5160-1-17.2. Provider agreement for providers

Provisions of provider agreements for long term care nursing facilities are defined in Chapter 5160-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5160-26 of the Administrative Code.

A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid program. All medicaid provider applications must be submitted through the medicaid information technology system (MITS) web portal. Provider applications submitted in paper format will be returned to the provider unprocessed.

If a provider application requires additional supporting documentation by the department for the application process to be completed, the supporting documentation may be sent through the MITS web portal or sent to the department through regular mail service.

A provider agreement is a contract between the Ohio department of medicaid ( ODM) and a provider of medicaid covered services. By signing this agreement the provider agrees to comply with the terms of the provider agreement, Revised Code, Administrative Code, and federal statutes and rules; and the provider certifies and agrees:

(A) To render medical services as medically necessary for the patient and only in the amount required by the patient without regard to race, creed, color, age, sex, national origin, source(s) of payment, or disability; submit claims only for services actually performed; and, bill ODM for no more than the usual and customary fee charged other patients for the same service.

(B) To ascertain and recoup any third-party resource(s) available to the consumer prior to billing ODM. ODM will then pay any unpaid balance up to the lesser of the provider's billed charge or the maximum allowable reimbursement as set forth in agency 5160 of the Administrative Code.

(C) To accept the allowable reimbursement for all covered services as payment-in-full, except as required in paragraph (B) of this rule. The provider will not seek reimbursement for that service, except as defined in rule 5160-1-09 of the Administrative Code, from the patient, any member of the family, or any other person.

(D) To maintain all records necessary and in such form so as to fully disclose the extent of services provided and significant business transactions. The provider will maintain such records for a period of six years from the date of receipt of payment or until any audit initiated within the required six year record maintenance period is completed.

(E) To furnish to ODM, the secretary of the department of health and human services, or the Ohio medicaid fraud control unit or their designees any information maintained under paragraph (D) of this rule for audit and review purposes. Audits may use statistical sampling. Failure to supply requested records within thirty days shall result in withholding of medicaid payments and may result in termination from the medicaid program.

(F) To inform ODM within thirty days of any changes including, but not limited to changes in licensure, certification, or registration status; ownership; specialty; additions, deletions, or replacements in group membership and hospital-based physician affiliations; and address, including all locations where services are rendered.

(G) To disclose ownership and control information, and to disclose the identity of any person who has been convicted of a criminal offense related to medicare, medicaid, or services provided under Title XX of the Social Security Act as in effect on November 15, 2018 (Title XX), as specified in rule 5160-1- 17.3 of the Administrative Code.

(H) That neither the individual practitioner, nor the company, nor any owner, director, officer, or employee of the company, nor any independent contractor retained by the company, is currently subject to sanction under medicare, medicaid, or Title XX; or, is otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries.

(I) To provide to ODM, through the court of jurisdiction, notice of any bankruptcy action brought by the provider. Notice shall be mailed to: office of legal services, Ohio department of medicaid.

(J) To comply with the appropriate advance directives requirements for hospitals, providers of home health care, personal care services, and hospices as specified in Chapter 3701-83 of the Administrative Code.

(K) To comply with the confidentiality safeguards and the use and release of information regarding public assistance recipients as described in section 5101.27 of the Revised Code.

(L) To comply with section 121.36 of the Revised Code and rule 5160-1-39 of the Administrative Code when providing home care services.

Effective: 9/19/2019
Five Year Review (FYR) Dates: 5/24/2019 and 09/19/2024
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03 ; 5164.02
Prior Effective Dates: 04/07/1977, 12/30/1977, 01/01/1979, 03/23/1979, 08/31/1979, 11/01/1979, 07/01/1980, 07/07/1980, 10/01/1987, 01/01/1993, 05/30/2002, 01/01/2004, 09/26/2004, 08/11/2005, 12/30/2005 (Emer.), 03/27/2006, 08/02/2011