Ohio Administrative Code Search

...(A) Definitions. For the purposes of rules promulgated by this agency in accordance with section 1347.15 of the Revised Code effective April 9, 2009, the following definitions apply: (1) "Access" as a noun means an instance of copying, viewing, or otherwise perceiving; whereas, "access" as a verb means to copy, view, or otherwise perceive. (2) "Acquisition of a new computer system" means th...

...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 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) 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,...

...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 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) 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...

...(A) As specified in Chapter 5160-1 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, frequency, extent, duration, and delivery setting of services provided to medicaid recipients, and to document significant business transactions. Medic...

...(A) Reimbursement for some items and/or services covered under the medicaid program is available only upon obtaining prior authorization from the Ohio department of job and family services (ODJFS). Prior authorization must be obtained from ODJFS or its designee by the provider before the services are rendered or the items delivered, unless the services meet the provisions in paragraph (F) of this rule. . (B) Service...

...(A) For purposes of this rule only: (1) "Medicaid covered service" is defined as a service that is eligible for coverage by the Ohio medicaid program and is delivered by a medical provider that qualifies for a medicaid provider agreement. (2) "Applicant for reimbursement" is defined as: (a) An individual who has been erroneously determined ineligible for the medicaid program or whose determination was incorrectly ...

...The department of medicaid (ODM) will make relief payments available to Ohio medicaid hospitals defined in paragraph (A) of this rule, as authorized under Section 270.15 of Amended Substitute House Bill 45 of the 134th General Assembly: (A) ODM will make available a one-time lump sum payment to the following hospital types: (1) "Critical access hospitals," as defined in rule 5160-2-05 of the Administ...

...This rule describes how hospitals are classified into mutually exclusive peer groups for purposes of setting rates and making payments under the "All Patient Refined-Diagnosis Related Group" (APR-DRG) inpatient prospective payment system, the "Enhanced Ambulatory Patient Grouping" (EAPG) outpatient prospective payment system or to those hospitals excluded from the prospective payment systems. (A) Definitio...

...(A) Definitions in Chapter 5160-2 of the Administrative Code. (1) "Cancer hospitals" are hospitals recognized by medicare that primarily treat neoplastic disease in accordance with 42 C.F.R. 412.23(f), effective October 1, 2025. (2) "Children's hospitals" are hospitals that primarily serve patients eighteen years of age and younger, have at least seventy-five beds, and are excluded from medicare prospective payment...

...This rule sets forth the data used to determine assessments and adjustments, and the data policies that are applicable for each program year for all providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Disproportionate share hospital" means a hospital that meets the requirements for disproportionate share st...

...(A) Applicability. The requirements of this rule apply as long as the United States centers for medicare and medicaid services (CMS) determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department of medicaid is informed that the assessment is an impermissible health care-related tax, the department shall promptly ...

...This rule is applicable for each program year for all medicaid-participating providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Total fee for service (FFS) medicaid costs" for each hospital means the sum of inpatient program costs reported on ODM 02930, schedule H, section I, columns 1 and 3, line 1 ...

...This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code. (A) Definitions for each psychiatric hospital. (1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from ...

...This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code. (A) Definitions for each psychiatric hospital. (1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from ...