Ohio Administrative Code Search

...graph, must have a system as follows. (1) Definitions. (a) "Home care dependent adult" means a consumer who: (i) Resides in a private home or other non-institutional, unlicensed living arrangement without a parent or guardian present; (ii) Requires, due to health and safety needs, regularly scheduled home care services to remain in the home or other living arrangement; and, (iii) Is sixty years of age or older, ...

...credentialing" (as in effect on October 1, 2021), this rule details the credentialing and recredentialing process for medicaid providers. (A) For purposes of this rule, the following definitions apply. (1) "Council for affordable quality healthcare (CAQH)" is a non-profit organization which created a process allowing ODM to use a single, uniform application for credentialing. This end-to-end proce...

...dual providers in accordance with rule 5160-1-42 of the Administrative Code. (B) "Delegate" and "Delegation" have the same meaning as in rule 5160-1-42 of the Administrative Code. (C) Entities seeking delegation will be expected to meet the following criteria to become an authorized delegate and to maintain delegate status: (1) Be an eligible provider as defined in rule 5160-1-17 of the Adm...

...caid copayments as defined in rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the Administrative Code, however, precludes a provider from requesting payment, collecting, or waiving the collection of medicare copayments from a medicaid recipient for medicare part D services. Medicaid recipient liability provisions set forth in rule 5160-1-13.1 of the Administrative Code do not ...

...caid copayments as defined in rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the Administrative Code, however, precludes a provider from requesting payment, collecting, or waiving the collection of medicare copayments from a medicaid recipient for medicare part D services. Medicaid recipient liability provisions set forth in rule 5160-1-13.1 of the Administrative Code do not ...

...caid copayments as defined in rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the Administrative Code, however, precludes a provider from requesting payment, collecting, or waiving the collection of medicare copayments from a medicaid recipient for medicare part D services. Medicaid recipient liability provisions set forth in rule 5160-1-13.1 of the Administrative Code do not ...

...caid copayments as defined in rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the Administrative Code, however, precludes a provider from requesting payment, collecting, or waiving the collection of medicare copayments from a medicaid recipient for medicare part D services. Medicaid recipient liability provisions set forth in rule 5160-1-13.1 of the Administrative Code do not ...

...caid copayments as defined in rule 5160-1-09 of the Administrative Code. Nothing in agency 5160 of the Administrative Code, however, precludes a provider from requesting payment, collecting, or waiving the collection of medicare copayments from a medicaid recipient for medicare part D services. Medicaid recipient liability provisions set forth in rule 5160-1-13.1 of the Administrative Code do not ...

...(A) For purposes of this rule only: (1) "Medicaid covered service" is defined as a service that is eligible for coverage by the Ohio medicaid program and is delivered by a medical provider that qualifies for a medicaid provider agreement. (2) "Applicant for reimbursement" is defined as: (a) An individual who has been erroneously determined ineligible for the medicaid program or whose determination was incorrectly ...

...(A) For purposes of this rule: (1) "Applicant for reimbursement" is: (a) An individual who has been determined eligible for a retroactive eligibility period in accordance with rule 5160:1-2-01 of the Administrative Code, and who is seeking reimbursement for medical expenses for which the individual paid for during this approved time period; or (b) An individual who, as a result of an eligibili...

... the following definitions apply. (1) "Attributed individual" is the Ohio medicaid covered individual for whom a qualified behavioral health entity eligible under this rule has accountability for providing behavioral health care coordination. (2) "Attribution" is the process through which medicaid covered individuals are assigned to a specific qualified behavioral health entity. The Ohio dep...

...(A) Definitions. (1) "Practitioner," for purposes of this rule, is a collective term for the following professionals: (a) Doctor of medicine or osteopathy; (b) Advanced practice registered nurse; (c) Dentist; (d) Optometrist; (e) Podiatrist; or (f) Chiropractor. (2) "Regular practitioner" is a practitioner enrolled in the Ohio medicaid program who regularly takes care of an individual's health ...

...(A) Definitions. (1) "Practitioner," for purposes of this rule, is a collective term for the following professionals: (a) Doctor of medicine or osteopathy; (b) Advanced practice registered nurse; (c) Dentist; (d) Optometrist; (e) Podiatrist; or (f) Chiropractor. (2) "Regular practitioner" is a practitioner enrolled in the Ohio medicaid program who regularly takes care of an individual's health car...

... rule, as authorized under Section 270.15 of Amended Substitute House Bill 45 of the 134th General Assembly: (A) ODM will make available a one-time lump sum payment to the following hospital types: (1) "Critical access hospitals," as defined in rule 5160-2-05 of the Administrative Code. (2) "Rural hospitals," as defined in rule 5160-2-05 of the Administrative Code. (B) The payment will be ...

...s rule and for each year thereafter: (1) Pursuant to paragraph (A) of this rule, each provider eligible to receive a directed SDP program payment will submit to ODM an additional IGT which is to be four per cent of the provider's computed IGT amount. (2) In subsequent SDP program years, ODM may establish a rate higher or lower than the rate described in paragraph (B)(1) of this rule as approve...

...except those excluded in paragraphs (A)(1) and (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R 482 effective as of October 1, 2016, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet the requirements for Title XVIII parti...

...pt those excluded in paragraphs (A)(1) and (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R 482 effective as of October 1, 2022, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet the established criter...

... context clearly indicates otherwise: (1) "Inpatient" - A patient who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyond midnight of the day of admission. (2) "Inpatient services" - Services which are ordinarily furnished in a hospital as defined in rule 5160-2-01 of the Administrative Code for the care and treatment of inpatients. Inpatient s...

...For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise: (A) "Diagnosis related groups (DRGs)" - a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting. The groupings used to assign cases to a DRG for claims ...

...For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise: (A) "Diagnosis related groups (DRGs)" is a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting. The groupings used to assign cases to a DRG for claim ...

...ent and outpatient hospital services. (1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code. (2) Inpatient or outpatient services related to the provision of the services described in this rule are not covered: (a) Abortions other...

...(A) Drugs. (1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis for use away from the hospital). (2) Administered inpatient drugs are considered inpatient services and are reimbursed as an inpatient se...

...(A) Drugs. (1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis for use away from the hospital). (2) Administered inpatient drugs are considered inpatient services and are reimburse...

...ve payment systems. (A) Definitions. (1) "Critical access hospitals" (CAH) are those hospitals that are certified as a critical access hospital by the centers for medicare and medicaid services (CMS) and excluded from medicare prospective payment in accordance with 42 C.F.R. 400.202 effective October 1, 2017. (2) "Rural hospitals" are those hospitals located in Ohio counties that are not cl...

...ve payment systems. (A) Definitions. (1) "Cancer hospitals" are those hospitals recognized by medicare that primarily treat neoplastic disease in accordance with 42 C.F.R. 412.23(f) effective October 1, 2022. (2) "Children's hospitals" are those hospitals that primarily serve patients eighteen years of age and younger and that are excluded from medicare prospective payment in accordance wit...