Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures

What this rule requires your agency to do

• 1Home modification (S5165) is limited to the amount prior-authorized on the PCSP, not to exceed $15,000 in a twelve-month calendar year; supplemental adaptive devices (T2029) and vehicle modification (T2039) not to exceed $10,000.(Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures)
• 2For waiver nursing (T1002), providers must use the U1 modifier when the individual is receiving infusion therapy.(Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures)
• 3Claims must be submitted to and reimbursed by ODM in accordance with Chapter 5160-1 of the Administrative Code.(Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures)
• 4Providers must use the 'TU' modifier when the entire claim is billed as overtime and 'UA' when only a portion is billed as overtime.(Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures)
• 5Providers must apply the U2/U3 modifiers when billing a second or third-plus visit to the same individual on the same date of service, and U4 for a single visit over twelve but not exceeding sixteen hours.(Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures)
• 6Reimbursement for a service is the lesser of the provider's billed charge or the Medicaid maximum rate.(Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures)
• 7Providers must bill personal care aide services under code T1019 and waiver nursing under T1002 (RN) or T1003 (LPN), not exceeding the Medicaid maximum rates set in the rule.(Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures)
• 8Providers must use the 'HQ' modifier for claims delivered in a group setting, reimbursed at the lesser of billed charge or seventy-five per cent of the Medicaid maximum.(Rule 5160-46-06 | Ohio home care waiver program: covered services, reimbursement rates, and billing procedures)