Nursing Facility Services. For Medicaid covered nursing facility stays, the MCP shall evaluate the member’s need for the level of services provided by a nursing facility. To make this decision, the MCP shall use the criteria for nursing facility-based level of care pursuant to OAC rules 5160-3-08, 5160-3-09, and 5160-1-01. The MCP shall evaluate for both intermediate and skilled levels of care concurrently when making a level of care determination. The MCP shall provide documentation of the member’s level of care determination to the nursing facility. If properly submitted by a provider, the MCP is required to accept the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form to prior authorize nursing facility services and determine level of care. The MCP shall maintain a written record that the criteria were met, or if not met, the MCP shall maintain documentation that a Notice of Action was issued in accordance with OAC rule 5160-26-08.4. In accordance with OAC rule 5160-3-14, the preadmission screening and resident review (PASRR) process must be completed before a level of care determination can be issued. The MCP shall have processes in place to ensure that PASRR requirements are met in accordance with OAC chapter 5160-3 prior to issuing a level of care determination. At a minimum, the MCP shall pay nursing facility providers in accordance with ORC section 5165.15. Additionally, the MCP shall ensure accurate claims payment to nursing facility providers by appropriately modifying payment pursuant to OAC rule 5160-3-39.1 when a member has patient liability obligations or lump sum amounts. Patient liability shall be applied as an offset against the amount Medicaid would otherwise reimburse for the claim. If the patient liability exceeds the amount Medicaid would reimburse, the claim shall be processed with a payment of zero dollars. The MCP is prohibited from paying for nursing facility services during restricted Medicaid coverage periods (RMCP). The MCP shall utilize HIPAA compliant enrollment files for patient liability obligations and RMCPs.
Appears in 10 contracts
Samples: Provider Agreement, Provider Agreement, Provider Agreement
