← Back to list
[Ohio] Appropriate Billing of Services
Act
by Aug 13, 2026
Effective date
Aug 13, 2026
Identified
Jul 14, 2026
Summary
CareSource (Ohio Medicaid & MyCare) is enforcing 12 specific billing compliance initiatives aligned with Ohio Administrative Code rules, effective August 13, 2026. Providers must immediately audit billing practices for dialysis frequency limits, post-operative E&M bundling, incontinence supply limits, inpatient service bundling, sedation bundling, observation unit caps, readmission consolidation, behavioral health same-day restrictions, hospice/NF overlap denials, HCBS/institutional overlap denials, and OTP unit limits. Non-compliance will result in claim denials and payment interruptions.
Get alerts when payers change rules like this one
We check CareSource and other payers every day and email you when a change matches your specialty and state.
Get CareSource alertsPolicy Monitoring is free. No card required.
What to do
by Aug 13, 2026 · 15 steps
01Billing team must implement the following compliance measures.
02Audit all dialysis claims to verify session frequency complies with OAC Rule 5160-13-02(A)(6)(a-e) and enforce prior authorization for excess sessions.
03Implement system rules to bundle all E&M services into surgical global period claims per OAC Rule 5160-4-06(B)(6)2—do not bill separate E&M on surgery day or post-operative period.
04Enforce incontinence product/supply frequency limits per OAC Rule 5160-10-21(B)2.
05Bundle all E&M services into inpatient dialysis professional service payment per OAC Rule 5160-4-22-14(B)(2)(c)—do not bill E&M separately.
06Do not bill separate conscious sedation for radiology per OAC Rule 5160-4-25(A)(6)2.
07Do not bill separate sedation or anesthesia for surgical services when provider performs both per OAC Rule 5160-4-22(A)(1)(a)2.
08Cap hourly observation services (G0378) to 24 units/day or 48 consecutive units (2 days max) per OAC Rule 5160-2-75(G)(6)(b/c).
09Consolidate next-day hospital readmissions to same facility as single DRG per OAC OAC 5160-2-65(M)(5).
10Add system logic to prevent same-day behavioral health diagnostic evaluation + therapy billing by same provider unless prior authorization exists per OAC Rule 5160-8-05(D)(3)(a)2.
11Deny NF room & board when member receives overlapping hospice services per OAC Rule 5160-56-06.
12Do not reimburse HCBS personal care aide or home-delivered meals during inpatient/SNF stays per OAC Rules 5160-44-01 and 5160-46-04.
13Enforce weekly methadone/buprenorphine administration limits per Rule 5122-40-06 using OTP Billing Guidance.
14Update billing software validation rules, encounter forms, and provider training materials.
15Contact CareSource Provider Services (1-800-488-0134) for clarification.
If missed: Failure to comply will result in claim denials and payment delays.
Codes mentioned
G0378
Original notice
[Ohio] Appropriate Billing of Services
caresource.com · Always check the source before changing claims.