Ohio Administrative Code Search

...(A) Definitions. (1) "Healthchek" is Ohio's early and periodic screening, diagnostic, and treatment (EPSDT) benefit for all medicaid recipients younger than twenty-one years of age, described in 42 U.S.C. 1396d(r) (as in effect 10/2017). (2) "Bright futures guidelines" are the American academy of pediatrics bright futures guidelines for preventive health care (rev. 2/2017), available at http://w...

...oll in the medicaid program that: (1) Meets the applicable provider requirements and standards in agency 5160 of the Administrative Code that address applicable service categories and provider types covered under the Ohio medicaid program; (2) Meets additional requirements and standards set forth in this rule; (3) Meets provider screening requirements and, when applicable, pays the fee for ...

...sing facilities are defined in Chapter 5160-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5160-26 of the Administrative Code. A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid program. All medicaid provider applications must be submitted through the medicaid informat...

... the following definitions apply: (1) "Affiliation" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (2) "Agent" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (3) "Disclosable event" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (4) "Disclosing provider" means a medicaid provider, managed...

...42 C.F.R. 455.450 (as in effect October 1, 2020) The revalidation process is as follows: (1) The Ohio department of medicaid (ODM) shall send a revalidation notice ninety days prior to the expiration date of the provider's time-limited agreement either to the provider's email or mailing address on file notifying the provider that it is required to revalidate its agreement. (2) The revalidation ...

...ule, the following definitions apply: (1) "Ownership or control interest" means having at least five per cent ownership, or interest, either directly, indirectly, or in any combination. (2) "Provider" has the same meaning as "eligible provider," as defined in rule 5160-1-17 of the Administrative Code. (3) "Provider Agreement" means an agreement as defined in rule 5160-1-17.2 of the Administrative Code or any rule...

...involuntarily in accordance with rule 5160-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program. (B) In considering an application for participation in the Ohio medicaid program by a former medicaid provider described in paragraph (A) of this rule, and except as provided by paragraphs (C) and (D) of t...

... matter involving a minor); (xxv) 2907.323 (illegal use of a minor in nudity-oriented material or performance); (xxvi) 2909.22 (soliciting or providing support for act of terrorism); (xxvii) 2909.23 (making terroristic threats); (xxviii) 2909.24 (terrorism); (xxix) 2913.40 (medicaid fraud); (xxx) If related to another offense under paragraph (E)(1)(a) of this rule, 2923.01 (...

...tions for purposes of this rule only: (1) A "participating provider" is an active provider who bills the medicaid program for rendered services, or who is an active provider who orders, prescribes, refers, or certifies but does not bill the medicaid program. (2) An "ordering or referring only provider" is a provider who orders, prescribes, refers, or certifies an item or service reported on a claim, and is not a bi...

...he same meaning as defined in rule 5160:1-1-01 of the Administrative Code. (B) To become a QE, the eligible entity must: (1) Have an active provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code; (2) Read the presumptive eligibility training guide found on the ODM website, www.medicaid.ohio.gov; and (3) Attest that it will meet the terms and conditions as a Q...

... the following definitions apply: (1) "Patient site" is the physical location of the patient at the time a health care service is provided through the use of telehealth. (2) "Practitioner site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth. (3) "Telehealth" is the direct delivery of health care services to a...

... the following definitions apply: (1) "Patient site" is the physical location of the patient at the time a health care service is provided through the use of telehealth. (2) "Practitioner site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth. (3) "Telehealth" is the direct delivery of health care services to a...

...t as otherwise provided in section 5164.46 of the Revised Code or a state agency's interagency agreement, claims are to be submitted directly to ODM through one of the following formats: (1) Electronic data interchange (EDI), in accordance with rule 5160-1-20 of the Administrative Code. (2) The ODM provider web portal; or (3) Pharmacy point-of-sale. (B) Claims should be submitted pursu...

... the following definitions apply: (1) "Covered entity" has the same meaning as in 45 C.F.R. 160.103 (as in effect on October 1, 2021). (2) "Electronic data interchange (EDI) transactions" are transactions developed by standards development organizations recognized by the federal centers for medicare and medicaid services (CMS) and adopted by the Ohio department of medicaid (ODM). The dif...

... the following definitions apply: (1) "Covered entity," has the same meaning as in 45 C.F.R. 160.103 (as in effect on October 1, 2018). (2) "Electronic data interchange (EDI) transactions" are transactions developed by standards development organizations recognized by the federal centers for medicare and medicaid services (CMS) and adopted by the Ohio department of medicaid (ODM). The di...

... performed in accordance with sections 5165.41 and 5124.41 of the Revised Code, any provider of services or goods contracting with the Ohio department of medicaid (ODM) pursuant to Title XIX of the Social Security Act who, without intent, obtains payment from the medicaid program in excess of the amount to which the provider is entitled becomes liable for payment of interest charged in accordance with this rule on t...

...(A) As specified in Chapter 5160-1 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, frequency, extent, duration, and delivery setting of services provided to medicaid recipients, and to document significant business transactions. Medic...

...ew" is defined in accordance with rule 5160-1-27 of the Administrative Code. (1) Hold and review without prior notification. (a) The Ohio department of medicaid (ODM) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons: (i) In response to allegations of fraud or other willful misrepresentation of claims submission;...

...the Ohio department of medicaid that: (1) Administers a component of the medicaid program under the terms of a contract with ODM under section 5162.35 of the Revised Code; and (2) Pays claims for medicaid services or reimburses local entities for claims paid for medicaid services. (B) "Hold and Review" is defined in accordance with rule 5160-1-27 of the Administrative Code. (C) Hold and review may be initiated b...

... the following definitions apply: (1) "Fraud" is defined as an intentional deception, false statement, or misrepresentation made by a person with the knowledge that the deception, false statement, or misrepresentation could result in some unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law. (2) "Waste and abu...

... the following definitions apply: (1) "Abuse" has the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1, 2023). (2) "Fraud" has the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1, 2023). (3) "Waste" means any preventable act such as inappropriate utilization of services or misuse of resources that results in unnecessary expenditures to the medicaid program...

...o the following types of information: (1) Names and addresses; and (2) Social security numbers; and (3) Medical services provided; and (4) Social and economic conditions or circumstances; and (5) Agency evaluation of personal information; and (6) Medical data, including diagnosis and past history of disease or disability; and (7) Any information received in connection with the identification of third party cov...

...nts, enrollees, or former recipients: (1) Names and addresses; (2) Social security numbers; (3) Medical services provided; (4) Social and economic conditions or circumstances; (5) Agency evaluation of personal information; (6) Medical data, including diagnosis and past history of disease or disability; (7) Any information received in connection with the identification of third...

...(A) In accordance with section 3798.10 of the Revised Code, a standardized authorization form that meets all requirements specified in 45 C.F.R. 164.508 and, where applicable, 42 C.F.R Part 2 as in effect on October 1, 2018, for the use and disclosure of protected health information is found in appendix A to this rule. (B) If the standardized authorization form is properly executed, and adequatel...

...tion of an authorized representative. (1) ) An individual may designate any person or organization to serve as that individual's authorized representative. Any person serving as an authorized representative must be at least eighteen years or older. (2) Authority for a person or organization to act on behalf of the individual accorded under state law, including but not limited to, a court order establishing legal gu...