5160-28-08.3 Cost-based clinics: submission and payment of RHC claims.

 

 

 

5160-28-08.3               Cost-based clinics: submission and payment of RHC claims.

 

 

 

(A)Claims for services provided to managed care plan (MCP) enrollees, including requests for prior authorization by an MCP of an RHC service, must be submitted in accordance with Chapter 5160-26 of the Administrative Code.

 

(B)In claims submitted to the department for all other services, an RHC must include the designated procedure code for an encounter.

 

(C)In  claims  submitted  to  the  department  for  supplemental  payment  for  services provided to an MCP enrollee, an RHC must also include the following data:

 

(1)The name of the MCP that paid for the RHC service;

 

(2) The identification code of the MCP, assigned by the department;

 

(3)The MCP payment plus amounts received from any other third-party payers; and

 

(4)Any other information, such as an adjustment reason code, that is necessary for the coordination of benefits.

 

(D)The department must pay a valid claim for supplemental payment within  four months. However, no supplemental payment will be made for a claim that is not submitted to the department within the limits specified in rule 5160-1-19 of the Administrative Code.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5160-28-08.3                                                                                                                         2

Replaces:                                                              Part of 5160-16-03, 5160-16-05

Effective:                                                             10/01/2016

Five Year Review (FYR) Dates:                         10/01/2021

CERTIFIED ELECTRONICALLY
Certification
09/19/2016
Date
Promulgated Under:	119.03
Statutory Authority:	5164.02
Rule Amplifies:	5164.02
Prior Effective Dates:	04/01/1980, 08/01/2001, 08/06/2001, 07/01/2006