5160-1-17. Eligible providers

This rule sets forth eligibility requirements for practitioners, group practices, or organizational providers enrolling with, and seeking reimbursement from, the Ohio medicaid program.

(A) Eligible provider means any practitioner, group practice, or organization identified by the Ohio department of medicaid (ODM) as a type of provider eligible to enroll in the medicaid program that:

(1) Meets the applicable provider requirements and standards in agency 5160 of the Administrative Code that address applicable service categories and provider types covered under the Ohio medicaid program;

(2) Meets additional requirements and standards set forth in this rule;

(3) Meets provider screening requirements and, when applicable, pays the fee for enrollment as a provider in the medicaid program in accordance with rule 5160-1-17.8 of the Administrative Code; and

(4) Is approved for participation in the medicaid program by ODM as evidenced by the issuance of both a signed "provider agreement" and an Ohio medicaid provider number.

(B) Eligible practitioners licensed by an Ohio licensing board may enroll as a medicaid provider in accordance with their active licensure and scope of practice as determined by the licensing entity.

(C) A provider can be assigned a professional group provider type when organized for the purpose of providing professional services under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755., 4757., 4759., or 4762. of the Revised Code, and meets the requirements in either paragraph (C)(1) or (C)(2) of this rule, and meets the additional requirements set forth in paragraphs (C)(3) to (C)(5) of this rule.

(1) A professional practice that is owned by an individual may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule, and the owner or member of the practice possesses a valid license, certificate, or other legal authorization issued under Chapter 4715., 4723, 4725.,4730., 4731., 4732., 4734., 4753., 4755., 4757., 4759., or 4762. of the Revised Code, and also meets the requirements found in paragraph (A)(1) of this rule.

A provider enrolling with the medicaid program that does not meet the provisions listed in paragraph (C) of this rule may only be enrolled as an individual provider.

(2) Any group of two or more individuals may be enrolled as a professional group practice if the practice is formed as an organizational structure listed in paragraph (C)(3) of this rule. ODM recognizes two types of professional group practices, a professional medical group and a professional dental group.

(a) A professional medical group is a group that consists of individual practitioners recognized by ODM as eligible members. These eligible members include but are not limited to: physicians, osteopaths, advanced practice nurses, physician assistants, psychologists, podiatrists, optometrists, chiropractors, licensed independent social workers, licensed professional clinical counselors, independent marriage and family counselors, licensed independent chemical dependency counselors, occupational therapists, physical therapists, speech therapists, acupuncturists, audiologists, opticians, ocularists, licensed dietitians and registered dietitian nutritionists. With the exception of an incorporated individual in accordance with paragraph (C)(3)(b) of this rule, the professional medical practice must consist of two or more members, of like or different scopes of practice or licensure.

(b) A professional dental group is a group that consists only of dentists. With the exception of an incorporated individual in accordance with paragraph (C)(3)(b) of this rule, the practice must consist of two or more dentists.

(c) An out of state professional medical group must abide by the requirements stated in rule 5160-1-11 of the Administrative Code.

(3) For the purposes of the Ohio medicaid program, a professional group practice may be organized in accordance with one of the following organization structures:

(a) A corporation formed under Chapter 1701. of the Revised Code.

(b) A limited liability company formed under Chapter 1705. of the Revised

Code.

(c) A non-profit corporation formed under Chapter 1702. of the Revised Code.

(d) A professional association formed under Chapter 1785. of the Revised Code.

(e) A partnership formed under Chapters 1776. and 1782. of the Revised Code.

(4) With the exception of hospitals, long term care facilities, home health agencies, hospice programs, and intermediate care facilities, each practitioner employed by or under contract with a group practice or an organization, including, but not limited to professional group practices, clinics, federally qualified health centers, and behavioral health facilities, who also meet the respective requirements in paragraph (A) of the rule, must have an approved individual provider agreement with ODM.

(5) Each practitioner, employed or under contract with a group practice or an organization that is actively enrolled as a provider in the Ohio medicaid program, shall affiliate themselves with their respective group practices or organizational providers when applying for a provider agreement with ODM.

(D) Requirements for obtaining and using national provider identifiers (NPI).

(1) For the purposes of receiving reimbursement for services rendered to medicaid recipients, ODM shall require providers and practitioners enrolling in the medicaid program to obtain a NPI.

(2) Providers, and practitioners, whether practicing independently or employed or under contract with a group practice or organization, who are identified by the american medical association's national uniform claim committee with a provider taxonomy number shall obtain a NPI and shall divulge the NPI to ODM upon enrollment.

(3) The name and NPI of the practitioner who furnishes services to medicaid recipients shall be on claims submitted to ODM for reimbursement. Claims submitted without a NPI will be denied.

(4) An organization with components or subparts is responsible for determining if any components or subpart of its organization require a separate NPI and, if so, shall obtain it for that component or subpart.

(E) As part of the initial medicaid provider application, an applicant shall include a list of all geographical locations at which it renders services under its NPI. An existing provider shall submit to ODM any additions or deletions to the list of locations within thirty calendar days of the change. An enrolled provider must also notify ODM of any provider affiliation additions or deletions within thirty days of the change. Failure to follow the requirements of this paragraph may prevent an applicant from being enrolled as a medicaid provider or if enrolled, may result in the termination of a provider agreement as provided for in rule 5160-1-17.6 of the Administrative Code.

(F) ODM does not enroll providers located outside of the United States and its territories.

Replaces: 5160-1-17

Effective: 11/25/2019
Five Year Review (FYR) Dates: 11/25/2024
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.31
Prior Effective Dates: 04/07/1977, 10/01/1987, 01/01/1995, 12/31/1996 (Emer.), 03/22/1997, 05/30/2002, 08/11/2005, 05/23/2007, 01/01/2008, 08/02/2011, 03/31/2012