Code › Title 3701 - Department of Health - Administration and Director › Chapter 3701-43 - Program for Medically Handicapped Children › Section 3701-43-09 - Criteria and procedures for payment of providers

Current through all regulations passed and filed through July 1, 2024
(A) The director
			 shall pay providers for diagnostic services and for treatment services and
			 goods furnished to recipients in accordance with this rule.
(B) The director shall pay only for services
			 or goods that have been authorized to be provided under the applicable
			 provisions of this chapter.
(C) A
			 provider shall submit a request for payment on a form prescribed by the
			 director and containing at least the name and identification number of the
			 applicant or recipient to whom the services or goods were provided, the
			 provider's identification number, a description of the goods or services
			 provided and the amount of the charges for the goods or services. The request
			 for payment shall be submitted so that it is received by the director no later
			 than twelve months after the last date on which goods or services included in
			 the request were furnished.
(D) If
			 the request for payment does not contain sufficient information for the
			 director to determine whether payment may be made, the director shall deny the
			 request. The director shall notify the provider within thirty days after
			 receipt of a request for payment that the request has been denied and of any
			 additional or corrected information necessary to process the request.
			 Additional information may include, but is not limited to, reports,
			 descriptions of the types or amounts of goods or services provided, the amount
			 of charges for the goods or services and information concerning submission of
			 claims for third-party benefits. The provider may resubmit the request for
			 payment but shall not resubmit the request so that it is received by the
			 director more than twenty-four months after the last date on which goods or
			 services included in the request were furnished.
(E) A provider shall submit claims for
			 medicaid benefits and for all other third-party benefits which may provide
			 payment for the services rendered or goods supplied and shall make all
			 reasonable efforts to assist the recipient to whom the goods or services were
			 provided and the recipient's parent, guardian or other legal representative to
			 submit claims for third-party benefits and any information necessary for
			 processing the claims. The claims for third-party benefits shall have been
			 submitted no less than sixty days before a request for payment is submitted to
			 the director under this rule.
(1) If any
			 payment is made for the goods or services by the medicaid program, the director
			 shall not make payment under this rule. If the recipient of the goods or
			 services giving rise to the request for payment is a medicaid recipient at the
			 time that the services or goods were furnished, the director shall not make
			 payment under this rule until after the medicaid program has denied payment for
			 the goods or services.
(2) If
			 payment is received by the provider through third-party benefits, other than
			 medicaid program benefits, for the goods or services, the director shall
			 subtract the amount of the third-party benefits from the amount determined
			 under paragraph (F) of this rule and shall pay the difference to the provider.
(3) If a provider receives payment
			 from the medicaid program or through other third-party benefits of at least the
			 amount determined under paragraph (F) of this rule from the program for goods
			 or services authorized to be provided by the director under the applicable
			 provisions of this chapter, the provider shall not seek payment of any
			 additional amount from the recipient, recipient's parent, guardian or other
			 legal representative.