Ohio Admin. Code 5160-1-11 - Out-of-state coverage
(A)
Out-of-state
providers:
(1)
Should be licensed, accredited, or certified by their
respective states to be considered eligible to receive reimbursement for
services provided to Ohio medicaid covered individuals.
(2)
Should meet any
standards applicable to the provision of the service in the state in which the
service is being furnished, as well as those standards set forth in the Ohio
medicaid program and in the Administrative Code.
(3)
Except as
provided in paragraph (A)(4) of this rule, need to enroll as Ohio medicaid
providers in order to obtain payment and follow appropriate billing procedures
in accordance with Chapter 5160-1 of the Administrative Code and Chapter 5160-3
of the Administrative Code for long term care nursing facility
services.
(4)
Who are rendering services to medicaid covered
individuals enrolled in a managed care plan (MCP) are not required to enroll
with the Ohio department of medicaid (ODM) when:
(a)
The out-of-state
provider is not in the MCP's network and is providing services under a single
case agreement; or
(b)
The out-of-state provider is a pharmacy that is
in-network with the MCP under a national contract.
(5)
May have their
out-of-state provider's enrollment application denied by ODM based on the
denial, censure or revocation of their professional license by the applicable
licensing board of any other state, or if the applicable licensing board in
Ohio denies, censures or revokes a professional license even if another state's
licensing board approves the respective provider.
(B)
Ohio medicaid
covered services will be reimbursed when rendered by out-of-state providers
only under the following circumstances:
(1)
The medically
necessary services are not available within the state of Ohio, and the use of
out-of-state providers to perform the services is authorized by the department
or its designee, or authorized in accordance with rule
5160-1-31
of the Administrative Code; or
(2)
The medical need
arose as a result of an emergency, an accident, or an illness which occurred
during a period of time the medicaid covered individual was temporarily absent
from Ohio; or
(3)
The individual's health would have been endangered if
care was postponed until the individual returned to Ohio or attempted to return
to Ohio; or
(4)
The provider location for the medically necessary
service is in a bordering state of Ohio, and it is the usual practice of
residents in that community to utilize out-of-state providers, so long as the
cost of the service does not exceed the cost of the service if provided by
in-state providers; or
(5)
The state determines on the basis of medical advice,
that the needed medical services or necessary supplementary resources are more
readily available in another state.
Replaces: 5160-1-11
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 07/01/1980, 10/01/1987, 05/30/2002, 07/01/2005, 11/02/2014
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