5101.573 Third-party duties - managed care organizations.
(A) Subject to divisions (B) and (C) of this section, a third party shall do all of the following:
(1) Accept the department of job and family services’ right of recovery under section 5101.58 of the Revised Code and the assignment of rights to the department that are described in section 5101.59 of the Revised Code;
(2) Respond to an inquiry by the department regarding a claim for payment of a medical item or service that was submitted to the third party not later than three years after the date of the provision of such medical item or service;
(3) Pay a claim described in division (A)(2) of this section;
(4) Not deny a claim submitted by the department solely on the basis of the date of submission of the claim, type or format of the claim form, or a failure by the medical assistance recipient who is the subject of the claim to present proper documentation of coverage at the time of service, if both of the following are true:
(a) The claim was submitted by the department not later than three years after the date of the provision of the medical item or service.
(b) An action by the department to enforce its right of recovery under section 5101.58 of the Revised Code on the claim was commenced not later than six years after the department’s submission of the claim.
(5)Consider the department’s payment of a claim for a medical item or service to be the equivalent of the medical assistance recipient having obtained prior authorization for the item or service from the third party;
(6)Not deny a claim described in division (A)(5) of this section that is submitted by the department solely on the basis of the medical assistance recipient’s failure to obtain prior authorization for the medical item or service.
(B) For purposes of the requirements in division (A) of this section, a third party shall treat a managed care organization as the department for a claim in which both of the following are true:
(1) The individual who is the subject of the claim received a medical item or service through a managed care organization that has entered into a contract with the department of job and family services under section 5111.17 of the Revised Code;
(2) The department has assigned its right of recovery for the claim to the managed care organization.
(C) The time limitations associated with the requirements in divisions (A)(2) and (A)(4) of this section apply only to submissions of claims to, and payments of claims by, a health insurer to which 42 U.S.C. 1396a(a)(25)(I) applies.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
5101.573 Third-party duties - managed care organizations.
(A) Subject to divisions (B) and (C) of this section, a third party shall do all of the following:
(1) Accept the department of job and family services’ right of recovery under section 5101.58 of the Revised Code and the assignment of rights to the department that are described in section 5101.59 of the Revised Code;
(2) Respond to an inquiry by the department regarding a claim for payment of a medical item or service that was submitted to the third party not later than three years after the date of the provision of such medical item or service;
(3) Pay a claim described in division (A)(2) of this section;
(4) Not deny a claim submitted by the department solely on the basis of the date of submission of the claim, type or format of the claim form, or a failure by the medical assistance recipient who is the subject of the claim to present proper documentation of coverage at the time of service, if both of the following are true:
(a) The claim was submitted by the department not later than three years after the date of the provision of the medical item or service.
(b) An action by the department to enforce its right of recovery under section 5101.58 of the Revised Code on the claim was commenced not later than six years after the department’s submission of the claim.
(5)Consider the department’s payment of a claim for a medical item or service to be the equivalent of the medical assistance recipient having obtained prior authorization for the item or service from the third party;
(6)Not deny a claim described in division (A)(5) of this section that is submitted by the department solely on the basis of the medical assistance recipient’s failure to obtain prior authorization for the medical item or service.
(B) For purposes of the requirements in division (A) of this section, a third party shall treat a managed care organization as the department for a claim in which both of the following are true:
(1) The individual who is the subject of the claim received a medical item or service through a managed care organization that has entered into a contract with the department of job and family services under section 5111.17 of the Revised Code;
(2) The department has assigned its right of recovery for the claim to the managed care organization.
(C) The time limitations associated with the requirements in divisions (A)(2) and (A)(4) of this section apply only to submissions of claims to, and payments of claims by, a health insurer to which 42 U.S.C. 1396a(a)(25)(I) applies.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
5101.573 Third-party duties - managed care organizations.
(A) Subject to divisions (B) and (C) of this section, a third party shall do all of the following:
(1) Accept the department of job and family services’ right of recovery under section 5101.58 of the Revised Code and the assignment of rights to the department that are described in section 5101.59 of the Revised Code;
(2) Respond to an inquiry by the department regarding a claim for payment of a medical item or service that was submitted to the third party not later than three years after the date of the provision of such medical item or service;
(3) Pay a claim described in division (A)(2) of this section;
(4) Not deny a claim submitted by the department solely on the basis of the date of submission of the claim, type or format of the claim form, or a failure by the medical assistance recipient who is the subject of the claim to present proper documentation of coverage at the time of service, if both of the following are true:
(a) The claim was submitted by the department not later than three years after the date of the provision of the medical item or service.
(b) An action by the department to enforce its right of recovery under section 5101.58 of the Revised Code on the claim was commenced not later than six years after the department’s submission of the claim.
(5)Consider the department’s payment of a claim for a medical item or service to be the equivalent of the medical assistance recipient having obtained prior authorization for the item or service from the third party;
(6)Not deny a claim described in division (A)(5) of this section that is submitted by the department solely on the basis of the medical assistance recipient’s failure to obtain prior authorization for the medical item or service.
(B) For purposes of the requirements in division (A) of this section, a third party shall treat a managed care organization as the department for a claim in which both of the following are true:
(1) The individual who is the subject of the claim received a medical item or service through a managed care organization that has entered into a contract with the department of job and family services under section 5111.17 of the Revised Code;
(2) The department has assigned its right of recovery for the claim to the managed care organization.
(C) The time limitations associated with the requirements in divisions (A)(2) and (A)(4) of this section apply only to submissions of claims to, and payments of claims by, a health insurer to which 42 U.S.C. 1396a(a)(25)(I) applies.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
