Ohio Administrative Code Search

...managed care entity as defined in rule 5160-26-01 of the Administrative Code, are prescribed drugs as defined in rule 5160-9-05 of the Administrative Code that are dispensed to an eligible recipient for use in the recipient's residence, including a nursing facility (NF), as defined in section 5165.01 of the Revised Code, or intermediate care facility for individuals with intellectual disabilities ...

... review (DUR), and patient counseling (1) Patient profiles, prospective DUR and patient counseling must be performed for medicaid patients by medicaid pharmacy providers in accordance with Chapter 4729-5 of the Administrative Code. (2) Documentation and records required by Chapter 4729-5 of the Administrative Code must be maintained in accordance with rule 5160-1-17.2 of the Administrative Code. (3) In addition to...

...eview (DUR), and recipient counseling (1) Recipient profiles, prospective DUR and recipient counseling must be performed for medicaid recipients by medicaid pharmacy providers in accordance with agency 4729 of the Administrative Code. (2) Documentation and records required by - agency 4729 of the Administrative Code must be maintained in accordance with rule 5160-1-17.2 of the Administrative Cod...

...(A) Definitions. (1) "340B ceiling price" means the highest price allowed to be charged by a manufacturer to a 340B covered entity as described in section 340B(a)(4) of the "Public Health Service Act," 42 U.S.C. 256b(a)(4) (in effect as of January 7, 2011). (2) "Actual acquisition cost (AAC)" means the best determination by the Ohio department of medicaid (ODM) of the actual amount the provi...

...the recipient in accordance with rules 5160-1-09 and 5160-9-09 of the Administrative Code. (B) The ingredient cost portion of the calculated allowable is determined in accordance with the following criteria: (1) No ingredient cost is allowed for a pandemic vaccine or any other medication, provided by the Ohio department of health or other government entity at no cost to the provider. (2) Fo...

... executed on a tamper-resistant form. (1) To be considered tamper resistant, a prescription form must contain all of the following three characteristics: (a) One or more features designed to prevent unauthorized copying of a completed or blank prescription form; (b) One or more features designed to prevent the erasure or modification of information written on the prescription by the prescriber; and (c) One or mor...

... executed on a tamper-resistant form. (1) To be considered tamper resistant, a prescription form must contain all of the following three characteristics: (a) One or more features designed to prevent unauthorized copying of a completed or blank prescription form; (b) One or more features designed to prevent the erasure or modification of information written on the prescription by the prescriber; ...

...ist specified in paragraph (C) of rule 5160-9-03 of the Administrative Code. (B) Rules 5160-1-09 and 5160-1-60 of the Administrative Code establish additional requirements regarding co-payments. (C) Rule 5160-1-09 of the Administrative Code establishes exceptions to the requirement that an individual pay a co-payment. (D) The exception established in paragraph (C)(4) of rule 5160-1-09 of the Administrative Code re...

...specified in paragraph (C) of rule 5160-9-03 of the Administrative Code. (B) Rules 5160-1-09 and 5160-1-60 of the Administrative Code establish additional requirements regarding co-payments. (C) Rule 5160-1-09 of the Administrative Code establishes exceptions to the requirement that an individual pay a co-payment. (D) The exception established in paragraph (C)(4) of rule 5160-1-09 of the Ad...

...ical supplies, and supplier services. (1) Additional conditions specific to a particular DMEPOS item or service may be set forth in other rules in this chapter of the Administrative Code. (2) Policies set forth in other rules in this chapter supersede any provisions in this rule with which they conflict. (B) Definitions that apply to rules in this chapter of the Administrative Code. (1) "Certi...

...(A) Scope. (1) This rule sets forth general coverage and payment policies for durable medical equipment (DME), prostheses, orthotic devices, medical supplies, and supplier services dispensed or rendered by an enrolled DMEPOS provider. (2) Additional conditions specific to a particular DMEPOS item or service may be set forth in other rules in this chapter of the Administrative Code. (3) Policies...

...(A) Scope. (1) This rule sets forth general coverage and payment policies for durable medical equipment (DME), prostheses, orthotic devices, medical supplies, and supplier services dispensed or rendered by an enrolled DMEPOS provider. (2) Additional conditions specific to a particular DMEPOS item or service may be set forth in other rules in this chapter of the Administrative Code. (3) Policies set forth in other ...

...(A) Definitions and explanations. (1) "Basic equipment package" is the following standard set of parts and accessories that come with a wheelchair at the time of purchase: (a) A sling or solid seat with back, a captain's chair, or a stadium-style seat; (b) Standard casters or wheels with tires; (c) Standard armrests; (d) Standard front rigging, such as non-elevating legrests with footrests or...

...(A) Definitions and explanations. (1) "Group 1," "group 2," and "group 3" are classes of pressure-reducing support surface. (a) Group 1 surfaces are generally non-powered pads or overlays that are designed to be placed on top of a hospital bed or standard mattress. They achieve their effect through the application of, for example, a gel layer, air pressure, natural lamb's wool, or synthetic ...

...(A) Definitions and explanations. (1) "Group 1," "group 2," and "group 3" are classes of pressure-reducing support surface. (a) Group 1 surfaces are generally non-powered pads or overlays that are designed to be placed on top of a hospital bed or standard mattress. They achieve their effect through the application of, for example, a gel layer, air pressure, natural lamb's wool, or synthetic ...

...(A) Coverage. (1) Separate payment may be made for a speech-generating device (SGD) furnished to a resident of a long-term care facility (LTCF). (2) The default certificate of medical necessity (CMN) form is the ODM 02924, "Certificate of Medical Necessity: Speech-Generating Devices" (rev. 7/2018). The CMN must include the following elements: (a) A formal, written report of a face-to-face evalu...

...(A) Coverage. (1) Separate payment may be made for a speech-generating device (SGD) furnished to a resident of a long-term care facility (LTCF). (2) The default certificate of medical necessity (CMN) form is the ODM 02924, "Certificate of Medical Necessity: Speech-Generating Devices" (rev. 7/2018). The CMN includes the following elements: (a) A formal, written report of a face-to-face evaluatio...

...(A) Definitions and explanations. (1) "Multiple-user lactation pump" is a lactation pump that is safe for sequential use by multiple individuals. (The term "hospital-grade," which is often applied to such a pump, is not recognized by the United States food and drug administration.) A multiple-user lactation pump comes with a separate set of accessories (e.g., breast shields, tubing) for each ...

...(A) Definitions. (1) "Sensor-augmented insulin pump system" is an insulin infusion pump equipped with a continuous glucose monitoring (CGM) sensor. The pump uses the glucose readings taken by the CGM sensor to modify the amount of insulin infused. (2) "Insulin pump," for purposes of this rule, is a collective term encompassing a portable external insulin infusion pump and a sensor-augmented insu...

...s chapter of the Administrative Code. (1) "Clinical consultation" is the formal evaluation by a physician or other qualified healthcare professional, performed on the written order of a treating practitioner, of test results that appear to be abnormal. Payment for the clinical consultation is based on the physician fee schedule relative value file published by the centers for medicare and medicai...

...n 42 C.F.R. part 486 subpart C (October 1, 2020). (B) Coverage. (1) The radiology procedures performed by a portable x-ray supplier have both a professional component and a technical component. (a) In general, a portable x-ray supplier performs the technical component of a procedure. (b) A portable x-ray supplier may receive payment for the technical component alone if it performs only the technic...

...n 42 C.F.R. part 486 subpart C (October 1, 2025). (B) Coverage. (1) The radiology procedures performed by a portable x-ray supplier have both a professional component and a technical component. (a) In general, a portable x-ray supplier performs the technical component of a procedure. (b) A portable x-ray supplier may receive payment for the technical component alone if it performs only the technical component an...

...(A) Providers. (1) An entity may enroll in medicaid as an independent diagnostic testing facility (IDTF) only if it meets the following criteria: (a) It meets all standards set forth in and provide services in accordance with 42 C.F.R. 410.33 (October 1, 2020); (b) It takes the following measures to establish accountability: (i) It ensures that each supervising practitioner attests in writin...

...(A) Providers. (1) An entity may enroll in medicaid as an independent diagnostic testing facility (IDTF) only if it meets the following criteria: (a) It meets all standards set forth in and provide services in accordance with 42 C.F.R. 410.33 (October 1, 2025); (b) It takes the following measures to establish accountability: (i) It ensures that each supervising practitioner attests in writing, at the time of the...

...gery as authorized under Chapter 4731. of the Revised Code. Advanced practice registered nurses in accordance with rule 5160-4-04 of the Administrative Code or a physician assistant in accordance with rule 5160-4-03 of the Administrative Code have the authority to conduct the face-to-face encounter. The face-to-face encounter with the individual will occur independent of any provision of home ...