Ohio Admin. Code 4123-6-14 - MCO bill submission to bureau
(A) The bureau shall review all bills
received from the MCO pursuant to paragraph (A)(1) of rule
4123-6-10 of
the Administrative Code for payment eligibility. The bureau's review may
include, but not be limited to, verification of the following:
(1) The services were delivered, rendered, or
directly supervised by providers who meet bureau credentialing and licensing
criteria;
(2) The bills conform to
standard clinical editing criteria in effect on the
billed date(s)
of service, including but
not limited to: the bureau's billing and reimbursement manual, the centers for medicare and medicaid services' healthcare
common procedure coding system (HCPCS), and the national correct coding
initiative (NCCI) guidelines
in effect on the
billed date(s) of service .
The
(B)
The bureau shall electronically transfer funds to the
MCO for allowed payments after receipt of a proper invoice and after a final
adjudication permitting payment for the bill. Upon receipt of funds from the
bureau, the MCO shall pay the provider within seven days or less. The MCO shall
pay to providers at least the amount electronically transferred by the bureau
to the MCO for reimbursement of provider services.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Prior Effective Dates: 02/16/1996, 01/15/1999, 02/01/2010, 11/13/2015
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(A) The bureau shall review all bills received from the MCO pursuant to paragraph (A)(1) of rule 4123-6-10 of the Administrative Code for payment eligibility. The bureau's review may include, but not be limited to, verification of the following:
(1) The services were delivered, rendered, or directly supervised by providers who meet bureau credentialing and licensing criteria;
(2) The bills conform to standard clinical editing criteria in effect on the billed date(s) of service, including but not limited to: the bureau's billing and reimbursement manual, the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS), and the national correct coding initiative (NCCI) guidelines in effect on the billed date(s) of service .
The
(B) The bureau shall electronically transfer funds to the MCO for allowed payments after receipt of a proper invoice and after a final adjudication permitting payment for the bill. Upon receipt of funds from the bureau, the MCO shall pay the provider within seven days or less. The MCO shall pay to providers at least the amount electronically transferred by the bureau to the MCO for reimbursement of provider services.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Prior Effective Dates: 02/16/1996, 01/15/1999, 02/01/2010, 11/13/2015