Rule 5160-4-04. Advanced practice registered nurse (APRN) services

119.03 (A) Definition. "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. The term encompasses a certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse-midwife (CNM), and certified nurse practitioner (CNP). (B) Coverage. (1) Unless a specific exception is noted, all other rules in agency 5160 of the Administrative Code that pertain to services rendered by a physician apply also to services rendered by an APRN. (2) For a covered service rendered by an APRN, payment may be made only if the following conditions are met: (a) The service is rendered to an Ohio-medicaid-eligible individual in a state in which the APRN is licensed or authorized to practice; (b) The service is within the scope of practice of the APRN's specialty; (c) The APRN personally rendered the service to an individual patient; and (d) The service cannot be performed by someone who lacks the skills and training of an APRN. (C) Payment. (1) Payment for a covered service rendered by a CRNA is made in accordance with rule 5160-4-21 of the Administrative Code. (2) Payment for a covered service rendered by a CNS, CNM, or CNP is the lesser of the billing provider's submitted charge or the applicable amount from the following list: (a) For a covered service rendered in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), eighty-five per cent of the medicaid maximum; (b) For a covered service rendered in a non-hospital setting, one hundred per cent of the medicaid maximum; or (c) For assistant-at-surgery services provided by a CNS, CNM, or CNP regardless of setting, twenty-five per cent of the medicaid maximum for the covered primary surgical procedure. (3) Payment for services rendered by a hospital-employed APRN will be made to the hospital. (4) In the event that payment for a covered service performed by an APRN is issued both to the APRN and to a contracting or supervising provider on behalf of the APRN, one of the issued payments is subject to recovery. Last updated January 3, 2022 at 9:48 AM Supplemental Information Authorized By: 5164.02 Amplifies: 5164.02 1/1/2027 3/1/1994 (Emer.), 6/1/2002, 4/1/2018