Ohio

To calculate a Ohio Medicaid claim at 100% of the state regulation rates, use the default settings. The required fields are identified on the image below. Optional fields are either applied or not applied based on the specific contract language.

The following settings are either required or recommended for Ohio Medicaid managed care contracts.

  • Override Provider Number – Type the preferred provider number.
  • Override Provider Date – Type or select the override provider date.
  • State Code – Defaults to OH (this value cannot be changed).
  • Percent Reimbursement – This should be set to 100% unless specified otherwise. The Percent Reimbursement override is applied after the node calculations.

Note: Refer to the contract to determine the options to select and the values to enter.

The following table describes the fields on the OH tab of the Medicaid - Facility reimbursement tool.

Field

Description

Override Provider Number

Preferred provider number. Up to ten alphanumeric digits.

Override Service Date

Preferred service date. Use MM/DD/YYYY format. Overrides the service date on the claim with the date you enter. You may use the anchor date instead of this option.

State Code

This field defaults to OH, and it cannot be changed.

Do not consume charges

Provides the option not to consume charges. This is used for contract carve outs.

Do not consume units

Provides the option not to consume units. This is used for contract carve outs.

Percent Reimbursement

Three digit percentage amount.

Pay lesser of billed charges or Medicaid reimbursement

Option to pay the lower amount of billed charges or calculated Medicaid reimbursement.

Use admit date instead of service date

Provides the option to apply pricing logic by claim instead of by date of service. Ohio Medicaid treats each date of service as a separate claim.

Note: Selecting this option allows managed care payors to apply the pricing logic to the entire claim instead of by date of service.

OP

Use EAPG

Use the EAPG groupers to group and price claims.

Set OH Revenue Code Overrides

This section allows you to enter percent overrides for specific revenue codes. To access the Set Revenue Code Overrides section, click Set Rev Code Overrides.

  • To enter an override, type the revenue code in the Revenue Code field and type the override percentage in the % field. For example, typing 250 in the Revenue Code field and 50 in the % field causes all revenue 250 codes to reimburse at 50% of charges.
  • To enter an override for a range of revenue codes, type the revenue code range in the Revenue Code field and type the override percentage in the % field. For example, typing 250-259 in the Revenue Code field and 50 in the % field causes revenue codes 250 through 259 to reimburse at 50% of charges.

Note: This allows pass-throughs and carve outs in managed care contracts to use this reimbursement tool.

Apply Modifier 50 Logic

Provides the option to apply to apply modifier 50 pricing when the facility is not billing detailed line items.

  • Outpatient surgical line items are reimbursed at 150% of the grouper rate when Apply Modifier 50 Logic checked.
  • Outpatient surgical line items are reimbursed at 100% of the grouper rate when Apply Modifier 50 Logic cleared.

Price to zero on error

Enable (check) this option to include accounts that fail to price due to an error display with an expected reimbursement amount of zero ($0). When this check box is disabled (not checked), accounts price to 100% of billed charges.

IP

Do not apply transfer logic to psych DRGs

Provides the option to allow the facility to ignore transfer logic on psych DRGs 425-435 and pay the full DRG instead.

  • When this option is selected, Psych DRGs will always get the full DRG payment when transferring from one hospital to another hospital.
  • This is often used for facilities that are transferring to a distinct part psych unit in the same hospital.
  • This logic was developed for V15 pricing.
  • This does not apply to APR DRG pricing.

Note: This is optional is for IP. It is not used for OP.

Price according to V15 DRG logic

Provides the option to process claims based on the CMS V15 logic instead of the V15 DRG logic.

  • V15 logic was in place prior to APR DRG logic.
  • APR DRG logic was effective for dates of discharge on or after 07/01/2013 in OH Medicaid.

Note: This is optional is for IP. It is not used for OP.

Do not pay outliers

Provides the option when you do not want outlier payments calculated on claims pricing against this contract profile.. This is used for contract carve outs.

Note: This is optional is for IP. It is not used for OP.