Ohio Administrative Code Search

...(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) An entering operator's initial rate shall be the rate the exiting operator would have received had the exiting operator continued to participate in the medicaid program. (B) The rate determined in paragraph (A) of this rule shall not be subject to adjustment until the following state fiscal year. (C) After the end of the state fiscal year in which the entering operator began participation in...

...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) 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...

...(A) Scope and definitions. (1) This rule sets forth provisions governing payment for the administration or management of anesthesia as a non-institutional professional service rendered by qualified medical practitioners. Provisions governing payment for anesthesia as a dental service are set forth in Chapter 5160-5 of the Administrative Code. (2) "Base unit" is an anesthesia-related component r...

...(A) Scope and definitions. (1) This rule sets forth provisions governing payment for the administration or management of anesthesia as a non-institutional professional service rendered by qualified medical practitioners. Provisions governing payment for anesthesia as a dental service are set forth in Chapter 5160-5 of the Administrative Code. (2) "Base unit" is an anesthesia-related component r...

...(A) This rule sets forth provisions governing payment for professional, non-institutional dental services. Provisions governing payment for dental services performed as the following service types are set forth in the indicated part of the Administrative Code: (1) Hospital services, Chapter 5160-2; (2) Nursing facility services, Chapter 5160-3; (3) Intermediate care facility services, C...

...(A) This rule sets forth provisions governing payment for professional, non-institutional dental services. Provisions governing payment for dental services performed as the following service types are set forth in : (1) Hospital services, Chapter 5160-2 of the Administrative Code; (2) Nursing facility services, Chapter 5160-3 of the Administrative Code; (3) Intermediate care facility servic...

...(A) This rule sets forth provisions governing payment for professional, non-institutional dental services. Provisions governing payment for dental services performed as the following service types are set forth in the indicated part of the Administrative Code: (1) Hospital services, Chapter 5160-2; (2) Nursing facility services, Chapter 5160-3; (3) Intermediate care facility services, C...

...(A) Scope. This rule sets forth provisions governing payment for behavioral health services provided by certain licensed professionals in non-institutional settings. (1) Provisions governing payment for behavioral health services as the following service types are set forth in the indicated part of the Administrative Code: (a) Cost-based clinic services, Chapter 5160-28; and (b) Medicaid school pro...

...(A) Scope. This rule sets forth provisions governing payment for professional, non-institutional spinal manipulation and related diagnostic imaging services. (B) Providers. (1) Rendering providers. The following eligible providers may render a service described in this rule: (a) A chiropractor, defined in Chapter 4734. of the Revised Code. (b) A mechanotherapist, defined in Chapter 4731. of th...

...(A) Scope. This rule sets forth provisions governing coverage and payment for professional, non-institutional spinal manipulation and related diagnostic imaging services. (B) Providers. (1) Rendering providers. The following eligible providers may render a service described in this rule: (a) A chiropractor, defined in Chapter 4734. of the Revised Code. (b) A mechanotherapist, defined in Chapter 4731. of the Revis...

...(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...