5160-11-09 Laboratory-related services: claim payment.

 

 

 

5160-11-09                  Laboratory-related services: claim payment.

 

 

 

(A)Any laboratory provider using the Ohio department of health (ODH) laboratory to perform a covered laboratory-related procedure for a medicaid-eligible individual must prepare specimens and complete necessary paperwork in accordance with all applicable ODH rules and practices. The laboratory provider is exempt from paying the ODH laboratory for the service; instead, the department will pay the ODH laboratory. The laboratory provider must not submit claims to the department for such procedures.

 

(B)For a covered global radiology procedure and its professional and technical components, the medicaid maximum payment amounts are specified in rule 5160-4-25 of the Administrative Code.

 

(C)For a covered laboratory-related service represented by a new healthcare common procedure coding system (HCPCS) procedure code that takes effect at the beginning of a calendar year, the initial maximum payment amount is established in accordance with rule 5160-1-60 of the Administrative Code.

 

(D)For any other covered laboratory-related service (global procedure, professional component, or technical component), the initial payment amount is the lesser of the submitted charge or the applicable medicaid maximum from the following list:

 

(1)For a molecular pathology procedure that is payable under the clinical laboratory fee schedule published by CMS, it is eighty per cent of the lowest payment amount established by CMS for any state, rounded to the nearest five-dollar multiple;

 

(2)For any other service that is payable under the clinical laboratory fee schedule published by CMS, it is ninety-five per cent of the Ohio-specific medicare allowed amount for that service; or

 

(3)For a service that is payable under the medicare physician fee schedule, it is ninety-five per cent of the Ohio-specific medicare allowed amount for that service.

 

(E)If the medicare amount for a service becomes less than the current medicaid maximum payment amount, then the medicaid maximum payment amount for that service is reestablished on the basis of the new medicare amount:

 

(1)For a molecular pathology procedure that is payable under the clinical laboratory fee schedule published by CMS, it is eighty per cent of the lowest payment amount established by CMS for any state, rounded to the nearest five-dollar multiple;

 

(2)For any other service that is payable under the clinical laboratory fee schedule published by CMS, it is ninety per cent of the Ohio-specific medicare allowed amount for that service; or

 

 

(3) For a service that is payable under the medicare physician fee schedule, it is ninety per cent of the Ohio-specific medicare allowed amount for that service.

(F) Both the medicare physician fee schedule and the clinical laboratory fee schedule are available from CMS, http://www.cms.gov.

(G) For convenience, a list of medicaid maximum payment amounts and additional claim-related information for clinical diagnostic procedures, molecular pathology procedures, and physician pathology procedures is available on the department's 'Fee Schedule and Rates' web page, which may be accessed through the department's main web page (http://medicaid.ohio.gov).

(H) The  payment  provisions  of  this  rule  supersede  entries  in  appendix  DD  to  rule 5160-1-60 of the Administrative Code that pertain to laboratory-related services.

Replaces:                                                              5160-11-05, part of 5160-11-08

Effective:                                                             04/01/2016

Five Year Review (FYR) Dates:                         04/01/2021

CERTIFIED ELECTRONICALLY

Certification

02/29/2016

Date

Promulgated Under:                           119.03

Statutory Authority:                           5164.02

Rule Amplifies:                                  5164.02

Prior Effective Dates:                         10/01/1984, 10/01/1984 (Emer), 12/30/1984,

05/09/1986, 02/17/1991, 02/01/1996 (Emer),

04/04/1996, 08/01/2001, 04/01/2004, 05/25/2006