Ohio Administrative Code Search

...(A) Non-contracting providers of emergency services must accept as payment in full from a managed care organization (MCO) the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of...

... (October 1, 2021); (4) Specify in provider contracts governed by rule 5160-26-05 of the Administrative Code the circumstances under which member co-payment amounts can be requested. If the MCO or SPBM implements a co-payment program, no provider can waive a member's obligation to pay the provider a co-payment except as described in paragraph (I) of this rule; (5) Ensure that the member ...

...BM), ODM or its designees will accept provider claim submissions for pharmaceuticals through ODM's managed care entities (MCEs) in the following manner: (A) Claims for pharmaceuticals that are dispensed by pharmacy providers are billed through ODM's SPBM. (B) For all other provider types, claims for pharmaceuticals are billed through an MCO, or in accordance with rule 5160-59-03 of the Administ...

...(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...

...aid 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 illness or substance use disorder. The list of recognized diagnoses can be accessed at www.medicaid...

...aid 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 illness or substance use disorder. The list of recognized diagnoses can be accessed at www.medicaid...

... 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 Administrative Code. (C) Records related to services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456....

... 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 Administrative Code. (C) Records related to services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456....

... 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) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, medicaid reimburs...

... 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) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, ...

...ecipient. (C) The ACT team is the sole provider to ACT recipients of outpatient behavioral health services, including level one outpatient services as defined by the American society of addiction medicine. (D) ACT services include but are not limited to the following: (1) Psychiatry and primary care as related to the mental health or substance use disorder diagnoses; (2) Service coordinati...

... made on the same day with the same provider for the same individual. (4) Other behavioral health individual services may be reimbursed on the same day as therapeutic behavioral group service-hourly and therapeutic behavioral group service per diem. (5) A medicaid recipient can receive one therapeutic behavioral group service per diem service per day. Prior authorization may be approved for a di...

...on the same day by the same billing provider for the same individual. (4) A medicaid recipient can receive one therapeutic behavioral group service per diem service per day per provider. Reimbursement of therapeutic behavioral group service per diem and therapeutic behavioral service hourly by more than one billing provider to the same individual on the same day is allowable with prior authorizat...

...n medicine. Medicaid will reimburse providers of these services outside the per diem rate paid to residential treatment programs. All treatment services, regardless of whether they are rendered by the residential treatment program or unaffiliated billing practitioners or agencies must be documented in the client's treatment plan maintained by the residential treatment provider. (D) The entity pr...

... 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) Services rendered by MRSS team staff described in rule 5122-29-14 of the Administrative Code that are eligible providers of behavioral health services in accordance with rule 5160-27-01 of the Administrative ...

...id Services (CMS) Publication 15-1, Provider Reimbursement Manual - Part 1" (October 1, 2015) or chapter 9 of "Centers for Medicare and Medicaid Services (CMS) Publication 100-04, Medicare Claims Processing Manual" (July 25, 2014), both of which are available at http://www.cms.gov; or (3) "Statement on Auditing Standards (SAS) No. 91, Federal GAAP Hierarchy" (April 2000), which may be obtained at...

...) encounter between a patient and a provider; for medicaid payment purposes, a covered service rendered through telehealth by an FQHC or RHC practitioner is a face-to-face encounter. For transportation services, a visit is a one-way trip provided to or from a site where a covered service is rendered on the same date. (a) Multiple encounters with one health professional or encounters with mult...

...(A) No provider may be simultaneously enrolled in medicaid as more than one type of cost-based clinic. (B) Unless otherwise noted, any limitations or requirements specified in the Revised Code or in agency 5160 of the Administrative Code apply to services rendered by a cost-based clinic. (C) Federally qualified health center (FQHC). (1) An FQHC must submit to the department a copy of the no...

...e obtains and uses its own medicaid provider number. No FQHC site is allowed to use the provider number of another FQHC site, even if the two share the same parent organization. (3) The responsibility of an FQHC to pay a health professional for performing a service is described in a written agreement between the FQHC and the health professional. (4) An FQHC notifies ODM in writing not later ...

...dministration of a vaccine or other provider-administered pharmaceutical; (b) Professional services (including the administration of a vaccine) furnished by a qualified healthcare practitioner (physician, physician assistant, advanced practice registered nurse, dietitian, pharmacist, registered nurse working under supervision), along with any services or supplies furnished incident to the profess...

...hat is newly enrolled as a medicaid provider submits a cost report covering the twelve-month period beginning either on the first day of the first calendar month or on the first day of the first full fiscal year after enrollment. (2) An FQHC or RHC that requests an adjustment of a per-visit payment amount (PVPA) based on a change in scope of an existing FQHC or RHC PPS service submits a cost ...

...s that are already enrolled as medicaid providers, ODM establishes new PVPAs equal to the current PVPAs revised to reflect the latest available medicare economic index (MEI) percentage. The new PVPAs are established by October first of each year and are in effect from October first through the following September thirtieth. (2) When an enrolled FQHC or RHC site requests adjustment of a PVPA, ODM ...

...ually as recruitment cost incurred by a provider of FQHC medical service. (B) Tests of reasonableness are applied to the allowable costs to establish limits. (1) For each FQHC service except transportation, a limit is established by dividing the allowable cost by the greater of two figures: (a) The number of allowable encounters; or (b) The product of the actual number of direct hours worked b...

...y as recruitment cost incurred by a provider of FQHC medical service. (B) Limits are established by applying tests of reasonableness to the allowable costs. (1) For each PPS service except transportation, a limit is established by dividing the allowable cost by the greater of two figures: (a) The total number of visits; or (b) The product of the actual number of direct hours worked by the prof...

... or RHC is newly enrolled as a medicaid provider; or (2) The FQHC or RHC plans to request the establishment or adjustment of a PVPA based on a change in scope of a prospective payment system (PPS) service. (C) The time period covered by the applicable cost report may be altered in one of the following ways: (1) The length of the period is set at not less than eight consecutive months nor more than twelve consecuti...