Ohio Admin. Code 5160-1-60.4 - By-report procedures, services, and supplies
(A)
The term
"by-report" identifies a covered procedure, service, or supply for which no
single maximum payment amount has been established and for which payment is not
determined by prior authorization. Claims for by-report procedures, services,
and supplies are reviewed manually by the department or its designee. The
purpose of the review is to determine whether the procedure code for the
by-report procedure, service, or supply reported on the claim is the most
appropriate and, if so, to establish a maximum payment amount for the
procedure, service, or supply on a case-by-case basis. Information must be
submitted on or with the claim (e.g., supporting documents such as operative
reports, clinical assessments, or other medical records) to identify the
particular by-report procedure, service, or supply.
(B)
By-report
procedures, services, and supplies are so indicated in the relevant rule in
agency 5160 of the Administrative Code or in its associated payment
schedule.
(C)
A non-covered procedure, service, or supply that is
reported on a claim with a by-report procedure code is
non-covered.
(D)
A claim for a by-report procedure, service, or supply
will not be reviewed further and may be denied under either of the following
conditions:
(1)
Information submitted on or with the claim does not
sufficiently identify the by-report procedure, service, or supply, and
additional documentation requested by the reviewer is not supplied; or
(2)
The
procedure, service, or supply can be reported appropriately with a different
procedure code for which a specific maximum payment amount has been
established.
(E)
When a claim has been denied because a different
procedure code adequately describes a procedure, service, or supply, the
provider may submit a new claim with the appropriate code. The new claim must
not be submitted for by-report consideration.
Replaces: 5160-4- 02.1
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, 01/08/1979, 02/01/1980, 05/19/1986, 07/01/1987, 04/01/1988, 09/01/1989, 01/01/2001, 08/02/2011
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(A) The term "by-report" identifies a covered procedure, service, or supply for which no single maximum payment amount has been established and for which payment is not determined by prior authorization. Claims for by-report procedures, services, and supplies are reviewed manually by the department or its designee. The purpose of the review is to determine whether the procedure code for the by-report procedure, service, or supply reported on the claim is the most appropriate and, if so, to establish a maximum payment amount for the procedure, service, or supply on a case-by-case basis. Information must be submitted on or with the claim (e.g., supporting documents such as operative reports, clinical assessments, or other medical records) to identify the particular by-report procedure, service, or supply.
(B) By-report procedures, services, and supplies are so indicated in the relevant rule in agency 5160 of the Administrative Code or in its associated payment schedule.
(C) A non-covered procedure, service, or supply that is reported on a claim with a by-report procedure code is non-covered.
(D) A claim for a by-report procedure, service, or supply will not be reviewed further and may be denied under either of the following conditions:
(1) Information submitted on or with the claim does not sufficiently identify the by-report procedure, service, or supply, and additional documentation requested by the reviewer is not supplied; or
(2) The procedure, service, or supply can be reported appropriately with a different procedure code for which a specific maximum payment amount has been established.
(E) When a claim has been denied because a different procedure code adequately describes a procedure, service, or supply, the provider may submit a new claim with the appropriate code. The new claim must not be submitted for by-report consideration.
Replaces: 5160-4- 02.1
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, 01/08/1979, 02/01/1980, 05/19/1986, 07/01/1987, 04/01/1988, 09/01/1989, 01/01/2001, 08/02/2011