Ohio Administrative Code Search

...dividuals who do not possess health insurance for the service provided. Charity care does not include bad debts, contractual allowances, or uncompensated care costs rendered to patients with insurance as described in paragraph (A)(13) of this rule. Each psychiatric hospital reports charges for charity care on ODM 02930, schedule F, section II, column 3. (3) "Inpatient days" is the sum of the ...

...e in supplying information about health insurance or medical benefits available so a hospital may determine any potential third-party resources that may be available. (8) Nothing in this rule will be construed to prevent a hospital from assisting or requiring an individual to apply for medicaid before the hospital processes an application under this rule. (D) Billing of claims. (1) Claims shoul...

...r of: (i) The sum of the deductible, coinsurance and co-payment amount as provided by medicare part A; or (ii) The medicaid maximum allowed amount, as described in paragraph (B)(1)(a) of this rule, minus the total prior payment, not to equal less than zero. The total prior payment includes the amount paid or payable by medicare and any other applicable third party payment for services billed. (c) If the department...

... (i) The sum of the deductible, coinsurance, and co-payment amount as provided by medicare part A; or (ii) The medicaid maximum allowed amount, as described in paragraph (B)(1)(a) of this rule, minus the total prior payment, not to equal less than zero. The total prior payment includes the amount paid or payable by medicare and any other applicable third-party payment for services...

...ible for benefits through a third party insurance as the primary payer for the services subject to pre-certification. (j) Transfers from one hospital to another hospital with the exception of those hospitals identified for intensified review in accordance with paragraph (C)(1) of rule 5160-2-07.13 of the Administrative Code. (k) Admissions for those elective surgical procedures or diagnoses which are not included i...

...me as a third-party payor (i.e., an insurance company), and this provision does not preclude the facility from obtaining information about medicare and medicaid eligibility or the availability of private insurance. The prohibition against third-party guarantees applies to all individuals and prospective individuals in all certified NFs regardless of payment source. This provision does not prohibit...

...t limited to: (i) Health benefits and insurance; (ii) Social benefits; and (iii) Home utilities. (iii) "Telephoning" means the ability to make and answer telephone calls or use technology to connect to community services and supports. (b) "Environmental management" means the ability of an individual to maintain the living arrangement in a manner that ensures the health and safety of the individual and inclu...

...NF provider), the surety (i.e., the insurance company), and the obligee (i.e., the resident and/or the Ohio department of medicaid (ODM) acting on behalf of the resident), wherein the principal and the surety agree to compensate the obligee for any loss of the obligee's funds that the principal holds, safeguards, manages, and accounts for. The purpose of a surety bond is to guarantee that a N...

... standards established under the health insurance portability and accountability act (HIPAA) (modified August 14, 2002), using the 837 health care claim institutional (837I) electronic format (2015), which is available on the National Uniform Billing Committee website at http://nubc.org/ subscriber/index.dhtml; or (b) The medicaid information technology system (MITS) web portal. (3) Claim submissions shall use the ...

...s for medicare or other third-party insurance cost-sharing, including coinsurance or deductible payments, associated with services that are included in the NF per diem rate. (B) Neither the medicaid eligible NF resident nor the Ohio department of medicaid (ODM) is responsible for any medicare or other third-party insurance cost-sharing, including coinsurance or deductibles, associated with se...

...he repair is not covered by warranty or insurance; and (c) The repair is not associated with routine maintenance or cleaning of the hearing aid. (C) Requirements, constraints, and limitations. (1) The provider must keep on file a copy of the manufacturer's original cost estimate, a copy of the manufacturer's final invoice detailing discounts and shipping costs, and (if applicable) an explan...

...s, significant phone numbers and health insurance identification numbers of the individual receiving the services; (b) The medical history of the individual receiving the services; (c) If the RN performing RN assessment services and/or RN consultation services is employed by an agency, the RN's name and contact information, the agency's contact information, and the agency's national provider ide...

...s, significant phone numbers and health insurance identification numbers of the individual receiving the services; (b) The medical history of the individual receiving the services; (c) If the RN performing RN assessment services and/or RN consultation services is employed by an agency, the RN's name and contact information, the agency's contact information, and the agency's national provider ide...

... copayments, premiums, deductibles, coinsurance and other member financial liabilities, if applicable; or (6) Denial, in whole or part, of payment for a service. A denial, in whole or in part, of a payment for a service solely because the claim does not meet the definition of a "clean claim" as defined in 42 C.F.R. 447.45(b) (October 1, 2021) is not an adverse benefit determination. (D) "Appea...

... enrollment via the ODM-produced Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant 834 daily and monthly enrollment files of new members, continuing members and terminating members. (5) The MCO and SPBM shall not be required to provide coverage until MCO or SPBM enrollment is confirmed via the ODM-produced HIPAA compliant 834 daily or monthly enrollment files except as...

...nation of benefits, including: (a) Insurance company name; (b) Insurance company billing address for claims; (c) Member's group number; (d) Member's policy number; and (e) Policy holder name. (6) The MCE must require providers who are submitting TPL claims to the MCE to request information regarding third party benefits from the member or his/her authorized representative. If the member or the m...

...ty income or social security disability insurance determination or has a score of two or greater on at least one of the items in the "mental health needs" or "risk behaviors" sections or a score of three on at least one of the items in the "life domain function" section of the adult needs and strengths assessment (ANSA) administered by an individual with a bachelor's degree or higher and with ...

..., under the state children's health insurance program (SCHIP), under Title XXI of the Act, that are allowable in accordance with applicable implementing federal, state, and local statutes, regulations, and policies, and the state plan approved by the secretary of health and human services and in effect at the time of the submission of this claim; and the expenditures included in the claim are base...

...ers, and in compliance with the "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on February 1, 2016), confidentiality of alcohol and drug abuse patient records as set forth in 42 C.F.R part 2 (as in effect on February 1, 2016) and the medicaid safeguarding information requirements set forth in 42 C.F.R. parts ...

...ers, and in compliance with the "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on October 1, 2020), confidentiality of alcohol and drug abuse patient records as set forth in 42 C.F.R part 2 (as in effect on October 1, 2020) and the medicaid safeguarding information requirements set forth in 42 C.F.R. parts 43...

...es (HCBS) settings; (iv) "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on July 1, 2017); (v) 42 C.F.R. part 2 (as in effect on July 1, 2017), confidentiality of alcohol and drug abuse patient records; and (vi) Incident management as described in rule 5160-43-06 of the Administrative Code. ...

...es (HCBS) settings; (iv) "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on October 1, 2020); (v) 42 C.F.R. part 2 (as in effect on October 1, 2020), confidentiality of alcohol and drug abuse patient records; and (vi) Incident management as described in rule 5160-44-05 of the Administrative ...

...d state laws, including the "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on February 1, 2016), confidentiality of alcohol and drug abuse patient records set forth in 42 C.F.R part 2 (as in effect on February 1, 2016), and the medicaid safeguarding information requirements set forth in 42 C.F.R. parts 431.30...

...d state laws, including the "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on October 1, 2020), confidentiality of alcohol and drug abuse patient records set forth in 42 C.F.R part 2 (as in effect on October 1, 2020), and the medicaid safeguarding information requirements set forth in 42 C.F.R. parts 431.300 ...

... request, furnish proof of licensure, insurance, and bonding for services from applicable jurisdictions. (8) Maintain, and upon request, furnish a list of the chemicals and substances used for each proposal. (9) Furnish to the individual, ODM, ODA, or their designee a warranty that covers the workmanship and materials involved in performing the service, as applicable. (10) Provide documen...