Ohio Administrative Code Search

...Paragraphs (A)(7) to (F)(4) of this rule do not apply to pharmacy services covered under the medicare part D program. Pharmacy services covered under the medicare part D program should be billed in accordance with rule 5160-9-06 of the Administrative Code. (A) Definitions. (1) "Medicare" is a federally financed program of hospital insurance (part A) and supplemental medical insurance (also called SMI ...

...(A) For qualified medicare beneficiaries and medicaid recipients enrolled in medicare part C managed health care plans (medicare advantage plans) the department will pay as cost sharing the lesser of the following amounts: (1) The provider's billed charges for the service (except for hospital and nursing facility services); or (2) The deductible, coinsurance and co-payment amount as provided...

...(A) The reimbursement methodology set forth in paragraph (B) of this rule is limited to medicare part B services that meet all of the following criteria: (1) Are not hospital services defined in accordance with Chapter 5160-2 of the Administrative Code; (2) Are not nursing facility services included in the nursing facility per diem as defined in accordance with Chapter 5160-3 of the Administrative Code; (3) Are co...

...(A) The Ohio department of aging (ODA) is responsible for the daily administration of the preadmission screening system providing options and resources today (PASSPORT) medicaid waiver program. ODA shall administer the waiver pursuant to an interagency agreement with the Ohio department of medicaid in accordance with section 5162.35 of the Revised Code. (B) The PASSPORT waiver provides home and com...

...(A) The Ohio department of aging (ODA) is responsible for the daily administration of the preadmission screening system providing options and resources today (PASSPORT) medicaid waiver program. ODA shall administer the waiver pursuant to an interagency agreement with the Ohio department of medicaid in accordance with section 5162.35 of the Revised Code. (B) The PASSPORT waiver provides home and com...

...(A) The Ohio department of aging (ODA) is responsible for the daily administration of the preadmission screening system providing options and resources today (PASSPORT) medicaid waiver program. ODA will administer the waiver pursuant to an interagency agreement with the Ohio department of medicaid in accordance with section 5162.35 of the Revised Code. (B) The PASSPORT waiver provides home and comm...

...(A) The Ohio department of aging (ODA) is responsible for the daily administration of the assisted living HCBS waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM), in accordance with section 5162.35 of the Revised Code. (B) The assisted living HCBS waiver is an alternative to nursing facility placement for persons age twenty-one ...

...(A) The Ohio department of aging (ODA) is responsible for the daily administration of the assisted living HCBS waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM), in accordance with section 5162.35 of the Revised Code. (B) The assisted living HCBS waiver is an alternative to nursing facility placement for persons age twenty-one ...

...(A) The Ohio department of aging (ODA) is responsible for the daily administration of the assisted living HCBS waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM), in accordance with section 5162.35 of the Revised Code. (B) The assisted living HCBS waiver is an alternative to nursing facility placement for persons age twenty-one ...

...(A) Definitions. (1) "Coordination of benefits" (COB) means the process of determining which health plan or insurance policy will pay first or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits for a medicaid covered individual. (2) "Coordinat...

...This rule sets forth requirements regarding co-payments by individuals for medicaid-covered services. (A) Certain medicaid services are subject to individual co-payments. Information regarding these services and co-payment amounts can be found in the following Administrative Code rules: (1) Co-payments for dental services are described in rule 5160-5-01 of the Administrative Code. (2) Co-payments for vision servic...

...(A) Out-of-state providers: (1) Should be licensed, accredited, or certified by their respective states to be considered eligible to receive reimbursement for services provided to Ohio medicaid covered individuals. (2) Should meet any standards applicable to the provision of the service in the state in which the service is being furnished, as well as those standards set forth in the Ohio med...

...(A) In accordance with 42 C.F.R. 447.15 (as in effect October 1, 2018), the medicaid payment for a covered service constitutes payment-in-full. It shall not be construed as a partial payment even when the payment amount is less than the provider's charge. (1) The provider shall not collect nor bill a medicaid recipient for any difference between the medicaid payment and the provider's charge,...

...(A) Definitions. (1) "Healthchek" is Ohio's early and periodic screening, diagnostic, and treatment (EPSDT) benefit for all medicaid recipients younger than twenty-one years of age, described in 42 U.S.C. 1396d(r) (as in effect 10/2017). (2) "Bright futures guidelines" are the American academy of pediatrics bright futures guidelines for preventive health care (rev. 2/2017), available at http://w...

...(A) Definitions. (1) "Healthchek" is Ohio's early and periodic screening, diagnostic, and treatment (EPSDT) benefit for all medicaid recipients younger than twenty-one years of age, described in 42 U.S.C. 1396d(r) (as in effect January 1,2025). (2) "Bright futures guidelines" are the American academy of pediatrics bright futures guidelines for preventive health care, available at http://www.aap.org. (3) "Medical n...

...This rule sets forth eligibility requirements for practitioners, group practices, or organizational providers enrolling with, and seeking reimbursement from, the Ohio medicaid program. (A) Eligible provider means any practitioner, group practice, or organization identified by the Ohio department of medicaid (ODM) as a type of provider eligible to enroll in the medicaid program that: (1) Meets the ap...

...Provisions of provider agreements for long term care nursing facilities are defined in Chapter 5160-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5160-26 of the Administrative Code. A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid program. All medicaid provider ap...

...(A) For the purposes of this rule, the following definitions apply: (1) "Affiliation" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (2) "Agent" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (3) "Disclosable event" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (4) "Disclosing provider" ...

...(A) Revalidation is the process that a provider is required to follow to renew and revalidate its provider agreement. Provider agreements must be revalidated no later than five years from the effective date of the original or the last revalidated provider agreement, whichever is applicable. In the event the center for medicare and medicaid services (CMS) waives or modifies the deadline, provider a...

...(A) For purposes of this rule, the following definitions apply: (1) "Ownership or control interest" means having at least five per cent ownership, or interest, either directly, indirectly, or in any combination. (2) "Provider" has the same meaning as "eligible provider," as defined in rule 5160-1-17 of the Administrative Code. (3) "Provider Agreement" means an agreement as defined in rule 5160-1-17.2 of the Admin...

...(A) An individual or entity that at one time was a participating provider in the Ohio medicaid program and whose provider agreement was terminated either voluntarily or involuntarily in accordance with rule 5160-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program. (B) In considering an application fo...

...(A) In accordance with 42 C.F.R. 455.410 (as in effect October 1, 2019) and rule 5160-1-17 of the Administrative Code in order to become an eligible provider, a provider must meet the screening requirements described in this rule and in section 5164.34 of the Revised Code and pay an applicable application fee if required in the appendix to this rule. Provider screening and application fees are req...

...(A) Definitions for purposes of this rule only: (1) A "participating provider" is an active provider who bills the medicaid program for rendered services, or who is an active provider who orders, prescribes, refers, or certifies but does not bill the medicaid program. (2) An "ordering or referring only provider" is a provider who orders, prescribes, refers, or certifies an item or service reported on a claim, and i...

...The Ohio department of medicaid (ODM) authorizes qualified entities (QEs) to determine presumptive eligibility (PE) based on self-attested information to grant immediate medicaid coverage to certain individuals seeking medicaid covered services. This rule sets forth eligibility requirements and responsibilities to maintain designation as a QE. (A) For the purposes of this rule, "qualified entity" has the...

...(A) For the purposes of this rule, the following definitions apply: (1) "Patient site" is the physical location of the patient at the time a health care service is provided through the use of telehealth. (2) "Practitioner site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth. (3) "Telehealth" is the direct deliver...