Rule 5160-35-01 | Definitions.
(A) For the purposes of Chapter 5160-35 of the Administrative Code, the following terms are defined.
(1) At the direction of: the communication of a practitioner plan of care to a licensed practical nurse as defined in Chapter 4723. of the Revised Code by a physician as defined in Chapter 4731. of the Revised Codeor a registered nurse as defined in Chapter 4723. of the Revised Code 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 as defined in Chapter 4723. of the Revised Code.
(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 eligible child's privacy 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 rule 5160-35-07 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 (IEP), a 504 plan, or a school services plan of care documenting medical necessity in that it indicates services that are allowable under medicaid. An eligible child can also be a student who is enrolled in an entity defined in paragraph (B)(1) of rule 5160-35-02 of the Administrative Code, who is between the ages of three and twenty-one years, who receives an allowable service outlined in rule 5160-35-07 of the Administrative Code.
(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) Practitioner of the healing arts: for purposes of Chapter 5160-35 of the Administrative Code, 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 3311.04 of the Revised Code.
(11) Medicaid authorized prescriber: means as defined in rule 5160-1-17 of the Administrative Code.
(12) Medicaid school program authorized referrer: is a practitioner of the healing arts who refers for services under the medicaid school component of the medicaid program defined in section 5162.366 of the Revised Code.
(13) Medically necessary: means as defined in rule 5160-1-01 of the Administrative Code. For the purpose of the medicaid school program, medically necessary services are education related services identified in the individualized education program (IEP), 504 plan, or school services plan of care that meet medicaid reimbursement requirements.
(14) Medicaid school program (MSP): means the program set forth in Chapter 5160-35 of the Administrative Code.
(15) MSP provider: educational entity as defined in section 5162.364 of the Revised Code and rule 5160-35-02 of the Administrative Code.
(16) Other costs: costs for service-related activities for which there is no current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) code and for which claiming is not possible by the MSP provider due to medicaid rule restrictions; administrative claiming, equipment, supplies, indirect costs, audit fees, and billing fees.
(17) 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 practitioner as defined in rule 5160-35-05 of the Administrative Code 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.
(18) State school: school under the control and supervision of the department of education and workforce (DEW) established for students who are deaf or blind as defined by section 3325.01 of the Revised Code.
(19) Supervision: is as defined in rules 4755:2-2-02, 4755:2-2-03, 4755:2-2-05 and, 4753-7-02, of the Administrative Code as applicable to each provider type.
(20) Telehealth: will be in accordance with rule 5160-1-18 of the Administrative Code.
(21) School services plan of care: a standardized and timebound template developed and maintained by the Ohio department of medicaid to be used by the MSP provider. The school services plan of care serves as documentation of the services an eligible child will receive as part of the medicaid school program to address an eligible child's physical, mental, or behavioral health needs that inhibit the eligible child's academic performance or regular school attendance. The school services plan of care details services provided to an eligible child as described in rules 5160-35-05, 5160-35-06, and 5160-35-07 of the Administrative Code and includes components described in paragraph (J) of rule 5160-35-05 of the Administrative Code. The school services plan of care is not a treatment record and does not qualify as a medical record. MSP providers will ensure compliance with the Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA). The school services plan of care does not supplant any state or federal processes or timelines related to identifying and serving students with disabilities.
(22) The 504 Plan: means as defined in rule 3301-13-01 of the Administrative Code.
(23) Eligible provider: means as defined in rule 5160-1-17 of the Administrative Code.
(24) Random Moment Time Study (RMTS): is defined as a tool used to analyze work done by employees and contractors over a specified time period. The RMTS is designed to document the level of effort MSP providers provide on a state-wide basis in compliance with the applicable RMTS guide provided by the Ohio department of medicaid.
Last updated January 1, 2026 at 12:00 AM
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