Ohio Admin. Code 5160-1-31 - Prior authorization [except for services provided through medicaid contracting managed care plans (MCPs)]

(A) Reimbursement for some items and/or services covered under the medicaid program is available only upon obtaining prior authorization from the Ohio department of job and family services (ODJFS). Prior authorization must be obtained from ODJFS or its designee by the provider before the services are rendered or the items delivered,unless the services meet the provisions in paragraph (F) of this rule. Items and/or services which require prior authorization are identified in Chapters 5101:3-2 to 5101:3-56 of the Administrative Code. Citations for some of these services are listed in paragraphs (A)(1) to (A)(5) of this rule.

(1) Prior authorization for transplantation services must be obtained by the hospital before the service is rendered in accordance with rule 5101:3-2-07.1 of the Administrative Code.

(2) In addition to services requiring prior authorization, some hospital inpatient and outpatient services may require pre-certification in accordance with rules 5101:3-2-40and5101:3-2-42oftheAdministrativeCode.

(3) Prior authorization for out of state coverage will be made in accordance with rule 5101:3-1-11oftheAdministrativeCode.

(4) Prior authorization for long-term care outlier services will be made in accordance with rules 5101:3-3-54.1 , 5101:3-3-54.5 , and 5101:3-3-87.1 of the Administrative Code.

(5) Prior authorization for pharmacy services will be made in accordance with Chapter 5101:3-9 of the Administrative Code.

(B) Services, supplies or prescription drugs that require prior authorization by the department are identified in Chapters 5101:3-2 to 5101:3-56 of the Administrative Code.

(C) All prior authorization requests must be submitted through the medicaid information technology system (MITS) web portal. Paper prior authorization requests will be returned to the provider unprocessed.

(B) Completed prior authorization forms and any necessary supporting documentation should be mailed or faxed to the location listed at the bottom of the request form. A duplicate copy of each request must be retained in the providers records. Telephone requests for prior authorization will only be accepted for pharmacy services.

(1) The following forms must be used when requesting prior authorization:

(a) Requests for authorization of medical services, supplies, equipment or transportation services must be submitted on the JFS 03142 "Prior Authorization" form (rev. 2/2003).

(b) Requests for the authorization of dental services must be submitted on the JFS 03612 "Prior Authorization for Dental Services" form (rev. 3/2003).

(c) Requests for the authorization of medically necessary transport must be submitted on the JFS 03452 "Practitioner Certification of Medical Necessity for Ambulette Transportation" form (rev. 07/2003) and must accompany form JFS 03142.

(2) Requests for prior authorization submitted to ODJFS or its designee must include correct HCPCS or CPT code(s) for that date of service in accordance with rule 5101:3-1-19.3 of the Administrative Code.

(3) When a request for prior authorization does not include documentation required for review of medical necessity, the request will be denied. The provider may submit a new request with the required documentation.

(C) (D) When the prior authorization request has been processed by ODJFS or its designee, the provider will receive notification indicating the decision for each item and/or service requested service, supply or prescription drug. Reimbursement by ODJFS is limited to those items as specified in the physicians orders and indicated in the approval notification Only those services, supplies or prescription drugs approved in the prior authorization notice will be reimbursed.

(D) (E) When a request for prior authorization has been approved, the notification will include a prior authorization (PA) number. In order for the provider to be reimbursed, the provider must use the assigned PA number when submitting on the medicaid claim for payment.

(E) (F) In situations where the provider considers a delay in providing items and/or services, supplies or prescription drugs requiring prior authorization to be detrimental to the health of the consumer, the services, supplies or prescription drugs may be rendered or item delivered and approval for reimbursement sought after the fact.

(F) (G) When a request for prior authorization is denied, ODJFS or its designee will issue a notice of medical determination and a right to a state hearing to the consumer. A copy of this denial notice will be sent to the county department of job and family services to be filed in the consumer's case record. Providers will also be notified of the denial.

(G) Reimbursement for a prior authorized service or item is contingent upon:

(1) The consumer being eligible for medicaid at the time the service is rendered.

(2) The provider renders services in accordance with the rules contained in Chapters 5101:3-2 to 5101:3-56 of the Administrative Code.

(3) The reduction of benefits by third-party payers, including medicare, have been properly applied to the request for payment from ODJFS.

(4) ODJFS's timely filing limitations for claims have not been violated in accordance with rule 5101:3-1-19.3 of the Administrative Code.

(5) The determination of medical necessity by ODJFS or its designee has been met in accordance with rule 5101:3-1-01oftheAdministrativeCode.

Notes

Ohio Admin. Code 5160-1-31

Effective: 8/2/2011
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 7/1/91 (Emer), 9/30/91, 5/30/02, 8/11/05