Ohio Administrative Code Search

...Care Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) Eligibility for managed care organization (MCO) enrollment. (1) Except as specified in paragraphs (B)(3) to (B)(5) of this rule, in mandatory service areas as permitted by 42 C.F...

...Care Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) The Ohio department of medicaid (ODM) will terminate a member from enrollment in a managed care organization (MCO) for any of the following reasons: (1) The member's permanent place ...

...Care Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) Except as otherwise provided in this rule, a managed care organization (MCO) and the single pharmacy benefit manager (SPBM) must ensure members have access to all medically necessary ...

...Care Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) A managed care organization (MCO) must ensure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appro...

...Care Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) The managed care organization (MCO) is responsible for payment of long-term services and supports (LTSS) respite services as defined in rule 5160-26-01 of the Administrative Code. (C...

...(A) Provider contracts. (1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule and...

...(A) Provider contracts. (1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule, 42...

...n to their contracting providers: (1) The MCE's grievance, appeal and state fair hearing procedures and time frames, including: (a) The member's right to file grievances and appeals and the requirements and time frames for filing; (b) The MCE's toll-free telephone number to file oral grievances and appeals; (c) The member's right to a state fair hearing, the requirements and time frames fo...

...located at http://medicaid.ohio.gov/. (1) These arrangements or procedures must be made available to ODM upon request. (2) The MCE must annually submit to ODM a report that summarizes the MCE's fraud, waste, and abuse activities for the previous year and identifies any proposed changes to the MCE's fraud, waste, and abuse program for the coming year. (B) ODM or its designee, the state auditor's...

...licies in accordance with 42 C.F.R. 438.100 (October 1, 2021), as applicable, to ensure each member has and is informed of his or her right to: (1) Receive all services the MCE is required to provide pursuant to the terms of the MCE provider agreement or contract, as applicable, with the Ohio department of medicaid (ODM). (2) Be treated with respect and with due consideration for their digni...

...Care Ohio plans as defined in rule 5160-58-01 of the Administrative Code. (B) Notice of action (NOA) by a managed care organization (MCO) or the single pharmacy benefit manager (SPBM). (1) When an adverse benefit determination has occurred or will occur, the MCO or SPBM shall provide the affected member with a NOA. (2) The language and format of the NOA shall comply with the requirements li...

...(A) Tort. (1) Pursuant to sections 5160.37 and 5160.38 of the Revised Code, the Ohio department of medicaid (ODM) maintains all rights of recovery (tort) against the liability of any third party payer (TPP) for the cost of medical services. (2) A managed care entity (MCE) is prohibited from accepting any settlement, compromise, judgment, award, or recovery of any action or claim by a member. (3...

...(A) Tort. (1) Pursuant to sections 5160.37 and 5160.38 of the Revised Code, the Ohio department of medicaid (ODM) maintains all rights of recovery (tort) against the liability of any third party payer (TPP) for the cost of medical services. (2) A managed care entity (MCE) is prohibited from accepting any settlement, compromise, judgment, award, or recovery of any action or claim by a member. (3...

...acy benefit manager as defined in rule 5160-26-01 of the Administrative Code. (B) If the MCO fails to fulfill its duties and obligations under 42 C.F.R. Part 438 (October 1, 2021), 42 U.S.C. 1396b(m) (as in effect July 1, 2022), 42 U.S.C. 1396u-2 (as in effect July 1, 2022), agency 5160 of the Administrative Code, or the MCO provider agreement, ODM will provide timely written notification to the ...

...e date of service. Pursuant to section 5167.101 of the Revised Code, the MCO shall not compensate a hospital for inpatient capital costs in an amount that exceeds the maximum rate established by ODM. (B) When ODM has approved the MCO's members to be referred to a non-contracting hospital pursuant to rule 5160-26-03 of the Administrative Code, the non-contracting hospital must provide the service for which the referr...

...Care Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) The managed care organization (MCO) may elect to implement a member co-payment program pursuant to section 5162.20 of the Revised Code for dental services, vision services, or non-eme...

...er treatment service covered in agency 5160 of the Administrative Code and is one of the following: (1) An entity operating in accordance with section 5119.36 of the Revised Code and Chapters 5122-24 to 5122-29 and Chapter 5160-1 of the Administrative Code and providing mental health or substance use disorder treatment services. (2) An entity furnishing mental health and/or substance use disorde...

...ets the conditions in paragraph (A)(1) or (A)(2) of this rule. An "eligible rendering provider" is an individual who meets one or more of the conditions stated in paragraphs (A)(3) to (A)(8) of this rule and is employed by or under contract with an eligible billing provider. (1) An entity certified by the Ohio department of mental health and addiction services operating in accordance with se...

...t all requirements found in agency 5160 of the Administrative Code unless otherwise specified. (1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illness or substance use disorder. The list of recognized diagnoses can be accessed at www.medicaid.ohio.gov. (2) Medicaid reimbursable behavioral health servi...

...t all requirements found in agency 5160 of the Administrative Code unless otherwise specified. (1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illness or substance use disorder. The list of recognized diagnoses can be accessed at www.medicaid.ohio.gov. (2) Medicaid reimbursable behavioral health servi...

...h services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services will abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code. (C) With the exception of pharmacists as described in paragraph (A...

...h services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services shall abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code. (C) Records related to services reimbursed under this rule are su...

...h services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services shall abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code. (C) Records related to services reimbursed under this rule are su...

...ealth services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services will abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code. (C) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27...

...h services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, medicaid reimbursement rates for services and practitioners described in Chapter 5160-27 of the Administrative Code are li...