Ohio Administrative Code|Rule 5160-1-17 | Eligible providers.

                                                
This rule sets forth eligibility requirements for
		practitioners, group practices, or organizational providers enrolling with, and
		seeking reimbursement from, the Ohio medicaid program.
(A) Eligible provider means any
		  practitioner, group practice, or organization identified by the Ohio department
		  of medicaid (ODM) as a type of provider eligible to enroll in the medicaid
		  program that:
(1) Meets the applicable
			 provider requirements and standards in agency 5160 of the Administrative Code
			 that address applicable service categories and provider types covered under the
			 Ohio medicaid program;
(2) Meets additional
			 requirements and standards set forth in this rule;
(3) Meets provider
			 screening requirements and, when applicable, pays the fee for enrollment as a
			 provider in the medicaid program in accordance with rule 5160-1-17.8 of the
			 Administrative Code; and
(4) Is approved for
			 participation in the medicaid program by ODM as evidenced by the issuance of
			 both a signed "provider agreement" and an Ohio medicaid provider
			 number.
(B) Eligible practitioners licensed by an Ohio licensing
		  board may enroll as a medicaid provider in accordance with their active
		  licensure and scope of practice as determined by the licensing
		  entity.
(C) A provider can be assigned a professional group
		  provider type when organized for the purpose of providing professional services
		  under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755.,
		  4757., 4759., or 4762. of the Revised Code, and meets the requirements in
		  either paragraph (C)(1) or (C)(2) of this rule, and meets the additional
		  requirements set forth in paragraphs (C)(3) to (C)(5) of this
		  rule.
(1) A professional
			 practice that is owned by an individual may be enrolled as a professional group
			 practice if the practice is formed as an organizational structure listed in
			 paragraph (C)(3) of this rule, and the owner or member of the practice
			 possesses a valid license, certificate, or other legal authorization issued
			 under Chapter 4715., 4723, 4725., 4730., 4731., 4732., 4734., 4753., 4755.,
			 4757., 4759., or 4762. of the Revised Code, and also meets the requirements
			 found in paragraph (A)(1) of this rule.
A provider enrolling with the medicaid program
			 that does not meet the provisions listed in paragraph (C) of this rule may only
			 be enrolled as an individual provider.
(2) Any group of two or
			 more individuals may be enrolled as a professional group practice if the
			 practice is formed as an organizational structure listed in paragraph (C)(3) of
			 this rule. ODM recognizes two types of professional group practices, a
			 professional medical group and a professional dental group.
(a) A professional medical group is a group that consists
				of individual practitioners recognized by ODM as eligible members. These
				eligible members include but are not limited to: physicians, osteopaths,
				advanced practice nurses, physician assistants, psychologists, podiatrists,
				optometrists, chiropractors, licensed independent social workers, licensed
				professional clinical counselors, independent marriage and family counselors,
				licensed independent chemical dependency counselors, occupational therapists,
				physical therapists, speech therapists, acupuncturists, audiologists,
				opticians, ocularists, licensed dietitians and registered dietitian
				nutritionists. With the exception of an incorporated individual in accordance
				with paragraph (C)(3)(b) of this rule, the professional medical practice must
				consist of two or more members, of like or different scopes of practice or
				licensure.
(b) A professional dental group is a group that consists
				only of dentists. With the exception of an incorporated individual in
				accordance with paragraph (C)(3)(b) of this rule, the practice must consist of
				two or more dentists.
(c) An out of state professional medical group must abide
				by the requirements stated in rule 5160-1-11 of the Administrative
				Code.
(3) For the purposes of
			 the Ohio medicaid program, a professional group practice may be organized in
			 accordance with one of the following organization structures:
(a) A corporation formed under Chapter 1701. of the Revised
				Code.
(b) A limited liability company formed under Chapter 1705.
				of the Revised Code.
(c) A non-profit corporation formed under Chapter 1702. of
				the Revised Code.
(d) A professional association formed under Chapter 1785.
				of the Revised Code.
(e) A partnership formed under Chapters 1776. and 1782. of
				the Revised Code.
(4) With the exception of
			 hospitals, long term care facilities, home health agencies, hospice programs,
			 and intermediate care facilities, each practitioner employed by or under
			 contract with a group practice or an organization, including, but not limited
			 to professional group practices, clinics, federally qualified health centers,
			 and behavioral health facilities, who also meet the respective requirements in
			 paragraph (A) of the rule, must have an approved individual provider agreement
			 with ODM.
(5) Each practitioner,
			 employed or under contract with a group practice or an organization that is
			 actively enrolled as a provider in the Ohio medicaid program, shall affiliate
			 themselves with their respective group practices or organizational providers
			 when applying for a provider agreement with ODM.
(D) Requirements for obtaining and using national provider
		  identifiers (NPI).
(1) For the purposes of
			 receiving reimbursement for services rendered to medicaid recipients, ODM shall
			 require providers and practitioners enrolling in the medicaid program to obtain
			 a NPI.
(2) Providers, and
			 practitioners, whether practicing independently or employed or under contract
			 with a group practice or organization, who are identified by the american
			 medical association's national uniform claim committee with a provider
			 taxonomy number shall obtain a NPI and shall divulge the NPI to ODM upon
			 enrollment.
(3) The name and NPI of
			 the practitioner who furnishes services to medicaid recipients shall be on
			 claims submitted to ODM for reimbursement. Claims submitted without a NPI will
			 be denied.
(4) An organization with
			 components or subparts is responsible for determining if any components or
			 subpart of its organization require a separate NPI and, if so, shall obtain it
			 for that component or subpart.
(E) As part of the initial medicaid provider application,
		  an applicant shall include a list of all geographical locations at which it
		  renders services under its NPI. An existing provider shall submit to ODM any
		  additions or deletions to the list of locations within thirty calendar days of
		  the change. An enrolled provider must also notify ODM of any provider
		  affiliation additions or deletions within thirty days of the change. Failure to
		  follow the requirements of this paragraph may prevent an applicant from being
		  enrolled as a medicaid provider or if enrolled, may result in the termination
		  of a provider agreement as provided for in rule 5160-1-17.6 of the
		  Administrative Code.
(F) ODM does not enroll providers located outside of the
		  United States and its territories.