5160-4-01. Physician services

(A) Payment may be made for a covered service rendered by a physician only if the following conditions are met:

(1) The physician is currently enrolled as an Ohio medicaid provider;

(2) The service is rendered to a medicaid-eligible Ohio recipient in a state in which the physician is licensed or authorized to practice; and

(3) The service is within the scope of practice of the physician's specialty.

(B) Separate payment may be made for covered professional services rendered by a physician employed by or under contract with a facility such as a hospital or long-term care facility (i.e., a "facility-based" physician) only if the following additional conditions are met:

(1) The services contribute directly to the diagnosis or treatment of an individual patient;

(2) Any applicable requirements set forth in agency 5160 of the Administrative Code are satisfied; and

(3) The expenses associated with the provision of the professional services are excluded from the cost report of the facility.

(C) In addition to professional services, a facility-based physician often performs other services that are of benefit to patients in general (e.g., teaching; research; administration; supervision of professional or technical personnel, residents, interns, or fellows; or service on provider committees). Payment for such services may be made only to the employing or contracting provider.

(D) For the sole purpose of demonstrating eligibility for incentive payments made in accordance with Section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA, Pub. L. No. 111-5 ), codified at 42 U.S.C. 1396b (February 1, 2017), and with the regulations published at 42 C.F.R. Part 495 (October 1, 2016), an optometrist operating within the appropriate scope of practice defined in section 4725.01 of the Revised Code is considered to be a physician.

Replaces: 5160-4-01

Effective: 10/1/2017
Five Year Review (FYR) Dates: 10/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 10/01/1983 (Emer), 12/29/1983, 09/01/1989, 03/26/2001, 09/01/2005, 10/25/2008, 08/02/2011, 12/02/2011 (Emer), 03/02/2012