Ohio Admin. Code 4123-6-26 - Claimant reimbursement
(A) When the claimant or any other person
making payment on behalf of the claimant, including a volunteer, pays for
medical services or supplies directly to a health care provider and the
claim or condition is subsequently
allowed
medical services or supplies meet the
criteria in paragraph (B) of rule 4123-6-16.2 of the Administrative Code ,
the payor shall be reimbursed upon submission of evidence of the receipt and
payment for that medical service or supply.
Except as otherwise provided in paragraphs (A)(1) and (A)(2) of this rule, the
payor will receive no more than the amount that would have been paid to the
health care provider as provided by this chapter.
(1) In cases where the payor is the
claimant's health insurer, if the claimant seeks reimbursement for an
out-of-pocket copayment, the claimant may be reimbursed for the copayment and
the claimant's health insurer may be reimbursed up to the amount that would
have been paid to the health care provider as provided by this
chapter.
(2) In cases where the
claimant pays a pharmacy out of pocket for an outpatient medication because the
medication is not payable under division (I) of section
4123.511
of the Revised Code on the date of service, if the medication later becomes
payable, the claimant may be reimbursed the full amount of the claimant's
out-of-pocket payment.
(B) When the bureau has already made payment
to the health care provider, the payor shall be informed to seek reimbursement
from the provider. The bureau shall inform a claimant or payor whether a health
care provider participates in the HPP or QHP.
(C) Requests for reimbursement pursuant to
this rule shall be subject to the timeframes set forth in division (B) of
section
4123.52
of the Revised Code and in rule
4123-3-23
of the Administrative Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 02/12/1997, 06/24/2011, 11/13/2015
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(A) When the claimant or any other person making payment on behalf of the claimant, including a volunteer, pays for medical services or supplies directly to a health care provider and the claim or condition is subsequently allowed medical services or supplies meet the criteria in paragraph (B) of rule 4123-6-16.2 of the Administrative Code , the payor shall be reimbursed upon submission of evidence of the receipt and payment for that medical service or supply. Except as otherwise provided in paragraphs (A)(1) and (A)(2) of this rule, the payor will receive no more than the amount that would have been paid to the health care provider as provided by this chapter.
(1) In cases where the payor is the claimant's health insurer, if the claimant seeks reimbursement for an out-of-pocket copayment, the claimant may be reimbursed for the copayment and the claimant's health insurer may be reimbursed up to the amount that would have been paid to the health care provider as provided by this chapter.
(2) In cases where the claimant pays a pharmacy out of pocket for an outpatient medication because the medication is not payable under division (I) of section 4123.511 of the Revised Code on the date of service, if the medication later becomes payable, the claimant may be reimbursed the full amount of the claimant's out-of-pocket payment.
(B) When the bureau has already made payment to the health care provider , the payor shall be informed to seek reimbursement from the provider. The bureau shall inform a claimant or payor whether a health care provider participates in the HPP or QHP.
(C) Requests for reimbursement pursuant to this rule shall be subject to the timeframes set forth in division (B) of section 4123.52 of the Revised Code and in rule 4123-3-23 of the Administrative Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 02/12/1997, 06/24/2011, 11/13/2015