5101:3-1-19.2   Medicaid Claim Formats for the Submission of Claims via Electronic Data Interchange (EDI) [Except for Services Provided through a Medicaid Managed Care Program]

Effective Date: May 23, 2007

Most Current Prior Effective Date:   April 1, 2005

(A)      Providers submitting claims electronically in compliance with EDI standards established under the Health Insurance Portability and Accountability Act of 1996 will use the 837 electronic transaction sets as follows:

(1)      When billing ODJFS in an EDI format, the following services must be submitted in the "837 Health Care Claim Professional (837P)" electronic format:

(a)      Physician services provided by individual physician practices, physician group practices, hospice organizations, and ambulatory surgery centers;

(b)      Hospice services;

(c)       Ambulatory surgery center facility services;

(d)      Ambulatory clinic services provided by fee-for-service clinics, federally qualified health centers, (FQHCs), rural health clinics, and (RHCs), outpatient health facilities (OHFs), with the exception of free standing dialysis clinic services;

(e)      Home health services;

(f)       Waiver services;

(g)      Private duty nursing services;

(h)      Podiatry services;

(i)        Diagnostic facility services;

(j)        Ambulance services;

(k)       Ambulette services;

(l)        Chiropractic services;

(m)     Durable medical equipment services;

(n)      Medical supply services;

(o)      Vision, optometric, optician and eyewear services;

(p)      Medicare crossover claims for professional services;

(q)      Independent psychology services;

(r)       Independent physical therapy services;

(s)       Independent laboratory services;

(t)       Independent portable x-ray facility services;

(u)      Advanced practice nurse (APN) services; provided by individual physician practices, group physician practices, hospice organizations, ambulatory surgery centers, RHC-based, FQHC-based, and OHF-based practices;

(v)       Osteopathic physician services;

(v)       Anesthesiology assistant services; and

(w)      Certified registered nurse anesthetist (CRNA) services.

(2)      When billing ODJFS in an EDI format, the following services must be submitted in the "837 Health Care Claim Institutional (837I)" electronic format:

(a)      Inpatient and outpatient hospital services;

(b)      Inpatient and outpatient hospital medicare crossover claims;

(c)       Nursing facility therapy services;

(d)      Nursing facility medicare crossover claims;

(e)      Nursing facility per diem rates services in accordance with Chapter 5101:3-3 of the Administrative Code; and

(f)       Free standing dialysis clinic services.

(3)      When billing ODJFS in an EDI format, dental services must be submitted in the "837 Health Care Claim Dental (837D)" electronic format.

(B)      ODJFS requires that providers use the health care financing administration's common procedures coding system (HCPCS) as referenced in rule 5101:3-1-19.3 of the Administrative Code to indicate the procedure and/or services rendered to the consumer as specified in rule 5101:3-1-60 of the Administrative Code, and appendix DD to rule 5101:3-1-60 of the Administrative Code.

(C)      "The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) 2005 Edition" is to be used to specify the diagnosis or nature of the injury of the patient related to the service provided.

Effective: 05/23/2007

R.C. 119.032 review dates: 03/06/2007 and 05/01/2012

Certification: CERTIFIED ELECTRONICALLY

Date: 05/11/2007

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 10/16/03 (Emer), 1/1/04, 4/1/05