Ohio Admin. Code 5160-27-03 - Reimbursement for community behavioral health services

(A) This rule sets forth the reimbursement requirements and rates for behavioral health services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code.

(B) Providers rendering community behavioral health services will abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code.

(C)(B) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, medicaid reimbursement rates for services and practitioners described in Chapter 5160-27 of the Administrative Code are listed in the appendix to this rule. Ohio medicaid will reimburse the provider the lower of either their usual and customary charges or the reimbursement amount described in the appendix to this rule. Practitioner-specific reimbursement rates that are not otherwise stated in the appendix to this rule are determined by paragraphs (B)(1) to (B)(5) of this rule.

(1) The reimbursement rate for physicians, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(2) The reimbursement rate for clinical nurse specialists, certified nurse practitioners, and physician assistants, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is eighty-five per cent of the medicaid maximum rate stated in the appendix to this rule; except for evaluation and management office/outpatient visits, psychiatric diagnostic evaluations, and smoking and tobacco cessation counseling the reimbursement rate is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(3) The reimbursement rate for practitioners described in paragraph (A)(5) of rule 5160-27-01 of the Administrative Code is the reimbursement rate percentage described in rule 5160-8-05 of the Administrative Code (medicaid maximum rate stated in the appendix to this rule). The reimbursement rates for services not defined in rule 5160-8-05 of the Administrative Code are stated in the appendix to this rule.

(4) The reimbursement rates for practitioners described in rule 5160-27-01 of the Administrative Code and not otherwise addressed in paragraph (D) (B) of this rule, are stated in the appendix to this rule.

(5) The reimbursement rate for pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code is set forth in rule 5160-8-52 of the Administrative Code.

(D)(C) The medicaid reimbursement rate for any of the following services provided for more than ninety minutes by the same billing provider, to the same recipient, on the same calendar day will be fifty per cent of the rate listed in appendix to this rule.

(1) Community psychiatric supportive treatment as described in rule 5122-29-17 of the Administrative Code.

(2) Therapeutic behavioral service as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(3) Psychosocial rehabilitation as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(4) Substance use disorder targeted case management as described in rule 5160-27-10 of the Administrative Code.

(E) Medicaid reimbursement is contingent upon providers maintaining complete and accurate documentation as required by Chapter 5160-27 of the Administrative Code.

(F)(D) Place of service (POS) codes for behavioral health services as described in paragraph (G) of rule 5160-27-02 of the Administrative Code are stated in the appendix to this rule. If a POS codes code is not stated, are not specified for a service, any valid POS code may be used.

(G)(E) Laboratory services, vaccines, and medications, not stated in the appendix to this rule, and administered in a prescriber office, may be reimbursed in accordance with rule 5160-1-60 of the Administrative Code.

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Notes

Ohio Admin. Code 5160-27-03

Effective: 1/1/2024
Five Year Review (FYR) Dates: 10/17/2023 and 01/01/2029
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5164.02
Rule Amplifies: 5162.05, 5164.02, 5164.03, 5164.15, 5164.76
Prior Effective Dates: 01/01/2018, 01/02/2018 (Emer.), 05/03/2018, 08/01/2019 (Emer.), 11/29/2019, 01/17/2021, 07/09/2021, 01/01/2022, 07/01/2022, 01/01/2023