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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-28. Cost-Based Clinic (FQHC, OHF, RHC) Services |
5160-28-03.1. Cost-based clinics: FQHC services, co-payments, and limitations
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(A) A federally qualified health center (FQHC) may be paid on a per-visit basis for providing any of the following FQHC services:
(1) Medical services, which may comprise any of five kinds of services or items:
(a) All services referenced at 42 U.S.C. 1395x(aa)(3) (current as of July 28, 2015);
(b) Professional services furnished by a physician, physician assistant, or advanced practice registered nurse, except for mental or behavioral health services provided by an advanced practice registered nurse in accordance with paragraph (A)(4) of this rule;
(c) Services and supplies incident to the professional services of a physician, physician assistant, advanced practice registered nurse, clinical social worker, or psychologist for which no separate payment is made;
(d) Services of a registered nurse acting under the direct supervision of a physician unless provided incident to a professional service as described in paragraph (A)(1)(c) of this rule; or
(e) Visiting nurse services if four conditions are satisfied:
(i) The service site is located in an area in which the United States secretary of health and human services (HHS) has determined that there is a shortage of home health agencies;
(ii) The services are furnished by either a registered nurse or a licensed practical nurse employed by or under contract with the FQHC;
(iii) The services are furnished to a homebound individual; and
(iv) The services are furnished under a written plan of treatment that is established by a physician, physician assistant, or advanced practice registered nurse or by a supervising physician of the FQHC; is signed by a physician, physician assistant, or advanced practice registered nurse or by a supervising physician of the FQHC; and is reviewed at least every sixty days by a supervising physician of the FQHC.
(2) Dental services, which are identified in Chapter 5160-5 of the Administrative Code;
(3) Physical therapy services or occupational therapy services, which are identified in Chapter 5160-8 of the Administrative Code;
(4) Mental health services, which are identified in rule 5160-8-05 of the Administrative Code;
(5) Speech pathology and audiology services, which are identified in Chapter 5160-8 of the Administrative Code;
(6) Podiatry services, which are identified in Chapter 5160-7 of the Administrative Code;
(7) Vision services, which are identified in Chapter 5160-6 of the Administrative Code, except for services rendered by a physician (e.g., an ophthalmologist);
(8) Chiropractic services, which are identified in Chapter 5160-8 of the Administrative Code; or
(9) Transportation services to or from an FQHC service site where a covered visit takes place on the same date.
(B) An FQHC may be required to enroll separately in medicaid as another type of provider and to use a non-FQHC medicaid provider number in order to receive separate payment for a service or supply that cannot be claimed as an FQHC service under paragraph (A) of this rule.
(C) Co-payments established in accordance with rule 5160-1-09 of the Administrative Code apply to services rendered by an FQHC. Co-payments for services rendered to managed care enrollees are applied in accordance with Chapter 5160-26 of the Administrative Code.
(D) For each set of dentures, an FQHC may submit one claim for providing the service and not more than two additional claims for follow-up encounters.