Lawriter - OAC - 5160-35-01 Definitions.

5160-35-01 Definitions.

(A) For the purposes of Chapter 5160-35 of the Administrative Code, the following terms are defined as:

(1) At the direction of: communication of a plan of care to a licensed practical nurse by a licensed physician or registered nurse who is acting within the scope of his or her practice under Ohio law for the provision of nursing services by the licensed practical nurse.

(2) Clinical setting: for the purpose of counseling and social work roles, a location in the school, or a location for which the medicaid school program provider has contracted for the delivery of services, where the child's confidentiality can be maintained when a service is being rendered.

(3) Community school: a public school, independent of any school district, established in accordance with Chapter 3314. of the Revised Code that is part of the state's program of education.

(4) Common procedural terminology (CPT): also known as current procedural terminology, is a list of descriptive terms and identifying codes, as published by the American medical association (AMA) for reporting medical services and procedures performed.

(5) Direct service costs: costs associated with salaries, benefits, and contract compensation for individuals and entities delivering services to an eligible child, services as defined in rule 5160-35-05 of the Administrative Code and as defined in paragraph (B)(2) of rule 5160-35-06 of the Administrative Code.

(6) Eligible child: a student for whom medicaid reimbursement may be sought through the medicaid school program who is enrolled in an entity defined in paragraph (B)(1) of rule 5160-35-02 of the Administrative Code, who is between the age of three to twenty-one, and has an individualized education program in which is indicated services that are allowable under medicaid.

(7) Healthcare common procedure coding system (HCPCS): is a uniform method for health care providers and medical suppliers to report professional services, procedures and supplies.

(8) The individualized education program (IEP) is as defined in section 3323.011 of the Revised Code.

(9) Licensed practitioner of the healing arts: for purposes of these rules, includes the qualified practitioners delineated in rule 5160-35-05 of the Administrative Code .

(10) Local education agency: school districts of the state as defined in sections 3311.01 to 3311.05 of the Revised Code.

(11) Medicaid authorized prescriber: a physician (M.D. or D.O.), podiatrist, dentist, or advanced practice nurse working within his or her scope of practice as defined by state law.

(12) Medicaid school program authorized referrer: is a licensed practitioner of the healing arts who refers for services under the medicaid school component of the medicaid program as set forth in section 5162.366 of the Revised Code.

(13) Medical home: a physician, physician group practice, or an advanced practice nurse with a current medicaid provider agreement, or a provider with a contract with an Ohio medicaid managed care plan. This provider serves as an ongoing source of primary and preventive care and provides assistance with care coordination for the patient.

(14) Medically necessary: skilled services recommended by a qualified licensed practitioner in accordance with rules 5160-35-05 and 5160-35-06 of the Administrative Code who is acting within the scope of his or her licensure that meet the requirements in rule 5160-1-01 of the Administrative Code and meet general principles regarding reimbursement for medicaid covered services found in rule 5160-1-02 of the Administrative Code. For the purpose of the medicaid school program, it is recognized that medically necessary services are those education related identified in the individualized education program (IEP) that meet medicaid reimbursement requirements.

(15) Medicaid school program (MSP): is as set forth in Chapter 5160-35 of the Administrative Code.

(16) MSP provider: educational entity that meets the qualifications delineated in rule 5160-35-02 of the Administrative Code.

(17) Other costs: costs for service-related activities for which there is no CPT or HCPCS code and for which claiming is not possible by the MSP provider due to medicaid rule restrictions; administrative claiming, equipment, supplies, indirect costs, and billing fees.

(18) Skilled services: services of such complexity and sophistication that the service can be safely and effectively performed only by or under the supervision of a licensed practitioner of the healing arts practicing within the scope of their licensure. Skilled services do not include services provided by persons not licensed in accordance with the Ohio Revised Code.

(19) State school: school under the control and supervision of the state board of education established for students who are deaf or blind as defined by section 3325.01 of the Revised Code.

(20) Supervision: is as defined in rules 4753-7-02, 4755-27-01, 4755-27-02, 4755-27-04, and 4755-7-04 of the Administrative Code.

(21) Telehealth: is the direct delivery of health care services to a patient via secure, synchronous, interactive, real-time electronic communication comprised of both audio and video elements in accordance with rule 5160-1-18 of the Administrative Code. Practitioners must act within their scope of practice and in accordance with their licensure agreements.



Effective: 7/1/2020
Five Year Review (FYR) Dates: 4/14/2020 and 07/01/2025
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 11/26/2008 (Emer.), 03/02/2009, 10/15/2009, 04/01/2015