Ohio Administrative Code Search

...vice" means the information sent to providers or plan beneficiaries (covered individuals) by any other third party payer, medicare, or medicaid to explain the adjudication of the claim. (4) "Medicare benefits" has the same meaning as in rule 5160-1-05 of the Administrative Code. (5) "Third party" (TP) has the same meaning as in section 5160.35 of the Revised Code. (6) "Third party b...

... payments, the following apply: (1) No provider may deny services to an individual who is eligible for the services on account of the individual's inability to pay the medicaid co-payment. Individuals who are not able to pay their medicaid co-payment may declare their inability to pay for services or medication and receive their services or medication without paying their medicaid co-payment amount. With regard to a...

...(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...

...hen 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, nor shall the provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, co-payment, missed appointment fee or other similar charge, other than medicaid co-payments as ...

...31 of the Administrative Code. (B) Providers. Healthchek screening, diagnostic, and treatment services may be rendered by eligible providers in an appropriate discipline, acting within the scope of practice authorized under state law and as set forth in agency 5160 of the Administrative Code. (C) Coverage. For medicaid-eligible individuals younger than twenty-one years of age, healthchek covers ...

...ers, 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 applicable provider requirements and standards in agency 516...

...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) Definitions: (1) "Disclosing provider" means a medicaid provider, managed care entity, or fiscal agent under contract with the department of medicaid (ODM). (2) "Managing employee" means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organiza...

... Revalidation is the process that a provider is required to follow to renew and revalidate its provider agreement. Provider agreements must be revalidated no later than five years from the effective date of the original or the last revalidated provider agreement, whichever is applicable. In the event the center for medicare and medicaid services (CMS) waives or modifies the deadline, provider agre...

...e Revised Code. (2) "Non-institutional provider" means any person or entity with a medicaid provider agreement other than a hospital, long-term care nursing facility, intermediate care facility for individuals with intellectual disabilities or medicaid contracting managed care plans. (B) The Ohio department of medicaid (ODM) shall suspend a medicaid provider agreement when at least one of the following conditions a...

...ndirectly, 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 Administrative Code or any rule contained in agency 5160 of the Administrative Code. (B) Termination for long term care nursing facilities and intermediate care facilities for individ...

...ty that at one time was a participating provider in the Ohio medicaid program and whose provider agreement was terminated either voluntarily or involuntarily in accordance with rule 5160-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program. (B) In considering an application for participation in the Oh...

...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 required at the time of enrollment and revalidation as defined in rule 5160-1-17.4 of the Administrative Code. ...

...f 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 is not a billing provider in th...

...ntity must: (1) Have an active provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code; (2) Read the presumptive eligibility training guide found on the ODM website, www.medicaid.ohio.gov; and (3) Attest that it will meet the terms and conditions as a QE by reading, signing, and sending ODM form 10252 "acknowledgment of terms and conditions governing the presum...

...vices rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is defined in rule 5122-29-31 of the Administrative Code. (d) Conversations or electronic communication between practitioners regarding a patient without the patient present is not considered telehealth unless the service would allow billing for practitioner to practitioner commu...

... services rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is defined in rule 5122-29-31 of the Administrative Code. (d) Conversations or electronic communication between practitioners regarding a patient without the patient present is not considered telehealth unless the service would allow billing for practitioner to practitioner commu...

...e Administrative Code. (2) The ODM provider web portal; or (3) Pharmacy point-of-sale. (B) Claims should be submitted pursuant to the national correct coding initiative and according to the coding standards set forth in the following guides: (1) The healthcare common procedure coding system; (2) The current procedural terminology codebook; (3) The current dental terminology codeb...

...ncounter information, or both, from providers (institutional, professional, or dental) of health care services to payers, either directly or via clearinghouses. (e) "ANSI X12 270 eligibility, coverage, or benefit inquiry" is a transaction used to inquire about the eligibility, benefits or coverage under a subscriber's health care policy. (f) "ANSI X12 271 eligibility, coverage, or benefit inform...

...nefits, or coverage. (c) "ANSI X12 274 provider information" is a transaction used to exchange demographic and educational or professional qualifications about health care providers between providers, provider networks, or any other entity that maintains or verifies health care provider information. (d) "ANSI X12 275 patient information" is a transaction used to communicate individual patient in...

...1 and 5124.41 of the Revised Code, any provider of services or goods contracting with the Ohio department of medicaid (ODM) pursuant to Title XIX of the Social Security Act who, without intent, obtains payment from the medicaid program in excess of the amount to which the provider is entitled becomes liable for payment of interest charged in accordance with this rule on the amount of the overpayment. The interest ra...

...f 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. Medicaid providers are required to provide...

... of medicaid (ODM) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons: (i) In response to allegations of fraud or other willful misrepresentation of claims submission; or (ii) When a provider has been indicted for a criminal offense. (b) ODM shall notify the provider in writing within ten business days that the pr...

...on is used to complement or follow-up a provider or certification or other quality review process; (2) In response to allegations of fraud or willful misrepresentation of claims submission; (3) Upon the request of the office of the attorney general, the office of inspector general, or the auditor of state; (4) When a provider's medicaid provider agreement is subject to termination; (5) When a provider has been ...

... the medicaid program are detected, providers will be subject to a review by ODM and the case will be referred to the attorney general's medicaid fraud control unit and/or the appropriate enforcement officials. If waste and abuse are suspected or apparent, ODM and/or the office of the attorney general will take action to gain compliance and recoup inappropriate or excess payments in accordance...