Resources and Information for Durable Medical Equipment (DME) and pharmacy providers.
CMH staff members are available to assist providers by supplying information and technical assistance. When contacting CMH be prepared to provide the following information:
- Your name
- Your telephone number
- Brief description of the question or problem, e.g., billing, insurance, authorization of services, provider enrollment status or financial review
- Best time to return your call
For a specific child’s case*, the following information will be needed:
- Child’s name
- Child’s birth date
- CMH case number, if available (the case number is located on the Letter of Approval (LOA) and on all correspondence from CMH related to the child)
- Child’s county of residence
*Please note: Confidentiality is carefully maintained. CMH cannot give out case information to anyone except a parent, guardian or the client if the client has reached 18 years of age. Once a release and consent form is signed, information may be given to CMH providers and public health nurses.
These individuals are responsible for the processing of claims to the CMH in a timely manner. They are able to assist providers with proper coding of invoices.
Customer Service Assistants
These individuals answer the main call center. They can also assist with general questions regarding the status of a case and eligibility.
Nurse Case Managers
The nurse case manager (NCM) is a registered nurse who determines CMH medical program eligibility and authorizes services. The NCM applies standards of care and regulations and interprets and assesses medical plans of treatment.
The provider management staff is responsible for the credentialing of all providers who apply to become active providers on the CMH program. They answer questions regarding provider qualifications, changes in addresses and billing information and remove providers who no longer meet CMH qualifications, relocate or request removal. Call 800-755-4769 to find an approved CMH provider.
Resource Payment Specialists
Resource payment specialists determine the financial eligibility of children for the Treatment Program. They make referrals and provide families with information for Ohio Department of Medicaid (ODM) Medicaid programs.
Third Party Resources
The staff in the Third Party Resources unit investigates sources of payment for medical services that may be available through Medicaid, private insurances and Medicare. They are available to assist providers and families in coordinating third-party benefits.
Field Nurse Case Managers
CMH employs registered nurses who serve as local representatives for CMH. They are available to local agencies that serve children who reside in the State of Ohio who have a potential or confirmed medical handicap. The field nurse Case Managers serve as liaisons with local health departments and community providers to the central office. These nurses are available to provide technical assistance and education/orientation to staff in local provider offices.
Social Work Consultant
A licensed, registered social worker is also available and primarily works as the CMH hospital coordinator. The primary role of the hospital coordinator is to act as an advocate for families who may need assistance in obtaining service for their children with special health care needs. The hospital coordinator works from Children’s Hospital Medical Center of Akron and MetroHealth Medical Center in Cleveland and can reached through the Northeast District Office.
All services authorized and paid by CMH must be provided by CMH-approved providers. CMH has a network of more than 8,000 health care providers throughout the state including physicians, dentists, therapists, registered dietitians, service coordinators, rehabilitation clinics (therapy services), hospitals, optometrists, audiologists, pharmacies, pharmacists, psychologists, speech pathologists, medical equipment suppliers, public health departments and nurse anesthetists.
Provider Eligibility and Enrollment
To receive a provider application, contact the provider management unit at CMH central office (614) 466-1700 or BCMH@odh.ohio.gov.
To be enrolled as a provider, an applicant must:
- Complete the CMH Provider Application Form
- Complete the Internal Revenue Service (IRS) W-9 Form
- Document professional training and experience in treating children with handicapping conditions
- Provide verification of credentials
- Sign the CMH Provider Agreement
- Participate as a provider for the Ohio Department of Medicaid (ODM) Medicaid program. This requirement is waived for health departments, service coordinators, community dietitians, certain individual therapists and pharmacists.
Authorization for Delivery of Services
All providers are authorized to provide services based on their scope of practice, licensure and/or certification. Physician providers must be board certified in an eligible specialty by the appropriate member board of the American Board of Medical Specialties or a certifying board of the American Osteopathic Association. Hospitals are designated by CMH to provide services, based on their staff, facilities and accreditation. In addition, comprehensive care and team management are encouraged and often required by CMH in its effort to assure quality care and services to children with specific medically handicapping conditions. For details regarding a hospital designation where you practice, you may contact the CMH field nurse case manager for your area at the CMH central office (614) 466-1700.
Removal of Providers from Active Status
A provider may request to be removed as an active provider at any time. Providers must notify CMH of any changes in provider status. CMH may remove a provider from active status if the provider has failed to notify CMH of changes in:
- Ownership, licensure, certification or registration status
- Mailing and/or billing address
- Federal tax identification number
Providers are notified 30 days prior to removal from the CMH program. Providers will have immediate removal if their tax identification number (TIN) is incorrect or their Medicaid providership has been terminated.
Payments by CMH to providers of services are regulated by relevant sections of the Ohio Revised Code, the Ohio Administrative Code and the CMH Provider Agreement.
Guidelines for Submitting Claims to CMH
- Claims must be received by the CMH within 12 months of the date the service was provided. CMH will reject claims that do not meet this time frame
- CMH will pay only for services or goods that have been authorized for payment by CMH and have been provided by CMH-approved providers.
- Providers may bill CMH no more than the provider customarily charges other patients for the same goods and services.
- Providers must submit claims only on forms prescribed by CMH.
- Claims submitted to CMH that are incomplete or not properly completed will be returned to the provider to be corrected.
- Providers will be paid by CMH for inpatient hospital care, outpatient care and all other medical assistance furnished by hospitals in accordance with reasonable cost principles established by the Medicare program, and for all other goods or services in accordance with the CMH fee schedule.
- All claims submitted to CMH for payment are subject to verification by CMH staff. CMH may contact providers, insurance companies, employers, families and others, as necessary, to request further information or verification.
Claims for payment by CMH should be submitted to:
Children with Medical Handicaps Program (CMH)
PO Box 1603
Columbus, OH 43216-1603
Pharmacy Point of Sale
The CMH utilizes an electronic point of sale (POS) system to adjudicate all drug claims from pharmacies. The POS system is administered by a contracted pharmacy benefit manager. For more information on the CMH POS program, please contact a CMH third-party management analyst at (614) 466-1700.
More specific information is available on the following topics:
- Billing instructions for CMS 1500
- Billing instructions for dental
- Billing instructions for CMS 1450, UB 04
- Claim error reasons (codes and descriptions)
- Co-pays and deductibles
- Insurance-covered claims
- Medicaid covered claims
- Pharmacy claims processing
- Submitting claims for adjustment
- Submitting claims to CMH when there is other third-party coverage
- Nutritional Supplement codes for billing
When billing CMH, coding should conform to American Medical Association current procedural terminology (CPT). Some coverage limitations are detailed below.
Allergy evaluations should be billed to CMH using CPT codes 95004-95075.
When billing for anesthesia, providers should bill the appropriate CPT anesthesia code using the modifier that best describes the service which was provided and report the actual anesthesia time in minutes. The following modifiers are payable by CMH:
-AA, -AD, -QK, -QX, -QY, -QZ.
Assistant at Surgery
When billing as an assistant at surgery, providers must bill using the surgical procedure code followed by the modifier 80. Assistants at surgery must be prior approved, along with the surgeon, in order to be paid.
Chemotherapy codes listed in the current CPT listing are payable through CMH.
The current ADA listing for general and oral surgical dental services are payable through CMH, using a “D” prefix (D0110-D9999).
Hemodialysis and peritoneal dialysis services may be billed under the codes listed in the current CPT listing and are payable through CMH.
The codes listed in the current CPT listing are payable through CMH and include recording, interpretation and report by a physician.
Gastroenterology services should be billed using the codes listed in the current CPT listing.
The method of payment for orthodontia services, Orthodontia by Phase, uses ADA codes D8050, D8070, D8080, D8090. Prior approval is required and billing codes/instructions are supplied with each approval.
The following codes are payable through CMH.
Physical therapy evaluations: 97001-97002 Basic Service
Occupational therapy evaluations: 97003, 97004 Basic Services
Occupational therapy: 97530 Major Service
Prosthetic Check-out: 97762 Major Service
The procedure codes, Z0802-Z0819, are not payable by CMH. Only code 90817 (psychological evaluation, up to six hours is payable.
Public Health Nurse Services
Public health nurse services should be billed using code 99539. This code is billed in 15-minute increments of service.
Radiology services should be billed under the codes listed in the current CPT listing. When billing for both the professional and technical components, no modifier should be used. The modifiers 26 (professional component only) and TC (technical component only) are payable through CMH.
Special Formula must be billed to CMH on a CMS 1500 billing form. At this time, NO special formula is able to be billed using the Point-of-sale, or POS, system. The following boxes on the CMS1500 form must be completed (Sample form)
1A: Insured’s ID Number
2: Patient’s Name (Last name, First name)
21: Diagnosis code
24A: Date of Service
24D: CMH-assigned NS code is placed in the CPT/HCPCS box
24G: Units (1 Unit = 100 calories of the special formula)
24J: Rendering Provider ID#
28: Total Charge
29: Amount Paid by Insurance (enter 0 if no payment received)
30: Balance Due
33 Billing Provider Address and Phone Number
33A: National Provider Identifier
33B: Additional Provider Number, if applicable
All special formulas on the CMH formulary have been assigned an “NS code”, and this NS code must be listed in box 24D of the CMS 1500 form in order to receive payment.
For the most complete list of the CMH formulary, including "NS codes", click CMH nutritional supplements.
Speech and Hearing
The following codes are payable through CMH:
Speech, language/hearing (limit one per year): 92506 Basic Service
Speech, language/hearing therapy: 92507 Major Service
Speech, language/hearing therapy group, 2 or more individuals: 92508 Major Service
Complex dynamic pharyngeal and speech evaluation by cine or video recording: 70371 Basic Service
Aural rehabilitation following cochlear implant: 92601-92604 Basic Service
Speech auditometry, threshold: 92555 Basic Service
Speech audiometry, threshold and speech discrimination: 92556 Basic Service
Surgeries should be billed using the codes in the current CPT listing. CMH will recognize a modifier of 50 to indicate a bilateral procedure. An operative report should be included with invoices for surgical services.
The following codes are payable through CMH:
Eyeglass frames: V2020; V2025
Contact lenses: V2599
Prosthetic eye, plastic, stock: V2621
Prosthetic eye, plastic, custom: V2623
Prosthetic eye, not otherwise classified: V2629
Eyeglasses: Use appropriate HCPCS codes
Hospital visits, including critical care, are payable only if inpatient hospital days are authorized through CMH.
The number of hospital visits payable through CMH to any one physician will not exceed the number of hospital days authorized.
Psychiatric consults (physician): 90801
- These codes payable only for children with selected conditions.
Hemophilus influenza vaccine for eligible patients: 90645-90648*
Hepatitis B vaccine for eligible patients: 90740-90748
Pneumococcal vaccine for eligible patients: 90732
Influenza virus vaccine: 90655-90662
*Some codes within this series may be non-covered.
The Children with Medical Handicaps Program uses three basic billing forms:
1. UB 04/CMS 1450 – Used solely for CMH-approved hospital inpatient/outpatient billing.
2. American Dental Association (ADA) billing form - Used for basic dental services.
3. CMS 1500 – Used as a multipurpose basic medical billing form to bill the following CMH-approved medical services:
- Physician services and hospital visits (Note: a copy of the operative report should be attached to all claims for surgical procedures)
- Orthodontic services
- Medical supplies
- Durable medical equipment
- Vision services
- Hearing services and hearing aids
- Therapy services
- Independent lab services
- Other basic medical services
Nutritional Supplement Codes for Billing
For the most complete list of the CMH formulary, including "NS codes", click CMH nutritional supplements.
Role of Public Health Nurse (PHN)
CMH views the local public health nurse as an essential member of the health care team. Public health nurses in public health agencies, as well as some nurses in CMH-contracted home health agencies, work with CMH to provide essential services to children with special health care needs and their families in their local communities.
Responsibilities of the Public Health Nurse:
- Identifies children who have medically handicapping conditions
- Informs families about the availability of the CMH program and enrollment requirements
- Refers children to CMH physician providers through the diagnostic referral process
- Makes home visits to children on the CMH program to provide:
- Nursing assessment of the child and family
- Assistance in developing nursing care plans
- Anticipatory guidance and health promotion
- Coordination of community services
- Ongoing follow-up as needed
- Performs service coordination activities including:
- Nursing assessment of the child and family
- Identification of the needs of the child and family
- Identification of linkages with appropriate services
- Education of the child and family about prescribed care
- Collaboration with other providers and agencies to ensure the family’s understanding and cooperation
- Promotion of independence in the child and family
- Preparation of families to seek appropriate support in times of crisis and transition
- Documents the nursing process and service coordination activities through PHN visit reports and comprehensive service plans
- Communicates with health care professionals and other providers, such as the Help Me Grow service coordinator, involved in the care of the child
- Works with the Help Me Grow service coordinators to provide consultative service, nursing assessment and referrals
Role of Physicians
A child on a CMH program must have their medical care managed by an MD or DO who is enrolled as a CMH provider. The physician may be a pediatrician, family practitioner or sub-specialty physician.
Managing, PCP, Specialists Roles
The managing physician:
- Identifies children within his/her practice who have handicapping or potentially handicapping conditions
- Informs families about the availability and services of the CMH program and requirements for enrollment
- Accepts referrals from public health nurses to evaluate children with potentially medically handicapping conditions
- Consults with families prior to requesting services from CMH
- Provides comprehensive, coordinated care through:
The managing physician is responsible for:
- Completion in full and submission of a Medical Application Form (MAF) to enroll the child on the CMH Diagnostic and/or Treatment Program; completion of an Interim Request Form to request additional services when needed; and submission of medical reports about the child’s condition annually and when special services are requested
Primary Care Physicians
The CMH strongly supports the medical home concept of family-centered, community-based, coordinated care and advocates for the role of primary care in meeting the comprehensive needs of children with special health care needs. The CMH program is not designed to provide primary care services related to well child care, immunizations or acute care, but does acknowledge the importance of the primary care physician in providing care for the child’s handicapping condition and coordinating services for the child with other CMH providers.
Other CMH physicians provide consultation and follow-up as necessary for the child. He/she communicates on a regular basis with the child’s managing physician to provide information on needs relating to care and services and notifies the managing physician of any care or services requiring approval or special authorization through the CMH.
Durable medical equipment (DME)
Durable medical equipment suppliers may be enrolled as Children with Medical Handicaps (CMH) providers in accordance with Ohio Administrative Code Rule 3701-43-05. All services authorized by CMH, including durable medical equipment and medical supplies, must be directly related to the client’s CMH-eligible condition. CMH requires prior authorization (PA) for selected equipment to ensure that the service is medically necessary and appropriate.
Major services are specific services which may be included in “service packages” for selected diagnoses or individually requested by the child’s managing physician. Examples include:
- Medical/Surgical Supplies: Includes items such as catheters, needles/syringes, alcohol wipes, urine and blood testing supplies, etc.
- Medical Equipment: Includes items such as wheelchairs, orthotics, percussors, IV or feeding pumps, oxygen, etc.
- Special Prescription Shoes: Shoes prescribed by a physiatrist or orthopedic surgeon.
- Special Formula: Oral or enteral formula necessary to promote normal growth and development for a child needing nutritional support, as determined by CMH policy. Also includes modular components such as MCT Oil and Polycose.
Does not include milk-based formula. A CMH Nutrition Support Request form and current growth chart must be submitted to CMH by the managing physician.
Note: CMH does not require a Prior Authorization Form be submitted; however, this is a requirement of Medicaid
- Ear Molds: Additional molds required due to growth of the child
- Maintenance and Repair: Authorized for medical equipment. A PA form is required for repairs greater than $150
Approval of selected CMH services requires the provider to submit a Prior Authorization Form and include a prescription from an appropriate CMH-prescribing physician, along with a letter of medical necessity to: Ohio Department of Health, CMH, PO Box 1603, Columbus, OH 43216-1603. Please do not submit packet to the Ohio Department of Job and Family Services.
Services Requiring Submission of a Prior Authorization Form
- Peritoneal dialysis
- Durable medical equipment
- Major maintenance and repair
Prior Authorization Requirements for Approval of Services
- Active CMH Treatment case
- CMH-eligible diagnosis
- The eligible services must relate to a CMH medically eligible diagnosis
- A recent medical report and signed prescription from an appropriate CMH physician provider (e.g. orthopedist, physiatrist, developmental pediatrician or neurologist for wheelchair or orthotics request).
Completion of the Prior Authorization Form
The following information must be provided:
- Provider number
- Provider name, address and telephone number
- Name of person completing form
- Date form completed
- Client’s case number
- Client’s name, address and telephone number
- Quantity, proper Healthcare Common Procedural Coding System (HCPCS) code and usual and customary charge. A copy of the invoice reflecting the acquisition cost must be attached using code E1399
- Description of service
- Information related to rental cost (if applicable)
- Dispensing date (Indicate “pending” if not yet dispensed)
- Attach prescription for the service, signed by the appropriate CMH physician provider and a letter of medical necessity
For more information, contact the CMH prior authorization nurse at CMH central office (614) 466-1700.
Pharmacies may be enrolled as CMH providers in accordance with Chapter 4729 of the Ohio Revised Code. Pharmacy services shall be prescribed by a physician approved under rule 3701-43-03 of the Ohio Administrative Code. All providers must complete a CMH Provider Application Form and sign a CMH Provider Agreement. If a pharmacy is a subsidiary of a large national pharmacy chain, it may be enrolled simply by calling CMH and requesting same from provider enrollment.
To obtain provider application materials, contact CMH Provider Management at (614) 466-1700 or BCMH@odh.ohio.gov.
Prescription medications area covered benefit for most eligible diagnoses. All medications must be directly related to the eligible handicapping condition.
CMH is obligated to use Ohio Medicaid’s drug formulary for minimum restrictiveness. CMH does not set pricing for cost of goods, but merely implements Medicaid’s pricing policies. Behavioral health problems and acute conditions are not eligible on the CMH program. Similarly, medications that treat behavioral health problems (e.g. depression, ADHD) or acute medical conditions (e.g. allergic iritis) are not covered services by the CMH. Some drugs excluded by Medicaid may be eligible for CMH coverage.
CMH does not cover brand-name drugs when a generic equivalent is available. If a therapeutic failure occurs with the generic drug, the CMH-credentialed physician must prior authorize use of the brand name drug by calling the POS Technical Call Center at 1-877-518-1545.
Clients with Other Insurance Coverage
It is the responsibility of all pharmacy providers to bill all other available third-party payers prior to billing CMH. This assures CMH is the “payer of last resort,” per the CMH Provider Agreement, the Ohio Revised Code, Chapter 3701 and the Ohio Administrative Code, Chapter 3701-43.
- The Point of Sale system and the CMH Letter of Approval contain information regarding each client’s private insurance and/or Medicaid status. If a parent states they no longer have insurance, or their insurance carrier has changed, please fax the current information to the attention of the CMH Third Party Unit (614-728-3616) for follow-up review and correction of records.
- For a child with insurance, a claim without a reasonable amount listed in the third-party liability (TPL) field will be automatically rejected by the online system. This denial indicates insurance must be billed first and the amount insurance is paying must be entered in the TPL field. CMH has identified a problem with some providers not billing the insurance company and instead listing inaccurate “token” amounts (e.g. one penny or one dollar) so the claim will process. This process is fraudulent. If a provider is found to be fraudulently billing, the provider may be referred to the Attorney General’s office for a compliance investigation.
- Pharmacies must follow proper procedures, including the prior authorization process, and bill Medicaid for pharmaceuticals provided to children who are active on the Medicaid program. It is not possible to bill CMH for any medication for any child who is Medicaid active.
Prior Authorization Process
Growth hormone is one drug that requires routine prior authorization. There is, in addition to growth hormone, a small list of other medications that require prior authorization. Pharmacies are notified via a computer message at the time of claim submission for adjudication if a specific drug will require prior authorization. The Ohio Department of Job and Family Services has its own prior authorization form that must be used for children whose pay source is Medicaid.