Section 5123-7-15 - Intermediate care facilities for individuals with intellectual disabilities - claim submission(A) Purpose This rule establishes procedures for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to submit claims and be paid for services rendered.
(B) Submission of claims for payment for services included in the ICFIID per diem rate(1) An ICFIID shall: (a) Submit claims for payment to the Ohio department of medicaid in accordance with rule 5160-1-19 of the Administrative Code.(b) Submit claims for payment either directly or through a "trading partner" as that term is defined in rule 5160-1-20 of the Administrative Code.(c) Be a medicaid provider in an active enrollment status for all dates within the claim span.(2) A single claim will include days of service provided, including qualifying leave days, for a single resident within a single calendar month and will not cross calendar months. If an ICFIID determines that a claim that has been paid should have included additional per diem service days, the ICFIID shall timely submit an adjustment claim correcting the entire calendar month's claim information.(3) When a medicaid-eligible resident of an ICFIID has a patient liability obligation, the entire monthly amount of patient liability, as determined in accordance with rule 5160:1-6-07 of the Administrative Code, will be reported by the ICFIID on the resident's monthly claim. When a resident is admitted, discharged, or transfers to another facility mid-month, the entire monthly amount of patient liability will be reported on the claim for that month. The patient liability will be applied as an offset against the amount medicaid would otherwise reimburse for the claim. When the patient liability exceeds the amount medicaid would reimburse, the claim will be processed with a payment of zero dollars.(4) The treatment of lump sum payments and their disposition regarding medicaid eligibility are addressed in rule 5160:1-3-05.8 of the Administrative Code; if however, the county department of job and family services and the medicaid-eligible resident determine that the lump sum will be assigned to the ICFIID as payment for past per diem services received by the resident, the ICFIID shall submit adjustment claims for as many prior months as necessary to fully offset the amount of the lump sum payment that was assigned to the ICFIID. When there are lump sum monies remaining after adjusting all prior payments, the ICFIID shall apply the remaining lump sum balance to current and future claims. When the resident is discharged or passes away prior to exhausting the lump sum payment, the ICFIID shall return the balance to the individual or the individual's estate.
Replaces: 5123:2-7-15
Ohio Admin. Code 5123-7-15
Effective: 4/27/2023
Five Year Review (FYR) Dates: 04/27/2028
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.03
Prior Effective Dates: 01/10/2013, 07/01/2015, 07/01/2017