Library: Policy

317:30-5-40.1. General information

Revised 11-26-18

(a) This Chapter applies to coverage in an inpatient and/or outpatient setting. Coverage is the same for adults and children unless otherwise indicated.

(b)Professional Services.Payment is made to a participating hospital group or corporation for hospital based physician's services. The hospital must have a Hospital Group Physician's Contract with OHCA for this method of billing.

(c) Prior Authorization.OHCA requires prior authorization for certain procedures to validate the medical need for the service.

(d) Medical necessity.Medical necessity requirements are listed at OAC 317:30-3-1(f) and 317:30-5-20.