Ohio Administrative Code Search

...(A) This rule does not apply to MyCare 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 ser...

...(A) An "eligible behavioral health provider" for purposes of this chapter is a provider of a mental health or substance use disorder 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 providin...

...(A) For the purposes of this chapter, an "eligible billing provider" is an entity that meets 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 th...

...(A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet 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 illne...

...(A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet 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 illne...

...(A) This rule sets forth the reimbursement requirements and rates for behavioral health 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 Ad...

...(A) This rule sets forth the reimbursement requirements and rates for behavioral health 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 A...

...(A) This rule sets forth the reimbursement requirements and rates for behavioral health 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 A...

...(A) This rule sets forth the reimbursement requirements and rates for behavioral health 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) ...

...(A) This rule sets forth the reimbursement requirements and rates for behavioral health 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 ser...

...(A) For the purposes of medicaid reimbursement, assertive community treatment (ACT) refers to the evidence based model of delivering comprehensive community based behavioral health services to adults with certain serious and persistent mental illnesses who have not benefited from traditional outpatient treatment. The ACT model utilizes a multidisciplinary team of practitioners to deliver services ...

...(A) For the purpose of medicaid reimbursement, therapeutic behavioral (day treatment), group service-hourly and per diem, is defined as an intensive, structured, goal-oriented, distinct and identifiable group treatment service that addresses the individualized mental health needs of the client. The therapeutic behavioral group service-hourly and per diem is clinically indicated by assessment. The ...

...(A) For the purpose of medicaid reimbursement, therapeutic behavioral (day treatment), group service-hourly and per diem, is defined as an intensive, structured, goal-oriented, distinct and identifiable group treatment service that addresses the individualized mental health needs of the client. The therapeutic behavioral group service-hourly and per diem is clinically indicated by assessment. The ...

...(A) For the purpose of medicaid reimbursement, substance use disorder treatment services shall be defined by and shall be provided according to the American society of addiction medicine also known as the ASAM treatment criteria for addictive, substance related and co-occurring conditions for admission, continued stay, discharge, or referral to each level of care (LOC). (B) Medicaid will reimburs...

...(A) Targeted case management assists an individual within the eligible target population to gain access to needed medical, social, educational and other services. (1) Targeted case management services shall include, at a minimum, the following activities: (a) Comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social or o...

...(A) Behavioral health nursing services are mental health and substance use disorder (SUD) nursing services performed by registered nurses or licensed practical nurses. They include those activities that are performed within professional scope of practice and in authorized settings by staff that are licensed by the Ohio board of nursing and are intended to address the behavioral and other physical ...

...(A) For the purpose of medicaid reimbursement, behavioral health crisis intervention is a timely intervention with medicaid recipients who are experiencing a life threatening or complex emergent situation related to mental illness or a substance use disorder. (1) The goals of crisis intervention are to ease the crisis, re-establish safety and institute interventions to minimize psychological ...

...(A) For the purposes of this rule, mobile response and stabilization service (MRSS), is the service as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-14 of the Administrative Code. (B) Eligible providers. (1) Providers certified by OhioMHAS in accordance with rule 5122-29-14 of the Administrative Code are eligible for MRSS reimbursement. (2) ...

...(A) For the purposes of this rule, mobile response and stabilization service (MRSS), is the service as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-14 of the Administrative Code. (B) Eligible providers. (1) Providers eligible to provide MRSS in accordance with rule 5122-29-14 of the Administrative Code and designated by OhioMHAS as regional ...

...(A) For the purposes of this rule, behavioral health peer support service is the service as set forth by the Ohio department of mental health and addiction services (OhioMHAS) in rule 5122-29-15 of the Administrative Code. (B) Eligible providers. (1) An eligible rendering provider of peer support services is: (a) A person who is eligible to provide peer support services in accordance with rule ...

...The following definitions apply for purposes of this chapter. Policies governing fee-for-service clinics are set forth in Chapter 5160-13 of the Administrative Code. (A) "Change in scope of service" is an alteration in aspects of a service such as the procedures or items that are furnished, the frequency with which they are furnished, and the personnel who furnish them. (1) Factors that constitute a...

...(A) "Change in scope of service" is an alteration in aspects of a prospective payment system (PPS) service such as the procedures or items that are furnished, the frequency with which they are furnished, and the type of personnel who furnish them. (1) A change in scope of service is characterized by such factors as are specified in the following non-exhaustive list: (a) The addition or discontin...

...(A) A federally qualified health center (FQHC) may receive prospective payment system (PPS) payment for providing any of the following FQHC PPS services: (1) In accordance with section 330 of the Public Health Services Act, 42 U.S.C. chapter 6A (October 1, 2021), medical services, which comprise any of four types of services: (a) Services referenced at 42 U.S.C. 1395x(aa)(3) (October 1, 2021...

...(A) Data entered into a cost report should represent "reasonable and allowable costs," which are defined in "Principles of reasonable cost reimbursement," 42 C.F.R. part 413 (October 1, 2021). (B) For purposes of payment determination, an FQHC or RHC submits a cost report in any of the following circumstances: (1) An FQHC or RHC that is newly enrolled as a medicaid provider submits a cost report...

...(A) A discrete, all-inclusive per-visit payment amount (PVPA) is established for each FQHC PPS service provided at an FQHC or related off-site location and for an RHC PPS service provided at an RHC or related off-site location. (1) For all FQHC or RHC sites that are already enrolled as medicaid providers, ODM establishes new PVPAs equal to the current PVPAs revised to reflect the latest available...