OAC 5160-1-08 sets forth the conditions under which Ohio Medicaid will reimburse for medically necessary covered services after a provider takes reasonable measures to obtain all third-party payment. Effective November 29, 2019, based on temporary permission from the Centers for Medicare and Medicaid Services (CMS), ODM amended OAC rule 5160-27-03 to add an exception to allow community behavioral health providers to submit a claim for Medicaid reimbursement when the provider billed a third party, the third party had not paid the claim within 30 days, and the provider had concerns regarding the recipient's access to care. Effective July 1, 2022, OAC 5160-27-03 will be amended to remove this provision. Beginning July 1, 2022, community behavioral health providers are required to follow standard third-party payment requirements for Medicaid providers outlined in OAC rule 5160-1-08.

This change means behavioral health providers will resume following the 90 days and 3 attempts outlined in paragraph E(1)(b) of 5160-1-08 starting 7/1/22. This rule requires submission of claims to third-party payers (TPP) prior to submitting to Medicaid. This change does not impact the Third Party Liability (TPL) bypass process. The Ohio Council has confirmed with ODM that the TPL bypass list will remain in effect. More information on the TPL bypass process and the TPL bypass list are available here.