Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.2 - Provider agreement for providers

Current through all regulations passed and filed through July 1, 2024
Provisions of provider agreements for long term care nursing
				facilities are defined in Chapter 5160-3 of the
				Administrative Code. Provisions for provider agreements for medicaid
				contracting managed care plans are defined in Chapter
				5160-26 of the Administrative Code.
A valid provider agreement with medicaid will act as a provider
				agreement for participation in the medicaid program. All medicaid provider
				applications must be submitted through the medicaid information technology
				system (MITS) web portal. Provider applications submitted in paper format will
				be returned to the provider unprocessed.
If a provider application requires additional supporting
				documentation by the department for the application process to be completed,
				the supporting documentation may be sent through the MITS web portal or sent to
				the department through regular mail service.
A provider agreement is a contract between the Ohio department
				of medicaid (ODM) and a
				provider of medicaid covered services. By signing this agreement the provider
				agrees to comply with the terms of the provider agreement, Revised Code,
				Administrative Code, and federal statutes and rules; and the provider certifies
				and agrees:
(A) To render medical
			 services as medically necessary for the patient and only in the amount required
			 by the patient without regard to race, creed, color, age, sex, national origin,
			 source(s) of payment, or disability; submit claims only for services actually
			 performed; and, bill ODM for no more than the usual and customary fee
			 charged other patients for the same service.
(B) To ascertain and recoup any third-party
			 resource(s) available to the consumer prior to billing
			 ODM.
			 ODM will
			 then pay any unpaid balance up to the lesser of the provider's billed charge or
			 the maximum allowable reimbursement as set forth in agency
								5160 of
			 the Administrative Code.
(C) To
			 accept the allowable reimbursement for all covered services as payment-in-full,
			 except as required in paragraph (B) of this rule. The provider will not seek
			 reimbursement for that service, except as defined in rule
			 5160-1-09 of the Administrative Code, from the
			 patient, any member of the family, or any other person.
(D) To maintain all records necessary and in
			 such form so as to fully disclose the extent of services provided and
			 significant business transactions. The provider will maintain such records for
			 a period of six years from the date of receipt of payment
			  or until any audit
			 initiated within the required six year
			 record maintenance period is completed.
(E) To furnish to ODM, the
			 secretary of the department of health and human services, or the Ohio medicaid
			 fraud control unit or their designees any information maintained under
			 paragraph (D) of this rule for audit and review purposes. Audits may use
			 statistical sampling. Failure to supply requested records within thirty days
			 shall result in withholding of medicaid payments and may result in termination
			 from the medicaid program.
(F) To
			 inform ODM within thirty days of any changes
			 including, but not limited to changes in
			 licensure, certification, or registration status; ownership; specialty;
			 additions, deletions, or replacements in group membership and hospital-based
			 physician affiliations; and address, including all
			 locations where services are rendered.
(G) To disclose ownership and control
			 information, and to disclose the identity of any person who has been convicted
			 of a criminal offense related to medicare, medicaid, or services provided under
			 Title XX of the Social Security Act as in
			 effect on November 15, 2018 (Title XX), as specified in rule
			 5160-1- 17.3 of the Administrative Code.
(H) That neither the individual practitioner,
			 nor the company, nor any owner, director, officer, or employee of the company,
			 nor any independent contractor retained by the company, is currently subject to
			 sanction under medicare, medicaid, or Title XX; or, is otherwise prohibited
			 from providing services to medicare, medicaid, or Title XX
			 beneficiaries.
(I) To provide to
			 ODM,
			 through the court of jurisdiction, notice of any bankruptcy action brought by
			 the provider. Notice shall be mailed to: office of legal services, Ohio
			 department of medicaid.
(J) To comply with the appropriate advance
			 directives requirements for hospitals, providers of home health care, personal
			 care services, and hospices as specified in Chapter 3701-83 of the
			 Administrative Code.
(K) To comply
			 with the confidentiality safeguards and the use and release of information
			 regarding public assistance recipients as described in section
			 5101.27 of the Revised
			 Code.
(L) To comply with section
			 121.36 of the Revised Code and
			 rule 5160-1-39 of the Administrative Code when providing
			 home care services.