5160-8-52 Services provided by a pharmacist.

(A) Definition. "Pharmacist" has the same meaning as in Chapter 4729:1-1 of the Administrative Code.

(B) Providers. An individual pharmacist may enroll in medicaid as a pharmacist provider.

(C) Coverage.

(1) Payment may be made only for a pharmacist service for which the following criteria are met:

(a) The service is within a pharmacist's scope of practice;

(b) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(c) For a service rendered by prescription, the pharmacist provider obtains an order issued by a practitioner having appropriate prescriptive authority and maintains supporting documentation; and

(d) The service is rendered for one of the following purposes:

(i) Managing medication therapy under a consulting agreement with a prescribing practitioner pursuant to section 4729.39 of the Revised Code;

(ii) Administering immunizations in accordance with section 4729.41 of the Revised Code; or

(iii) Administering medications in accordance with section 4729.45 of the Revised Code.

(2) Nothing in this rule precludes a medicaid managed care organization described in Chapters 5160-26 and 5160-58 of the Administrative Code from paying pharmacists for additional purposes, within scope of practice, including care management services that are rendered by a pharmacist without a consult agreement.

(3) Payment may be made for covered telehealth services in accordance with rule 5160-1-18 of the Administrative Code.

(4) Services may be rendered through a standing order or protocol as described in Chapter 4729. of the Administrative Code.

(D) Claim payment.

(1) For a covered pharmacist service rendered at a federally qualified health center (FQHC) or rural health clinic (RHC), payment as an FQHC medical service or an RHC medical service is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For a covered immunization, injection of medication, or provider-administered pharmaceutical, payment is made in accordance with rule 5160-4-12 of the Administrative Code.

(3) For all other covered pharmacist services, payment is the lesser of the submitted charge or eighty-five per cent of the medicaid maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

(4) No separate payment will be made for pharmacist services provided in an inpatient or outpatient hospital, emergency department, or inpatient psychiatric facility place of service.

Effective: 1/17/2021

Five Year Review (FYR) Dates: 01/17/2021

CERTIFIED ELECTRONICALLY

_________________________________

Certification

01/07/2021

_________________

Date

Promulgated Under: 119.03

Statutory Authority: 5164.02

Rule Amplifies: 5164.02

5160-27-01 Eligible provider for behavioral health services.

(A) An "eligible behavioral health provider" for purposes of this chapter is a provider of a mental health or substance use disorder treatment service covered in agency 5160 of the Administrative Code and is one of the following:

(1) An entity operating in accordance with meeting the certification requirements set forth in section 5119.36 of the Revised Code and Chapters 5122-24 to 5122-29 and Chapter 5160-1 of the Administrative Code and providing mental health or substance use disorder treatment services.

(2) An entity furnishing mental health and/or substance use disorder services operating in a bordering state and operating in accordance with meeting the requirements set forth in rule 5160-1-11 of the Administrative Code. The entity must be an eligible and enrolled provider with the state medicaid agency in the state where the entity operates.

(3) Physician, as described in Chapter 4731 of the Revised Code, or physician assistant, as described in Chapter 4730 of the Revised Code,licensed by the state of Ohio medical board and practicing according to in accordance with agency 4731 and agency 4730 of the Administrative Code respectively and Chapter 5160-4 of the Administrative Code, or a clinical nurse specialist or certified nurse practitioner, as described in Chapter 4723 of the Revised Code, licensed by the Ohio board of nursing and practicing according to agency 4723 of the Administrative Code. The practitioner described in this paragraph must be an employee or an independent contractor of an entity operating in accordance with meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule.

(4) Registered nurse or licensed practical nurse as defined in 4723.01 of the Revised Code licensed by the Ohio board of nursing and practicing according to agency 4723 of the Administrative Code. The nurse must be an employee or an independent contractor of an entity operating in accordance with meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule. A registered nurse or licensed practical nurse must work under an order authorized by one of the practitioners listed in paragraph (A)(3) of this rule, except when a registered nurse performs a nursing regimen in accordance with section 4723.01 of the Revised Code or rule 5160-27-11 of the Administrative Code.

(5) A licensed practitioner type described inmeeting the requirements stated in rule 5160-8-05 of the Administrative Code and who is an employee or an independent contractor of an entity operating in accordance with meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule.

(6) An unlicensed practitioner operating in accordance with meeting the following requirements as applicable:

(a) An unlicensed practitioner providing mental health services who holds a valid high school diploma or equivalent and has both work experience and training related to the service(s) being provided, and is an employee or an independent contractor of an entity operating in accordance withmeeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule. These practitioners must operate under the general supervision of one of the practitioners listed in paragraphs (DE)(1) to (DE)(1610) of this rule, in accordance with paragraph (D)(2)(b) of rule 5160-8-05 of the Administrative Code.

(b) An unlicensed practitioner providing substance use disorder services must operate under the general supervision, in accordance with paragraph (D)(2)(b) of rule 5160-8-05 of the Administrative Code, of one of the practitioners listed in paragraphs (DE)(1) to (DE)(1610) of this rule, be an employee or an independent contractor of an entity operating in accordance with meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule, and be one of the following provider types:

(i) A chemical dependency counselor assistant operating in accordance with agency 4758 of the Administrative Code, and certified by the Ohio chemical dependency professionals board and practicing according to rule 5160-8-05 of the Administrative Code.

(ii) A peer recovery supporter who is meeting all of the following requirements:

(a) Certified as a peer recovery supporter by the Ohio department of mental health and addiction services; and.

(b)Be eighteen Eighteen years of age or older and has have a high school diploma or equivalent.

(iii) A care management specialist who meets meeting the following criteriarequirements:

(a) Be eighteen years of age or older and have a high school diploma or equivalent.

(b) Have an understanding of substance use disorder treatment and recovery including how to engage a person in treatment and recovery.

(c) Have an understanding of health care systems, social service systems, and the criminal justice system.

(7) A pharmacist operating in accordance with rule 5160-8-52 of the Administrative Code. The pharmacist will be an employee or an independent contractor of an entity described in paragraph (A)(1) or (A)(2) of this rule.

(B) All practitioners shall practice within their professional scope of practice.

(C) Supervisors shall ensure that individuals whom they supervise meet the appropriate education and training qualifications for the service(s) they render.

(D) Provider agencies shall have an active provider agreement with the Ohio department of medicaid.

(E)(D) Supervising practitioners:The following practitioners shall have an active provider agreement with the Ohio department of medicaid:

(1) Physician.

(2) Physician assistant.

(3) Certified nurse practitioner.

(4) Clinical nurse specialist.

(5) Psychologist.

(6) Board licensed school psychologist.

(7) Licensed independent social worker.

(8) Licensed professional clinical counselor.

(9) Licensed independent marriage and family therapist.

(10) Licensed independent chemical dependency counselor.

(11) Licensed practical nurse.

(12)(11) Registered nurse.

(12) Licensed marriage and family therapist.

(13) Licensed chemical dependency counselor II.

(14) Licensed chemical dependency counselor III.

(15) Licensed professional counselor.

(16) Licensed social worker.

(F) An eligible provider meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule must ensure that all contact information for their business including all physical locations where services are rendered are listed correctly in the medicaid information technology system (MITS) and updated within thirty days of any change in operations.

Effective: 1/17/2021

Five Year Review (FYR) Dates: 1/1/2023

CERTIFIED ELECTRONICALLY

________________________________

Certification

01/07/2021

_________________

Date

Promulgated Under: 119.03

Statutory Authority: 5162.02, 5164.02

Rule Amplifies: 5162.03, 5164.02, 5162.371, 5119.391

Prior Effective Dates: 01/01/2018, 08/01/2019 (Emer.), 11/29/2019

5160-27-02 Coverage and limitations of behavioral health services.

(A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified.

(1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illness or substance use disorder. The list of recognized diagnoses can be accessed at www.medicaid.ohio.gov.

(2) Medicaid reimbursable behavioral health services are limited to medically necessary services defined in rule 5160-8-05 of the Administrative Code and Chapter 5160-27 of the Administrative Code. Providers shall follow the requirements in rule 5160-8-05 of the Administrative Code and Chapter 5160-27 of the Administrative Code regarding services that cannot be billed in combination with other services.

(B) The following services have limitations on the amount, scope or duration of service that can be rendered to a recipient within a certain timeframe. These limits can be exceeded with prior authorization from ODM or its designee.

(1) Screening, brief intervention and referral to treatment (SBIRT) as defined by the American medical association's current procedural terminology book. Limitation for this service is one per code, per recipient, per billing provider, per calendar year.

(2) Assertive community treatment (ACT) as defined in rule 5160-27-04 of the Administrative Code is available on or after the date as determined by prior authorization approval.

(3) Intensive home based treatment (IHBT) as defined in rule 5160-27-05 of the Administrative Code is available on or after the date as determined by prior authorization approval.

(4) Community psychiatric supportive treatment (CPST) services as defined in rule 5122-29-17 of the Administrative Code and meet the following requirements:

(a) All CPST services provided in social, recreational, vocational, or educational settings are allowable only if they are documented mental health service interventions addressing the specific individualized mental health treatment needs as identified in the recipient's individualized service plan.

(b) A billable unit of service for CPST may include either face-to-face or telephone contact between the mental health professional and the recipient or an individual essential to the mental health treatment of the recipient.

(c) CPST services are not covered under this rule when provided in a hospital setting, except for the purpose of coordinating admission to the inpatient hospital or facilitating discharge to the community following inpatient treatment for an acute episode of care.

(d) Medicaid reimbursement of CPST services is described in rule 5160-27-03 of the Administrative Code.

(5) Psychiatric diagnostic evaluation and psychiatric diagnostic evaluation with medical services are each limited to one encounter per recipient, per billing provider, per calendar year.

(C) The following services delivered to recipients with substance use disorders have limitations on the amount, scope or duration of service that can be rendered to a recipient within a certain timeframe. These limits can be exceeded with prior authorization from the ODM designated entity.

(1) Substance use disorder assessment as referenced in rule 5160-27-09 of the Administrative Code is limited to two hours per recipient, per billing provider, per calendar year.

(2) Substance use disorder urine drug screening as referenced in rule 5160-27-09 of the Administrative Code, is limited to one per day, per recipient.

(3) Substance use disorder peer recovery support as referenced in rules 5160-27-09 and 5160-43-04 of the Administrative Code is limited to four hours per day per recipient.

(4) Substance use disorder partial hospitalization as described in rule 5160-27-09 of the Administrative Code is available on or after the date as determined by prior authorization approval. The prior authorization request must substantiate that the recipient meets the partial hospitalization level of care of twenty or more hours of service per week. In accordance with rule 5160-1-27 of the Administrative Code ODM may retrospectively review the case that the number of hours of service delivered matches the approved level of care.

(5) Substance use disorder residential level of care as described in rule 5160-27-09 of the Administrative Code is available for up to thirty consecutive days without prior authorization per medicaid recipient for the first and second admission, during the same calendar year. If the stay continues beyond thirty days of the first or second stay, prior authorization is required to support the medical necessity of continued stay. If medical necessity is not substantiated and not approved by the ODM designated entity, only the initial thirty consecutive days will be reimbursed. Third and subsequent admissions during the same calendar year must be prior authorized by the ODM designated entity from the date of admission.

(D) The medications listed in the appendix to rule 5160-27-03 or appendix DD to rule 5160-1-60 of the Administrative Code are covered by ODM when rendered and billed by an eligible provider as described in rule 5160-27-01 of the Administrative Code. The medication must be administered by a qualified practitioner acting within their professional scope of practice.

(E) Laboratory services, vaccines, and medications administered in a prescriber office may be administered in accordance with rule 5160-1-60 of the Administrative Code.

(F) Medical and evaluation and management services stated in the appendix to rule 5160-27-03 of the Administrative Code or appendix DD to rule 5160-1-60 of the Administrative Code are covered by ODM when rendered by:a practitioner as described in paragraphs (A)(3) and (A)(4) of rule 5160-27-01 of the Administrative Code and operating within their scope of practice.

(1) A practitioner as described in paragraphs (A)(3) and (A)(4) of rule 5160-27-01 of the Administrative Code and operating within their scope of practice; or

(2) A pharmacist, in accordance with rule 5160-8-52 of the Administrative Code.

(G) CMS place of service code set descriptions may be found at www.cms.gov. The department further defines place of service 99 as "community," and this place of service may only be used when a more specific place of service is not available. Place of service 99 shall not be used to provide services to a recipient of any age if the recipient is being held in a public institution as defined in 42 C.F.R. 435.1010 (October 1, 2016).

(H) The activities that comprise or are included in the aforementioned medicaid reimbursable behavioral health services must be intended to achieve identified treatment plan goals or objectives. Providers shall maintain treatment records and progress notes as specified in rules 5160-01-27 and 5160-8-05 of the Administrative Code. A treatment plan for mental health services may only be developed by a practitioner who, at a minimum, meets the therapeutic behavioral services practitioner requirements found in paragraphs paragraph (A)(2)(6)(a)(i) and (A)(2)(a)(ii) of rule 5160-27-08 5160-27-01 of the Administrative Code. A treatment plan for substance use disorder services may only be developed by a practitioner who, at a minimum meets the practitioner requirements found in paragraph (A)(6)(b)(i) or (A)(6)(b)(iii) of rule 5160-27-01 of the Administrative Code.

(I) The medications and services listed in the appendix to rule 5160-27-03 of the Administrative Code or the opiate treatment service section of appendix DD to rule 5160-1-60 of the Administrative Code are reimbursed by the department when rendered and billed by an opiate treatment program as described in Chapter 5122-40 of the Administrative Code and licensed as such by the Ohio department of mental health and addiction services and/or federally certified as such as stated in 42 CFR 8.11 (October 1, 2016). Reimbursement rates are determined by the methodology described in paragraph (E) of rule 5160-4-12 of the Administrative Code or as listed in the appendix to rule 5160-27-03 of the Administrative Code or as listed in appendix DD to rule 5160-1-60 of the Administrative Code.

(J) When permitted, provision of any service addressed in Chapter 5160-27 of the Administrative Code by telehealth interactive videoconferencing as defined in rule 5122-29-31 of the Administrative Code, must comply with the appropriate telehealth interactive videoconferencing requirement(s) found in rule 5122-29-31 5160-1-18 of the Administrative Code.

(K) The services described in this chapter shall not substitute or supplant natural supports and do not include any of the following:

(1) Educational, vocational, or job training services.

(2) Room and board.

(3) Habilitation services including but not limited to financial management, supportive housing, supportive employment services, and basic skill acquisition services that are habilitative in nature.

(4) Services to recipients who are being held in a public institution as defined in 42 C.F.R. 435.1010 (October 1, 2016);

(5) Services to individuals residing in institutions for mental diseases as described in 42 C.F.R. 435.1010 (October 1, 2016);

(6) Recreational and social activities, including but not limited to art, music, and equine therapies;

(7) Services that are covered elsewhere in agency 5160 of the Administrative Code; and

(8) Transportation for the recipient or family.

(L) Peer recovery services as defined in rule 5122-29-15 of the Administrative Code are covered when delivered:

(1) Through the specialized recovery services program in accordance with rule 5160-43-04 of the Administrative Code; or

(2) As a component of assertive community treatment as defined in rule 5160-27-04 of the Administrative Code: or

(3) As a component of substance use disorder residential treatment as defined in rule 5160-27-09 of the Administrative Code; or

(4) As a substance use disorder outpatient treatment service in accordance with rule 5160-27-09 of the Administrative Code.

(L) Health home services as described in rule 5122-29-33 of the Administrative Code shall be available until July 1, 2018, at which time the service shall be terminated. Until that date eligibility for health home services is determined as follows:

(1) Health home enrollment is restricted to persons with serious and persistent mental illness as defined in rule 5122-29-33 of the Administrative Code and in accordance with additional eligibility criteria defined by the Ohio department of medicaid in collaboration with the Ohio department of mental health and addiction services as stated in the eligibility criteria document created on May 16, 2014 and available at www.medicaid.ohio.gov.

(2) Persons who do not meet the eligibility criteria stated in the eligibility criteria document will continue to be eligible for health home services if they meet the following criteria:

(a) They are enrolled in a health home located in Adams, Butler, Lawrence, Lucas, or Scioto counties for an effective date prior to July 1, 2014, and

(b) The health home in which they were enrolled prior to July 1, 2014, delivered a health home service to the person during the month of June 2014.

(3) Health home services must be provided only in geographical regions approved by the centers for medicare and medicaid services (CMS).

(4) When a health home enrollee or the parent or guardian requests to disenroll from the health home, the health home must process the disenrollment within three business days. The request for disenrollment, including the date the request was made, must be recorded in the client record.

(5) Health home services must be provided in accordance with rule 5122-29-33 of the Administrative Code. Health home services performed after the development of the single, person-centered, integrated care plan must be directly linked to the goals and actions documented in the single, person-centered integrated care plan. Health home services shall be documented as necessary to establish medical necessity as defined in Chapter 5160-1 of the Administrative Code.

Effective: 1/17/2021

Five Year Review (FYR) Dates: 4/30/2023

CERTIFIED ELECTRONICALLY

________________________________

Certification

01/07/2021

_________________

Date

Promulgated Under: 119.03

Statutory Authority: 5164.02, 5162.05, 5162.02

Rule Amplifies: 5164.02, 5164.88, 5164.76, 5164.15, 5164.03

Prior Effective Dates: 01/01/2018, 01/02/2018 (Emer.), 05/03/2018

Ohio Department of Medicaid

Health Home SPMI/SED Enrollee Identification Methodology

Using Updated Mental Health Diagnosis Codes

May 16, 2014

To be enrolled in an Ohio Mental Health -Health Home, a Medicaid consumer must meet at least ONE of the four pathways during the research time: period* ¹

1. Medicaid Mental Health Claims History

A. Four or more visits with one or more of the following Mental Health codes (data provided by OhioMHAS):

AND

B. One or more Medicaid claims containing a primary or secondary mental health diagnoses listed in "Attachment 1*- Health Home Mental Health Diagnosis Codes."

2. High Mental Health pharmaceutical use defined as:

A. Received 12 or more prescriptions during the research time period from the following drug classes or lists

i. Psychotherapy medications, Tranquilizers, Antipsychotics;

ii. Antimanic Agents;

iii. Anticonvulsant, Benzodiazepine;

iv Anticonvulsant, Misc;

v. Any drug listed on Attachment 2* Health Home Mental Health Pharmaceuticals

vi If the client is age 18 or younger, any drug listed on Attachment 3* Additional Health Home Mental Health Pharmaceuticals for Consumers 18 and Younger

¹ The research time period will be updated regularly based on updated Medicaid claims data. As of April 2014,the research time period will be Jan 1- Dec 31, 2013.

•Attachments 1, 2 and 3 referenced above are available on the web site of Ohio Department of Mental Health Addiction Services at the following link: http://mha.ohio.gov/Default.aspx?tabid=601

OR

B. Received any office administered antipsychotic medication ("J code injectable") AND In addition to 2A OR 2B, the enrollee must have BOTH:

C. One or more Medicaid claims containing a primary or secondary mental health diagnoses listed in "Appendix A: Health Home Mental Health Diagnosis Codes."

AND

D. Meets the cost threshold of greater than or equal to the average total Medicaid cost of the SPMI/SED overall population ($10,471 for SPMI; $5,653 for SED)

3. History of Hospital Inpatient Admission

A. Has had at least one inpatient hospital admission during the research period for any primary diagnosis

AND

B. Has had one or more Medicaid claims containing a primary or secondary mental health diagnoses listed in "Appendix A: Health Home Mental Health Diagnosis Codes."

AND

C. Has had Medicaid claims during the research period of at least the average total cost of SPMIISED overall population ($10,471 for SPMI; $5,653 for SED)

4. History of Emergency Room Use

A. Has had 4 or more visits to a hospital emergency department

AND

B. One or more Medicaid claims containing a primary or secondary mental health diagnoses listed in " Appendix A: Health Home Mental Health Diagnosis Codes."

AND

C. Has Medicaid claims during the research period of at least the average total cost of the SPMI/SED overall population ($10,471 for SPMI; $5,653 for SED)

5160-27-03 Reimbursement for community behavioral health services.

(A) This rule sets forth the reimbursement requirements and rates for behavioral health services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code.

(B) Providers rendering community behavioral health services shall abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code.

(C) Records related to services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456.3 (October 1, 2016) and rule 5160-01-27 of the Administrative Code.

(D) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, Medicaidmedicaid reimbursement rates for services and practitioners described in Chapter 5160-27 of the Administrative Code are listed in the appendix to this rule. Ohio medicaid shall reimburse the provider the lower of either their usual and customary charges or the reimbursement amount described in the appendix to this rule.

(1) The reimbursement rate for physicians, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(2) The reimbursement rate for clinical nurse specialists, certified nurse practitioners, and physician assistants, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is eighty-five per cent of the medicaid maximum rate stated in the appendix to this rule; except for evaluation and management office/outpatient visits, psychiatric diagnostic evaluations, and smoking and tobacco cessation counseling the reimbursement rate is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(3) The reimbursement rate for practitioners described in paragraph (A)(5) of rule 5160-27-01 of the Administrative Code is the reimbursement rate percentage described in rule 5160-8-05 of the Administrative Code (medicaid maximum rate stated in the appendix to this rule). The reimbursement rates for services not defined in rule 5160-8-05 of the Administrative Code are stated in the appendix to this rule.

(4) The reimbursement rates for practitioners described in rule 5160-27-01 of the Administrative Code and not otherwise addressed in paragraph (D) of this rule, are stated in the appendix to this rule.

(5) The reimbursement rate for pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code is set forth in rule 5160-8-52 of the Administrative Code.

(E) The medicaid reimbursement rate for any of the following services provided for more than ninety minutes by the same billing provider, to the same recipient, on the same calendar day will be fifty per cent of the rate listed in appendix to this rule.

(1) Community psychiatric supportive treatment as described in rule 5122-29-17 of the Administrative Code.

(2) Therapeutic behavioral service as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(3) Psychosocial rehabilitation as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(4) Substance use disorder targeted case management as described in rule 5160-27-10 of the Administrative Code.

(F) Providers identified in rule 5160-27-01 of the Administrative Code must identify the rendering practitioner as follows:

(1) For practitioners who are eligible to enroll with Ohio medicaid and who meet the requirements of Chapter 5160-27 of the Administrative Code, list their national provider identifier number in the rendering field on the claim, or

(2) For licensed practitioners who do not have an independent professional scope or for practitioners that are unlicensed, include the modifier that accurately describes their credentials.

(G) Medicaid reimbursement is contingent upon providers maintaining complete and accurate documentation as required by Chapter 5160-27 of the Administrative Code.

(H) Medicaid behavioral health claims submitted for reimbursement must comply with the requirements of the national correct coding initiative of the centers for medicare and medicaid services.

(I) Behavioral health services that are reimbursable by medicare shall be billed first to medicare in accordance with rule 5160-1-05 of the Administrative Code unless otherwise provided by paragraph (K) of this rule. Failure to do so may result in denial of the medicaid claim.

(J) Behavioral health services that are reimbursable by a third party health care insurer shall be billed first to the third party health care insurer in accordance with rule 5160-1-08 of the Administrative Code unless otherwise provided by paragraph (K) of this rule. Failure to do so may result in denial of the medicaid claim.

(K) If a behavioral health provider, as defined in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code, has billed a third party in accordance with either paragraph (I) or paragraph (J) of this rule and the third party has not paid the claim within thirty days, and the provider has concerns regarding the recipient's access to care, the provider may submit the claim for medicaid reimbursement. The provider must include, with the submitted claim, a certification statement that the provider waited thirty days, access to care for the recipient is a concern, and no response was received from the third party.

(L) Place of service codes for behavioral health services as described in paragraph (G) of rule 5160-27-02 of the Administrative Code are stated in the appendix to this rule.

Effective: 1/17/2021

Five Year Review (FYR) Dates: 4/30/2023

CERTIFIED ELECTRONICALLY

________________________________

Certification

01/07/2021

________________

Date

Promulgated Under: 119.03

Statutory Authority: 5162.02, 5164.02

Rule Amplifies: 5162.05, 5164.02 , 5164.03, 5164.15, 5164.76

Prior Effective Dates: 01/01/2018, 01/02/2018 (Emer.), 05/03/2018, 08/01/2019 (Emer.), 11/29/2019