Ohio Administrative Code Search

...in calculating the debt estimate: (1) Overpayments determined due to ODM pursuant to section 5165.108 of the Revised Code, including the following: (a) Overpayments owed to ODM for adjudicated final fiscal audit periods. (b) Overpayments identified in proposed adjudication orders that have been issued but not adjudicated. (c) Overpayment amounts for any outstanding periods where a final fi...

...in calculating the debt estimate: (1) Overpayments determined due to ODM pursuant to section 5165.108 of the Revised Code, including the following: (a) Overpayments owed to ODM for adjudicated final fiscal audit periods. (b) Overpayments identified in proposed adjudication orders that have been issued but not adjudicated. (c) Overpayment amounts for any outstanding periods where a final fi...

...urposes of division (C) of section 5165.52 of the Revised Code, the debt estimate for change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal is considered provided by the Ohio department of medicaid (ODM) on the date of mailing, date of personal service, or date of publication. (B) Initial debt summary report. (1) Whenever ODM issues an ...

.... For dates of services preceding July 1, 2005, NFs shall submit the form "Nursing Facility Payment and Adjustment Authorization" (JFS 09400, rev. 10/2012) directly to the Ohio department of job and family services (ODJFS) for the reimbursement of services. The county department of job and family services (CDJFS) and NFs shall use the "Facility/CDJFS Transmittal" (JFS 09401, rev. 4/2011) form to exchange informatio...

... set forth in paragraph (A)(2) of rule 5160-1-19 of the Administrative Code, NF providers shall submit medicare crossover claims and claims for medicaid reimbursement for allowable services that are not included in the NF per diem rate in accordance with the requirements set forth in rule 5160-1-19 of the Administrative Code. (B) Requirements for submitting NF per diem claims. (1) A NF provider submitting a claim f...

...mit claims in accordance with rule 5160-1-19 of the Administrative Code. Additional requirements specific to the submission of long-term care per diem claims are in paragraphs (B) to (E) of this rule. (B) Additional requirements to be met prior to submitting claims for services included in the per diem. (1) Individual is a medicaid recipient for the dates of service. (2) Individual is not in ...

...ts annually to comply with section 5165.10 of the Revised Code. (1) The chart of accounts in table 1 to table 8 of appendix A to this rule is to establish the minimum level of detail to allow for cost report preparation. (2) If the chart of accounts in appendix A to this rule is not used by the provider, it is the responsibility of the provider to relate its chart of accounts directly to the ...

...and medicaid services (CMS) publication 15-1, Chapter 1 entitled "Depreciation," (December 15, 2011), available on the internet at http://www.cms.gov/, and shall use the following guidelines: (1) Any expenditure for an item that costs five thousand dollars or more and has a useful life of two or more years per item must be capitalized and depreciated over the asset's useful life. (2) A provider ...

...iem, except as specified under Chapter 5160-3 of the Administrative Code. Non-reimbursable costs include but are not limited to: (A) Fines or penalties paid under sections 5165.1010, 5165.72 to 5165.77, 5165.83, and 5165.99 of the Revised Code. (B) Disallowances made during the audit of NF cost reports that are sanctioned through adjudication in accordance with Chapter 119. of the Revised Code. (C) Costs that exc...

...(A) As used in this rule: (1) "Annual facility average case mix score" is the score used to calculate the facility's cost per case-mix unit. (2) "Assessment reference date (ARD)" is the last day of the observation (or "look back") period that the MDS 3.0 assessment covers for the resident. (3) "Case mix report" is a report generated by the Ohio department of medicaid (ODM) and distributed t...

...ntains the following core components: (1) As set forth in rule 5160-3-43.1 of the Administrative Code, a uniform resident assessment instrument (minimum data set version 3.0 (MDS 3.0)), that provides the data used to group residents into case mix categories. The MDS 3.0 includes section S. Information regarding section S is available on the ODM website at http://medicaid.ohio.gov/PROVIDERS/Provid...

...ule are the same as set forth in rules 5160-3-01, 5160-3-43.1, and 5160-3-43.4 of the Administrative Code. (B) To determine resident case mix scores, the Ohio department of medicaid (ODM) shall process resident assessment data submitted by NFs in accordance with rule 5160-3-43.1 of the Administrative Code, and shall classify residents in accordance with rule 5160-3-43.2 of the Administrative Code...

...initions. For purposes of this rule: (1) "Ancillary and support costs," "cost center," "direct care costs," "rebasing" and "tax costs" have the same meaning as in section 5165.01 of the Revised Code. (2) "Cost center report" means a report submitted to the Ohio department of medicaid (ODM) by a nursing facility provider that identifies the amount spent on each cost center included in rebasing. (B) Direct care spe...

...tax costs determined under section 5165.21 of the Revised Code except for the initial rate for new providers. ODM shall determine each new nursing facility's initial per medicaid day payment rate for tax costs in accordance with section 5165.151 of the Revised Code. (B) For purposes of calculating the initial rate for tax costs pursuant to division (A)(4)(a) of section 5165.151 of the Revised...

...g facility provides on or after January 1, 2012, "medicaid maximum allowable amount" means one hundred per cent of the nursing facility's medicaid rate on the date that the service was provided. (B) For qualified medicare beneficiaries (QMB) as defined in rule 5160:1-3-02.1 of the Administrative Code and medicaid consumers admitted to a nursing facility as a medicare part A benefit, the Ohio department of medicaid ...

...(A) In accordance with section 5165.151 of the Revised Code, the Ohio department of medicaid (ODM) shall determine the initial rate for the fiscal year in which the NF begins participation in the medicaid program for a NF with a first date of licensure and subsequent certification on or after July 1, 2006, including a NF that replaces one or more existing facilities, or a NF with a first date of l...

...daily basis in accordance with section 5162.35 of the Revised Code. Pursuant to section 5162.021 of the Revised Code, DODD may develop rules and policies governing the administration of the ICF-IID program, which shall be filed in Chapter 5123:2-7 of the Administrative Code upon review and approval by ODM in compliance with 42 C.F.R. 431.10 (July 15, 2013). (B) In collaboration with DODD, ODM sha...

... (ICFs-IID) in accordance with section 5162.35 of the Revised Code. Pursuant to section 5162.021 of the Revised Code, DODD may develop rules and policies governing the administration of the ICF-IID program, which are filed in Chapter 5123-7 of the Administrative Code upon review and approval by ODM. (B) In collaboration with DODD, ODM will create and implement oversight measures related to the IC...

...ffective for periods on or after July 1, 2019. (A) Definitions. (1) "Ancillary care costs" are costs for services other than direct care, incurred by the ICF/IID that are reasonable and provided to ICF/IID residents through an ICF/IID employee or through a contractual arrangement with the ICF/IID. For the purpose of the ICF/IID cost reporting and rate calculation, ancillary care costs include ...

... effective for periods on or after July 1, 2024. (A) Definitions. (1) "Ancillary care costs" are costs for services other than direct care, incurred by the state-operated intermediate care facility for individuals with intellectual disabilities that are reasonable and provided to ICF/IID residents through an ICF/IID employee or through a contractual arrangement with the ICF/IID. For the purpose of the ICF/IID cost ...

... if the following conditions are met: (1) The physician is currently enrolled as an Ohio medicaid provider; (2) The service is rendered to a medicaid-eligible Ohio recipient in a state in which the physician is licensed or authorized to practice; and (3) The service is within the scope of practice of the physician's specialty. (B) Separate payment may be made for covered professional services rendered by a physic...

...the following conditions are met: (1) The services contribute directly to the diagnosis or treatment of an individual patient; (2) Any applicable requirements set forth in agency 5160 of the Administrative Code are satisfied; and (3) The expenses associated with the provision of the professional services are excluded from the cost report of the facility. (B) In addition to professional...

...initions that apply to this rule. (1) "Independent practitioner" is a practitioner who, under Ohio law, may provide healthcare services without supervision. (2) "Non-independent practitioner" is a practitioner who, under Ohio law, may provide healthcare services only with supervision. (3) "Supervision" is a collective term encompassing two types of professional oversight: (a) A practitione...

...set forth in paragraph (B) of rule 5160-4-02 of the Administrative Code do not apply when both of the following criteria are met: (1) A healthcare service is provided by a resident participating in an approved graduate medical education (GME) program; and (2) The conditions specified in 42 C.F.R. 415.174 (October 1, 2020) are satisfied. (B) No separate payment will be made for services rend...

...e in which the services are provided. (1) Ambulance. Policies for E&M services provided during ambulance transport by hospital staff members are set forth in rule 5160-2-04 of the Administrative Code. Payment for E&M services provided during ambulance transport by practitioners who are not hospital staff members is subject to the following conditions: (a) Such services involve direct face-to-face co...