[Ohio] Appropriate Billing of Services

By August 13, 2026: Billing team must implement the following compliance measures: (1) Audit 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; (2) Implement 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; (3) Enforce incontinence product/supply frequency limits per OAC Rule 5160-10-21(B)2; (4) Bundle 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; (5) Do not bill separate conscious sedation for radiology per OAC Rule 5160-4-25(A)(6)2; (6) Do not bill separate sedation or anesthesia for surgical services when provider performs both per OAC Rule 5160-4-22(A)(1)(a)2; (7) Cap 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); (8) Consolidate next-day hospital readmissions to same facility as single DRG per OAC OAC 5160-2-65(M)(5); (9) Add 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; (10) Deny NF room & board when member receives overlapping hospice services per OAC Rule 5160-56-06; (11) Do not reimburse HCBS personal care aide or home-delivered meals during inpatient/SNF stays per OAC Rules 5160-44-01 and 5160-46-04; (12) Enforce weekly methadone/buprenorphine administration limits per Rule 5122-40-06 using OTP Billing Guidance. Update billing software validation rules, encounter forms, and provider training materials. Contact CareSource Provider Services (1-800-488-0134) for clarification. Failure to comply will result in claim denials and payment delays.