Ohio Administrative Code Search

...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...

... "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Disproportionate share hospital" means a hospital that meets the requirements for disproportionate share status as defined in rule 5160-2-09 of the Administrative Code. (2) "Governmental hospital" means a county hospital with more than five hundred beds or a state-owned and -operated hospital with more than ...

...t the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department of medicaid is informed that the assessment is an impermissible health care-related tax, the department shall promptly refund to each hospital the amount of money currently in the hospital care assurance match fund that has been paid by the hospital, plus any investm...

... "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Total fee for service (FFS) medicaid costs" for each hospital means the sum of inpatient program costs reported on ODM 02930, schedule H, section I, columns 1 and 3, line 1 and outpatient medicaid program costs as reported on ODM 02930, "Ohio Medicaid Hospital Cost Report," section II, column 1, line 10 f...

...bed in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code. (A) Definitions for each psychiatric hospital. (1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from state and local governments for inpatient services for the applicable state fiscal year. In accordance ...

...bed in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code. (A) Definitions for each psychiatric hospital. (1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from state and local governments for inpatient services for the applicable state fiscal year. In accordance ...

...(A) Appeals. Pursuant to Chapter 5160-70 of the Administrative Code, final settlements that are based upon final audits by the department may be appealed by hospitals under Chapter 119. of the Revised Code. Rule 5160-2-24 of the Administrative Code describes final fiscal audits and final settlements performed by the department. Rules 5160-1-27 and 5160-1-29 of the Administrative Code describe the audits performed b...

...le of all admissions retrospectively. (1) While the nature of the review will vary depending on the category of admission, all admissions selected will be reviewed to determine whether care was medically necessary on an inpatient hospital basis; to determine if the care was medically necessary as defined in rule 5160-1-01 of the Administrative Code; to determine whether the discharge occurred at a medically appropri...

...ayment systems. (A) Applicability. (1) Cost-related reimbursement, where payments are made for services to approximate cost based on a historical cost-to-charge ratio, and where no subsequent reconciliation occurs, applies to: (a) All outpatient hospital services provided by hospitals excluded from outpatient prospective payment as set forth in rule 5160-2-05 of the Administrative Code. (b) ...

... eligible provider, as defined in rule 5160-2-01 of the Administrative Code, to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (A)(7) of this rule. Effective for medicaid cost reports fil...

... eligible provider, as defined in rule 5160-2-01 of the Administrative Code, is to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (A)(7) of this rule. Any hospital tha...

...(A) General provisions. (1) Audits will be conducted by the Ohio department of medicaid for services rendered by the hospital under the medicaid program. The examination of hospital costs and charges will be made in consideration with generally accepted auditing standards necessary to fulfill the scope of the audit. To facilitate this examination, providers are required to make available all records and source docum...

...(A) General provisions. (1) Audits will be conducted by the Ohio department of medicaid for services rendered by the hospital under the medicaid program. The examination of hospital costs and charges will be made in consideration with generally accepted auditing standards necessary to fulfill the scope of the audit. To facilitate this examination, providers will make available all records and sou...

...Rule 5160-1-08 of the Administrative Code sets forth general provisions regarding requirements that the department make payment for covered services only after any available third-party benefits are exhausted. In addition to those general provisions, this rule identifies other requirements applicable to services provided by hospitals. (A) All hospitals are to utilize third-party resources for all services a consumer...

...Rule 5160-1-08 of the Administrative Code sets forth general provisions that the department make payment for covered services only after any available third-party benefits are exhausted. In addition, this rule identifies other provisions applicable to services provided by hospitals. (A) All hospitals are to use third-party resources for all services a consumer receives while in the hospital. If a hos...

...fee program implemented under sections 5168.20 to 5168.28 of the Revised Code. (A) Definitions For purposes of the hospital franchise fee program only, ''total facility costs'' are as defined in section 5168.20 of the Revised Code, and also exclude a hospital's costs associated with providing care to recipients of the medicare program as shown on the cost-reporting data used for purposes of determ...

...tification program. (A) Definitions. (1) An "emergency admission" is an admission to treat a condition requiring medical and/or surgical treatment within the next forty-eight hours when, in the absence of such treatment, it can reasonably be expected that the patient may suffer unbearable pain, physical impairment, serious bodily injury or death. (2) "Medical necessity" is defined in rule 5160-1-01 of the Administ...

...ule, the following definitions apply: (1) A "hospital" is a provider eligible under rule 5160-2-01 of the Administrative Code. (2) "Medical necessity" is as defined in rule 5160-1-01 of the Administrative Code. (3) "Pre-certification" is a process whereby the Ohio department of medicaid (ODM) or its contracted medical review entity assures that covered psychiatric services are medically necessary and are provided ...

...amount calculation described in rule 5160-2-25 of the Administrative Code. (A) Definitions. (1) "Inpatient case mix" means the sum of the relative weight values for all discharges during the calendar year preceding the calendar year that precedes the state fiscal year (SFY) of the cost coverage add-on divided by the total number of discharges during the same calendar year. (2) "Freestanding p...

...d amount calculation described in rule 5160-2-25 of the Administrative Code. (A) Definitions. (1) "Inpatient case mix" means the sum of the relative weight values for all discharges during the calendar year preceding the calendar year that precedes the state fiscal year (SFY) of the cost coverage add-on divided by the total number of discharges during the same calendar year. (2) "Freestanding ...