Ohio Administrative Code Search

...ained 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) Services, supplies or prescription drugs that require prior authorization by the department are identified in Chapters 5101:3-2 to 5101:3-56 of the Administrative Code. (C) All prior authorization requests must be submitted through the...

...) If the authorized representative is a provider or staff member or volunteer of an organization, the authorized representative must affirm that he or she will adhere to the regulations in 42 C.F.R. Part 431 Subpart F (as in effect October 1, 2015), 42 C.F.R. 447.10 (as in effect October 1, 2015), 45 C.F.R. 155.260(f) (as in effect October 1, 2015), as well as other relevant state and federal laws concerning conflict...

...(A) Home care service providers, as defined in this paragraph, must have a system as follows. (1) Definitions. (a) "Home care dependent adult" means a consumer who: (i) Resides in a private home or other non-institutional, unlicensed living arrangement without a parent or guardian present; (ii) Requires, due to health and safety needs, regularly scheduled home care services to remain in the home or other living a...

...g standards found in 42 CFR 422.204, "provider selection and credentialing" (as in effect on October 1, 2021), this rule details the credentialing and recredentialing process for medicaid providers. (A) For purposes of this rule, the following definitions apply. (1) "Council for affordable quality healthcare (CAQH)" is a non-profit organization which created a process allowing ODM to use a single,...

... medicaid (ODM) authorizes eligible provider delegates to perform credentialing activities on behalf of individual providers in accordance with rule 5160-1-42 of the Administrative Code. (B) "Delegate" and "Delegation" have the same meaning as in rule 5160-1-42 of the Administrative Code. (C) Entities seeking delegation will be expected to meet the following criteria to become an authorized ...

...the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments a...

...the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments a...

...the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments a...

...d 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 delayed, and who is seeking reimbursement for medical expenses incurred during the time period when the individual should have been covered b...

...ive Code; (b) Delivered by an eligible provider who qualifies for one of the following: (i) A medicaid provider agreement as described in rule 5160-1-17.12 of the Administrative Code; or (ii) An approved contract or single case agreement with a medicaid managed care entity (MCE); (c) A reimbursable medical service as defined in rule 5160-1-02 of the Administrative Code. (d) A phys...

... procedure, service, or supply, the provider may submit a new claim with the appropriate code. The new claim must not be submitted for by-report consideration.

...tive Code if an outpatient hospital provider; and (3) Within ninety calendar days of approval to participate as a QBHE, have an active provider contract with each medicaid managed care plan (MCP); (4) Submit an application to become a QBHE. ODM reserves the right to deny any QBHE enrollment application it determines is not in compliance with the requirements of this rule. A QBHE may seek rec...

...itute practitioner meets the applicable provider screening requirements described in rule 5160-1-17.8 of the Administrative Code; (e) The substitute practitioner has not been sanctioned under medicare, medicaid, or Title XX and is not otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries; and (f) The substitute practitioner receives payment from the re...

...ata to be utilized for establishing provider payment amounts are fee-for-service (FFS) payments for state fiscal year 2022 and reflected in the ODM management information technology system (MITS) on January 31, 2023. (b) Each payment is the product of the ratio of each hospital's total FFS payments to the total FFS payments for all eligible hospitals as defined in paragraph (A) of this rule, mult...

...(Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet the requirements for Title XVIII participation and has in effect a hospital utilization review plan applicable to all patients who receive medical assistance under Title XIX. The following hospitals are excluded from participation: (1) Tuberculosis hospitals, and (2) Hospital...

...ent hospital services. (1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code. (2) Inpatient or outpatient services related to the provision of the services described in this rule are not covered: (a) Abortions other than those tha...

...hospital services. (1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code. (2) The following inpatient or outpatient services related to the provision of the services described in this rule are not covered: (...

...ty-five beds and enrolled as a medicaid provider on or after January 1, 2011 shall: (a) For the purposes of setting base rates, for inpatient services as described in rule 5160-2-65 of the Administrative Code and outpatient services as described in rule 5160-2-75 of the Administrative Code, be grouped into its natural urban or rural hospital peer group as described in paragraph (A)(2) or (A)(5) o...

...ive beds and enrolled as a medicaid provider on or after January 1, 2011, will: (a) For the purposes of setting base rates, for inpatient services as described in rule 5160-2-65 of the Administrative Code and outpatient services as described in rule 5160-2-75 of the Administrative Code, be grouped into its natural rural or urban hospital peer group as described in paragraph (A)(7) or (A)(9) of th...

...licable 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 status as defined in rule 5160-2-09 of the Administrative Code. (2) "Governmental hospital" means a county...

...m 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 and outpatient medicaid program costs a...

...tional information that may support the provider's position. (2) If the submitted request for a reconsideration is incomplete, the department or the medical review entity will notify the provider of missing documentation. The notice will give the provider two business days to submit the missing documentation. (3) The department will conduct an administrative review of the reconsideration decision if the provider su...

...eny payment to or recoup payment from a provider who has transferred patients inappropriately. (2) ODM may review readmissions to determine if the readmission as defined in rule 5160-2-02 of the Administrative Code is appropriate. (a) If the readmission is related to the first hospitalization, ODM will determine if the readmission resulted from complications or other circumstances that arose because of an early dis...

...d delivered at a hospital where the provider has clinical privileges, and where such services are permissible to be provided by the hospital under its certificate of authority granted under Chapters 3711., 3727., and 5119. of the Revised Code. Hospitals will be responsible for providing basic, medically necessary hospital-level services to those persons described in paragraph (C) of this rule. (2...

...medicaid program requires each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (A)(7) of this rule. Effective...