Eligibility, Certification, Face-to-Face Encounter, and Ohio Medicaid Certificate of Medical Necessity
Sets out how the Agency confirms that each patient qualifies for the services billed: for Medicare, the practitioner’s certification, the face-to-face encounter no more than 90 days before or within 30 days after the start of care, homebound status and skilled need, recertification at least every 60 days, and the bar on certifying practitioners with a financial relationship; for Ohio Medicaid, the face-to-face encounter documented on the ODM 07137 Certificate of Medical Necessity, the part-time or intermittent hour limits, the post-hospital and increased-services rules, and the plan of care and waiver services plan.
- Policy number
- OH-HH-ADM-03
- Version
- 1.0
- Main rule
- 42 CFR §424.22
- Library
- Ohio home health · 59 policies
- Category
- Service delivery
- Sections
- 21
In short
- For Medicare patients, document at each assessment why the patient is homebound and needs skilled care.
- Medicare needs a face-to-face encounter no more than 90 days before or 30 days after the start of care, and recertification at least every 60 days.
- Ohio Medicaid needs the ODM 07137 Certificate of Medical Necessity, or a plan of care with all its data elements, before billing.
- Keep Ohio Medicaid schedules within the daily and weekly hour limits unless the clinical manager approves an allowed exception.
- Do not bill until the certification, encounter and signed orders are complete.
What's inside
21 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §424.22 and OAC 5160-12-01)
- 5. Eligibility Screening at Intake
- 6. Medicare: Verifying Eligibility and Homebound Status
- 7. Medicare: The Certification
- 8. Medicare: The Face-to-Face Encounter
- 9. Medicare: Recertification and the Plan of Care
- 10. Ohio Medicaid: Face-to-Face Encounter and the ODM 07137
- 11. Ohio Medicaid: Part-Time or Intermittent Limits
- 12. Ohio Medicaid: Plan of Care and Waiver Services Plan
- 13. Financial Relationships With Certifying Practitioners
- 14. Responsibilities
- 15. Records and Compliance Monitoring
- 16. Staff Training
- 17. References
- 18. Related Policies and Forms
- 19. Approval
- 20. Revision History
An inspector may ask
- Show me the certification and the face-to-face encounter documentation for this Medicare patient.
- How did you verify homebound status at the initial and comprehensive assessments?
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