Ohio Administrative Code Search

...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...

...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 require direct face-to-face co...

...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...

...(A) General provisions. (1) "Current procedural terminology (CPT)" is a comprehensive listing of medical terms and codes published by the American medical association, www.ama-assn.org, for the uniform designation of diagnostic and therapeutic procedures in surgery, medicine, and the medical specialties. "Healthcare common procedure coding system (HCPCS)" is a numeric and alphanumeric code set ma...

...(A) General provisions. (1) A "not otherwise specified," "unlisted," or "miscellaneous" procedure code should be reported on a claim only if no procedure code is available that identifies the particular service or item provided. (2) No separate payment is made for an immunization, injection, infusion, vaccine, toxoid, or provider-administered pharmaceutical as a medical service if it is provide...

...ided during treatment. (B) Coverage. (1) Chemotherapy provided in a hospital setting (inpatient hospital, outpatient hospital, emergency department) is a hospital service, for which payment is made in accordance with Chapter 5160-2 of the Administrative Code. No separate payment is made to a practitioner for either chemotherapy administration or a chemotherapeutic agent provided in a hospital se...

...(A) Coverage. (1) In general, payment may be made to an eligible provider for performing a medically necessary surgical procedure on an eligible recipient. The following limitations, however, apply. (a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and postoperative care, or any proced...

...(A) Coverage. (1) In general, payment may be made to an eligible provider for performing a medically necessary surgical procedure on a medicaid-eligible individual. The following limitations, however, apply. (a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and post...

... the standards set forth in 42 CFR 416.166 (October 1, 2017). Such procedures are listed on the department's website http://www.medicaid.ohio.gov/provider/feeschedulesandrates. (B) Payment may be made to a physician for performing a covered surgical procedure in an ASC even if the surgery is not itself a covered ASC surgical procedure. (C) Payment may be made to a physician for performing th...

... the standards set forth in 42 CFR 416.166 (October 1, 2017). Such procedures are listed on the department's website https://medicaid.ohio.gov/resources-for-providers/billing/fee-schedule-and-rates/fee-schedule-and-rates. (B) Payment may be made to a physician for performing a covered surgical procedure in an ASC even if the surgery is not itself a covered ASC surgical procedure. (C) Payment may...

...(A) Coverage. (1) Total (global) procedure. Payment may be made to a practitioner for performing both the professional and technical components of a radiology or imaging procedure if two conditions are met: (a) The technical component was not performed in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or a hospital emergency department); and (b) The practitioner who submitted the claim ei...

...(A) Coverage. (1) Total (global) procedure. Payment may be made to a practitioner for performing both the professional and technical components of a radiology or imaging procedure if two conditions are met: (a) The technical component was not performed in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or a hospital emergency department); and (b) The practitioner who su...

... part of the Administrative Code: (1) Hospital services, Chapter 5160-2; (2) Nursing facility services, Chapter 5160-3; (3) Intermediate care facility services, Chapter 5123:2-7; (4) Federally qualified health center services, Chapter 5160-28; (5) Ambulatory surgery center services, Chapter 5160-22; and (6) Telehealth services, rule 5160-1-18. (B) Definitions. (1) "Metropolitan ...