5160-12-03. Medicare certified home health agencies: qualifications and requirements

(A) A medicare certified home health agency ( MCHHA) that meets the requirements of this rule is eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5160-1- 17.2 of the Administrative Code.

(B) MCHHAs are required to:

(1) Be certified for medicare participation by the Ohio department of health (ODH) in accordance with Chapter 3701-60 of the Administrative Code.

(2) Meet the conditions of participation in accordance with 42 C.F.R. Part 484 (October 1, 2014).

(3) Implement policy components for home health and private duty nursing (PDN) as specified in the " medicare benefit policy manual, chapter seven: home health services" ( January 14, 2014) for the following sections:

(a) Section 20 " Conditions to be met for coverage of home health services" ;

(b) Secton 30.2" Services are provided under a plan of care established by and approved by a physician" to Section 30.3 " under the care of a physician" ; and

(c) Section 40 "Covered services under a qualifying home health plan of care" to Section 50.3 " medical social services" .

(4) Comply with all applicable requirements for medicaid providers in Chapter 5160-1 of the Administrative Code.

(5) Comply with all federal, state and local laws and regulations as applicable.

(6) Have back up staff available to provide services when the MCHHA's regularly scheduled staff cannot or do not meet their obligation to provide services.

(7) Submit written notification to the individual at least thirty days prior to the last date of service when terminating a service unless:

(a) The individual's treating physician has discontinued home health services;

(b) The treating physician has been notified that goals have been met;

(c) The individual no longer resides at their known place of residence or their whereabouts are unknown;

(d) The individual or another person has harmed or threatened to harm staff of the MCHHA ;

(e) The individual requested that services be terminated; or

(f) The individual has been enrolled in a medicaid managed care plan (MCP).

(8) Contact the individual's medicaid MCP when applicable to request prior authorization for home health and PDN services.

(9) Maintain documentation on all aspects of services provided in accordance with this chapter. All documentation must be complete prior to billing for services provided in accordance with this chapter and is subject to monitoring by ODM . This includes but is not limited to:

(a) Clinical records , including all signed orders .

(b) Time keeping records that indicate the date and time span of the services provided during each visit, and the type of service provided.

(10) Obtain the completed and signed ODM 07137 "Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services" (rev. 7/2014), which certifies the medical necessity for services in accordance with rule 5160-12-01 or rule 5160-12-02 of the Administrative Code.

Effective: 7/1/2015
Five Year Review (FYR) Dates: 04/14/2015 and 07/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02 , 5162.03
Prior Effective Dates: 4/7/77, 5/1/87, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer) 10/30/92, 7/1/93 (Emer), 9/1/93, 1/1/96, 7/1/98, 9/29/00, 9/1/05, 7/1/06, 11/08/07