Ohio Administrative Code Search

...(A) Debt estimate. For the purposes of division (C) of section 5165.52 of the Revised Code, the debt estimate for change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal is considered provided by the Ohio department of medicaid (ODM) on the date of mailing, date of personal service, or date of publication. (B) Initial debt summary report. (1...

...(A) Forms. For dates of services preceding July 1, 2005, NFs shall submit the form "Nursing Facility Payment and Adjustment Authorization" (JFS 09400, rev. 10/2012) directly to the Ohio department of job and family services (ODJFS) for the reimbursement of services. The county department of job and family services (CDJFS) and NFs shall use the "Facility/CDJFS Transmittal" (JFS 09401, rev. 4/2011) form to exchange i...

...(A) Requirements for submitting claims for services not included in the NF per diem rate. Notwithstanding the requirements set forth in paragraph (A)(2) of rule 5160-1-19 of the Administrative Code, NF providers shall submit medicare crossover claims and claims for medicaid reimbursement for allowable services that are not included in the NF per diem rate in accordance with the requirements set forth in rule 5160-1-...

...(A) Nursing facilities shall submit claims in accordance with rule 5160-1-19 of the Administrative Code. Additional requirements specific to the submission of long-term care per diem claims are in paragraphs (B) to (E) of this rule. (B) Additional requirements to be met prior to submitting claims for services included in the per diem. (1) Individual is a medicaid recipient for the dates of servi...

...(A) The Ohio department of medicaid (ODM) requires that all facilities file cost reports annually to comply with section 5165.10 of the Revised Code. (1) The chart of accounts in table 1 to table 8 of appendix A to this rule is to establish the minimum level of detail to allow for cost report preparation. (2) If the chart of accounts in appendix A to this rule is not used by the provider, it ...

...(A) Depreciation on buildings, components, and equipment used in the provision of patient care that are not reimbursable by medicaid directly to the medical equipment supplier may be paid for through the NF per diem rate. (B) For purposes of determining if an expenditure should be capitalized, NF providers are to refer to the centers for medicare and medicaid services (CMS) publication 15-1, Chap...

...The following costs are not reimbursable to NFs through the NF per diem, except as specified under Chapter 5160-3 of the Administrative Code. Non-reimbursable costs include but are not limited to: (A) Fines or penalties paid under sections 5165.1010, 5165.72 to 5165.77, 5165.83, and 5165.99 of the Revised Code. (B) Disallowances made during the audit of NF cost reports that are sanctioned through adjudication in a...

...(A) As used in this rule: (1) "Annual facility average case mix score" is the score used to calculate the facility's cost per case-mix unit. (2) "Assessment reference date (ARD)" is the last day of the observation (or "look back") period that the MDS 3.0 assessment covers for the resident. (3) "Case mix report" is a report generated by the Ohio department of medicaid (ODM) and distributed t...

...The Ohio department of medicaid (ODM) shall pay each eligible NF a per resident per day rate for direct care costs established prospectively for each facility. The department shall establish each facility's rate for direct care costs semiannually. Each facility's rate for direct care costs shall be based on a case mix payment system. (A) The Ohio medicaid case mix payment system for direct care contains ...

...(A) The definitions of all terms used in this rule are the same as set forth in rules 5160-3-01, 5160-3-43.1, and 5160-3-43.4 of the Administrative Code. (B) To determine resident case mix scores, the Ohio department of medicaid (ODM) shall process resident assessment data submitted by NFs in accordance with rule 5160-3-43.1 of the Administrative Code, and shall classify residents in accordance w...

...(A) Definitions. 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 c...

...(A) The Ohio department of medicaid (ODM) shall pay a provider a per medicaid day payment rate for 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 t...

...(A) For nursing facility services the nursing 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) 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...

...(A) The Ohio department of developmental disabilities (DODD), through an interagency agreement with the Ohio department of medicaid (ODM), administers the medicaid program for services provided by intermediate care facilities for individuals with intellectual disabilities (ICFs-IID) on a daily basis in accordance with section 5162.35 of the Revised Code. Pursuant to section 5162.021 of the Revised...

...(A) The Ohio department of developmental disabilities (DODD), through an interagency agreement with the Ohio department of medicaid (ODM), and with oversight by ODM, administers the medicaid program for services provided by intermediate care facilities for individuals with intellectual disabilities (ICFs-IID) in accordance with section 5162.35 of the Revised Code. Pursuant to section 5162.021 of t...

...This rule describes the methodology for calculating payment rates for state-operated intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) operated by the Ohio department of developmental disabilities (DODD) and is effective 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 ...

...This rule describes the methodology for calculating payment rates for state-operated intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) operated by the Ohio department of developmental disabilities (DODD) and is 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 ...

...(A) Payment may be made for a covered service rendered by a physician only 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 ...

...(A) Separate payment may be made for covered professional services rendered by a physician employed by or under contract with a facility such as a hospital or long-term care facility (i.e., a "facility-based" physician) only if the following conditions are met: (1) The services contribute directly to the diagnosis or treatment of an individual patient; (2) Any applicable requirements set...

...(A) Definitions 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 prac...

...(A) The provisions 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 fo...

...(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site 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 practitione...

...(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site 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 practitione...

...(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site 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 practitione...