5160-29-01 Eligible providers.

 

 

 

TO BE RESCINDED

 

5160-29-01                  Eligible providers.

 

 

In order to be determined eligible as an "outpatient health facility" (OHF) under the medicaid program, a facility must be determined by ODJFS to be in compliance with the conditions and provisions set forth in this rule.

 

(A)    An "eligible outpatient health facility" means a facility, other than an outpatient hospital facility, which:

 

(1)   Provides comprehensive primary health services, as defined in paragraph (E) of this rule, by or under the direction of a physician at least five days per week on a forty-hour-per-week basis to outpatients; and

 

(2)   Is operated by one of the following:

 

(a)   The board of health of a city or general health district; or

 

(b)   Another public agency; or

 

(c)   A nonprofit private agency or organization under the direction and control of a governing board that has no health-related responsibilities other than the direction and control of one or more such outpatient health facilities.

 

(3)     Receives at least seventy-five per cent of its operating funds from public sources. "Public sources" means the following:

 

(a)   Federal funds;

 

(b)   State funds;

 

(c)   City funds; and

 

(d)  County funds.

 

(4)   Is not eligible to be enrolled as an federally qualified health center (FQHC) or rural health clinic (RHC) as specified in rules 5101:3-28-01 and 5101:3-16-01 of the Administrative Code.

 

(B)   If an OHF has a current, valid provider number as either an FQHC or a RHC, the

 

 

 

provider must bill for services under the FQHC or RHC provider number in accordance with the policies set forth in Chapter 5101:3-28 or 5101:3-16 of the Administrative Code. Medicaid providers may only be enrolled as one type of alternative payment clinic for a single enrollment period. An "alternative payment clinic" shall be defined as an OHF, FQHC, or rural health clinic.

(C)   In addition to meeting the standards set forth for ambulatory health care centers under rule 5101:3-13-01 of the Administrative Code, an eligible outpatient health facility must also meet the requirements of division (C) of section 5111.04 of the Revised Code as follows:

(1)   Has health and medical care policies developed with the advice of and subject to review by an advisory committee of professional personnel, including one or more physicians, one or more dentists if dental care is provided, and one or more registered nurses.

(2)    Has a medical director, a dental director if dental care is provided, a nursing director, physicians, dentists, nursing, and ancillary staff appropriate to the scope of services provided.

(3)   Requires that the care of every patient be under the supervision of a physician, provides for medical care in case of emergency, has in effect a written agreement with one or more hospitals and one or more other outpatient facilities, and has an established system for the referral of patients to other resources and a utilization review plan and program.

(4)   Maintains clinical records on all patients.

(5)    Provides nursing services and other therapeutic services in compliance with applicable laws and rules and under the supervision of a registered nurse, and has a registered nurse on duty at all times when the facility is in operation.

(6)   Follows approved methods and procedures for the prescribing, dispensing, and administration of drugs and biologicals.

(7)     Maintains the accounting and record-keeping system required under federal laws and regulations for the determination of reasonable and allowable costs. Requirements for accounting and record-keeping systems adequate to be reimbursed on a prospective cost-related basis are described in rule 5101:3-29-05 of the Administrative Code.

(D)   Each site approved as an OHF will have an individual provider agreement and will

have a unique provider number assigned by the Ohio department of job and family services with the exception of those outpatient health facilities which meet the provisions of paragraphs (D)(1) to (D)(3) of this rule. A "site" is defined as a service delivery location which independently meets all requirements set forth in this rule except for services provided to hospitalized or temporarily home-bound patients. Services provided at locations other than the approved site are not recognized as OHF services. If a legal entity operates more than one qualified site as defined in this paragraph, a single provider number may be assigned, at the legal entity's option, if all of the following requirements are met:

(1)      Each  participating  site  operated  by  the  legal  entity  independently  meets requirements for service provision as defined in paragraph (E) of this rule.

(2)    The legal entity operating the sites assures that the requirements set forth in paragraphs (A) to (C)(7) of this rule are met for each participating site.

(3)    The legal entity has a single, central, uniform accounting and record-keeping system applying to all participating sites.

(E)    "Comprehensive primary health services" are those covered preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services provided by or under the direction of a physician at least five days per week on a forty-hour-per-week basis that include all of the following:

(1)   On-site provision of:

(a)   Services of physicians, physician assistants, and advanced practice nurses;

(b)      Covered preventive health services, such as children's eye and ear examinations, perinatal services, well-child services, and pregnancy prevention/contraceptive management in accordance with rule 5101:3-21-02 of the Administrative Code;

(c)   Covered obstetrical care services, including a prenatal risk assessment for every woman receiving prenatal services, and at-risk pregnancy services as described in Chapter 5101:3-4 of the Administrative Code for every woman diagnosed at risk of premature birth or poor pregnancy outcome;

(d)  Diagnostic laboratory services including, at a minimum:

(i)    Chemical examinations of urine by strip or tablet methods or both

(including urine ketones);

(ii)   Microscopic examinations of urine sediment;

(iii)   Hemoglobin or hematocrit;

(iv)   Blood sugar;

(v)   Gram stain;

(vi)   Examination of stool specimens for occult blood;

(vii)   Pregnancy tests;

(viii)   Primary culturing for transmittal to a certified laboratory;

(ix)   Test for pinworm; and

(x)   Drawing blood for a lead poisoning screening.

(e)   Diagnostic radiological services including at a minimum:

(i)   Chest X-ray; and

(ii)   X-rays necessary to diagnose treatment of a broken foot, ankle, leg, arm, or hand.

(2)   On-site provision of or arrangement for:

(a)   Transportation services; and

(b)   Emergency medical services.

Effective:	10/01/2016
Five Year Review (FYR) Dates:	02/10/2016
CERTIFIED ELECTRONICALLY
Certification
09/19/2016
Date
Promulgated Under:	119.03
Statutory Authority:	5164.02
Rule Amplifies:	5162.03, 5164.02, 5164.05, 5164.70
Prior Effective Dates:	11/10/1983, 04/18/1988, 11/01/2001, 05/01/2005,
	07/01/2009