Ohio Administrative Code Search

...(A) Scope. This rule sets forth provisions governing payment for skilled therapies as non-institutional professional services furnished by skilled therapists and skilled therapist assistants or aides. Provisions governing payment for skilled therapies as the following service types are set forth in the indicated part of the Administrative Code: (1) Hospital services, Chapter 5160-2; (2) Nurs...

...(A) Scope. This rule sets forth provisions governing payment for skilled therapies as non-institutional professional services furnished by skilled therapists and skilled therapist assistants or aides. Provisions governing payment for skilled therapies as the following service types are set forth in the indicated part of the Administrative Code: (1) Hospital services, Chapter 5160-2; (2) Nurs...

...(A) Covered prescribed drugs Drugs covered by the Ohio department of medicaid (ODM) pharmacy program, or a managed care plan 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 patient for use in the patient's residence, including a nursing facility (NF), as defined in section 5165...

...(A) Covered prescribed drugs Drugs covered by the Ohio department of medicaid (ODM) pharmacy program, or a 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 sectio...

...(A) Patient profiles, prospective drug utilization 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...

...(A) Recipient profiles, prospective drug utilization review (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 ...

...(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...

...(A) Payment for prescribed drugs is the lesser of the provider's billed charges or the calculated allowable, after any coordination of benefits is applied as described in paragraph (E) of this rule. For prescribed drugs that are subject to a co-payment, the amount paid by the Ohio department of medicaid (ODM) is decreased by the amount equal to the co-payment billed to the recipient in accordance ...

...(A) The pharmacy claim to the Ohio department of medicaid (ODM) or its designee, the pharmacy point-of-sale vendor, must reflect the actual national drug code (NDC) on the container from which the product was dispensed. (B) All records of prescriptions must comply with federal and state regulations and shall be retained by the provider for a period of six years from the date of payment of the claim and if an audit i...

...(A) The pharmacy claims submitted to the Ohio department of medicaid (ODM) or its designee, the pharmacy point-of-sale vendor, must reflect the actual national drug code (NDC) on the container from which the product was dispensed. (B) All records of prescriptions must comply with federal and state regulations and be retained by the provider for a period of six years from the date of payment of th...

...(A) For a drug to be considered for coverage without prior authorization in accordance with rule 5160-9-03 of the Administrative Code, the following information may be requested from the manufacturer or labeler: (1) Trade name of the drug. (2) Generic name of the drug. (3) National drug code number (NDC). (4) Package sizes available. (5) Strengths. (6) Therapeutic use(s). (7) List of therapeutic ingredients. ...

...(A) This rule sets forth general coverage and payment policies for durable medical equipment (DME), prostheses, orthotic devices, medical/surgical 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 ...

...(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. (1) "Major repair" is a repair for which the combined medicaid allowed amounts for materials and labor exceed one hundred twenty dollars for an orthotic or prosthetic device or one hundred dollars for any other item. (2) "Minor repair" is a repair for which the combined medicaid allowed amounts for materials and labor do not exceed one hundred twenty dollars for an orthotic or ...

...(A) Definitions. (1) "Major repair" is a repair for which the combined medicaid allowed amounts for materials and labor exceed one hundred twenty dollars for an orthotic or prosthetic device or one hundred dollars for any other item. (2) "Minor repair" is a repair for which the combined medicaid allowed amounts for materials and labor do not exceed one hundred twenty dollars for an orthotic or ...

...(A) Definitions and explanations. (1) "Assistance," for purposes of this rule, is help with bathing-related tasks that individuals cannot accomplish by themselves, such as getting into and out of a bathing chair, moving in and out of the bathing area, or fastening and unfastening securements and positioners. The term does not include actual bathing (soaping, shampooing, scrubbing, rinsing). ...

...(A) Coverage. (1) Payment may be made for a high-frequency chest wall oscillation (HFCWO) device on a rental/purchase basis. (2) The default certificate of medical necessity (CMN) is form ODM 10229, "Certificate of Medical Necessity: High-Frequency Chest Wall Oscillation Devices" (7/2018). (3) An initial trial period of at least two months is required. Payment may be made for rental during ...

...(A) Coverage. (1) Payment may be made for a high-frequency chest wall oscillation (HFCWO) device on a rental/purchase basis. (2) Purchase of a HFCWO device will not be considered without an initial trial period lasting at least two months, excluding any portion that coincides with an inpatient hospital stay. Payment may be made for rental during this trial period. (3) The default certificate of...

...(A) Provider requirements. A provider of apnea monitors for use in the home must be capable of performing all of the following services: (1) Arranging to have certified individuals provide infant cardiopulmonary resuscitation (CPR) training to caregivers; (2) Providing education and instruction on the mechanical aspects of monitors; and (3) Providing a technician twenty-four hours a day to ...

...(A) Coverage. (1) Initial payment may be made for rental of an apnea monitor for a period not to exceed four months, and after the first four months payment may be made either for additional rental or for purchase, only if the following conditions are satisfied: (a) The monitoring unit meets current United States food and drug administration guidelines. (b) The provider is capable of perfor...

...(A) Definition. "Basic hearing test" is an evaluation of an individual's ability to hear that includes the following components: (1) Testing of air-conducted stimuli at thresholds of five hundred hertz (Hz), one thousand Hz, two thousand Hz, and four thousand Hz; (2) Assessment of air-conducted speech awareness or speech reception threshold; (3) Establishment of most comfortable and most un...

...(A) Definition. "Basic hearing test" is an evaluation of an individual's ability to hear that includes the following components: (1) Testing of air-conducted stimuli at thresholds of five hundred hertz (Hz), one thousand Hz, two thousand Hz, and four thousand Hz; (2) Assessment of air-conducted speech awareness or speech reception threshold; (3) Establishment of most comfortable and most un...

...(A) Definitions. (1) "Blood gas study" is the measurement of such characteristics of blood as the partial pressure of oxygen (PO2) or oxygen saturation. The term applies either to pulse oximetry or to an arterial blood gas (ABG) study. (2) "Group I" and "group II" criteria are sets of clinical indicators used to determine the coverage of oxygen without prior authorization. (a) Group I criteria....

...(A) Provider requirement. A provider of custom-made or custom-fitted compression garments must either employ or contract with a certified fitter and must keep documentation of this relationship on file. (B) Coverage. (1) The default certificate of medical necessity (CMN) form is the ODM 01905, "Certificate of Medical Necessity: Compression Garments" (rev. 7/2018). (2) Payment may be made on...