Ohio Administrative Code Search

...t-reporting purposes, each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, is 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 th...

... audit. To facilitate this examination, providers are required to make available all records and source documents necessary to fully disclose the extent of services provided to program recipients, the corresponding costs and charges made and payments received for such services, for the period corresponding to the cost-reporting period. The principle objective of the audit is to enable the department to determine that...

...it. To facilitate this examination, providers will make available all records and source documents necessary to fully disclose the extent of services provided to program recipients, the corresponding costs and charges made and payments received for such services, for the period corresponding to the cost-reporting period. The principle objective of the audit is to enable the department to determine...

... (C) Hospitals not enrolled as medicaid providers (1) Hospitals, as defined in section 5168.20 of the Revised Code, that are not enrolled in the medicaid program shall, upon request, submit to the department an electronic copy of the hospital's medicare cost report (CMS 2552-10) or audited financial statements for the period described in section 5168.21 of the Revised Code. (2) Hospitals not ...

...epartment of medicaid (ODM) will notify providers of the standards of medical practice to be used by the department. If the department should change the protocols, providers will be notified sixty business days in advance. (4) An "elective admission" is any admission that does not meet the emergency admission definition in paragraph (A)(1) of this rule. (5) "Elective care" is medical or surgical treatment that may ...

...finitions apply: (1) A "hospital" is a provider eligible under rule 5160-2-01 of the Administrative Code. (2) "Medical necessity" is as defined in rule 5160-1-01 of the Administrative Code. (3) "Pre-certification" is a process whereby the Ohio department of medicaid (ODM) or its contracted medical review entity assures that covered psychiatric services are medically necessary and are provided in the most appropria...

... effective date of this rule, eligible providers of hospital services as defined in rule 5160-2-01 of the Administrative Code and assigned to prospective payment peer group as described in rule 5160-2-05 of the Administrative Code are subject to the enhanced ambulatory patient grouping system (EAPG) prospective payment methodology utilized by the Ohio department of medicaid as described in this rule. (A) ...

...CMS) publication 15-1 entitled "The Provider Reimbursement Manual - Part 1" (rev. 9/21/17). (3) Generally accepted accounting principles in accordance with standards prescribed by the "American Institute of CPAs" (AICPA) as in effect June 26, 2018. (B) "Intermediate care facility for individuals with intellectual disabilities" (ICF-IID) has the same meaning as in section 5124.01 of the Revis...

...d 5165. of the Revised Code regarding provider agreements, and provisions in rules 5160-3-02.1 and 5160-3-02.2 of the Administrative Code, execution and maintenance of a provider agreement between the Ohio department of medicaid (ODM) and the operator of a NF also are contingent upon compliance with requirements set forth in this rule. (A) Definitions. (1) "Closure" means the discontinuance of the use...

...h a nursing facility operator whose provider agreement has been involuntarily terminated is required to operate without recurrence of the deficiencies that were the basis for termination. Participation in the medicare and medicaid programs may resume only following that period. If corrections were made before submission of a new request for participation, the period of compliance before the new re...

...terminate, deny, or not revalidate a NF provider agreement upon thirty days written notice to the NF. (2) Notices and termination orders must comply with provisions set forth in sections 5164.38 and 5165.77 of the Revised Code. (B) Reasons for which ODM may terminate, deny, or not revalidate a NF provider agreement. (1) In accordance with section 5164.33 of the Revised Code, ODM may terminate, ...

... beds" mean beds that are counted in a provider facility that meets medicaid standards. A count of facility beds may differ depending on whether the count is used for certification, licensure, eligibility for medicare or medicaid payment formulas, or other purposes. (3) "Distinct part" means a portion of an institution or institutional complex that is certified to provide skilled nursing facilit...

...rtified beds as counted in the medicaid provider agreement also certified under medicare as SNF beds, in accordance with section 5165.082 of the Revised Code and the provisions of this rule. (2) Exceptions to mandatory medicare participation are: (a) RNHCIs. (b) Veteran's homes operated under Chapter 5907. of the Revised Code. (c) Out-of-state providers of long term care institutional services...

...t of any emergency or disaster, the provider shall notify each resident's family, guardian, sponsor, next of kin, or other person responsible for the resident. (2) In cases where residents are relocated, within one working day after the relocation of residents, the provider shall give notification of the following to the Ohio department of health (ODH): (a) The name and location of the ...

...ding any interest accrued, from the provider; or (b) Periodic payments. Periodic payments, including any interest accrued, in accordance with a schedule approved by ODM for a period not to exceed twelve months; or (c) Medicaid payment offset. Following the date on which the fine plus interest becomes due, an appropriate reduction to medicaid payments made to the provider for care rendered to m...

...idation of, a nursing facility (NF) provider agreement. Payment shall not be made under this provision for services rendered on or after the effective date of ODM issuance of a final order of adjudication pursuant to Chapter 119. of the Revised Code, except as provided in paragraph (B) of this rule. (B) Payment may be provided up to thirty days following the effective date of termination or non-r...

...erminate or not revalidate the medicaid provider agreement. (C) The following requirements apply: (1) During the appeals process provided by the state survey agency for the proposed termination or non-renewal of certification, payment for covered services provided to eligible residents is available if: (a) Payment is for those residents admitted prior to the effective date of an order issue...

...itial medicaid certification and NF provider agreement. (4) For current residents of a facility in the process of obtaining its initial medicaid certification and NF provider agreement, the level II requirements have to be met prior to the effective date of the NF provider agreement between ODM and the newly certified NF or prior to the availability of medicaid payment for the medicaid eligib...

...rule are in violation of their medicaid provider agreements. This is true regardless of the payment source for the individual's NF stay. (2) Adverse PASRR determinations may be appealed in accordance with division 5101:6 of the Administrative Code. (3) Level II resident review determinations made by OhioMHAS or DODD in accordance with section 1919(e)(7) of the Social Security Act, as in effe...

...ible prospective NF resident. (2) A NF provider shall not accept preadmission bed-hold payments from a medicaid eligible prospective NF resident or from any other source on the prospective resident's behalf as a precondition for NF admission. (C) Determination of NF bed-hold day or NF occupied day. To determine whether a specific day during a resident's stay is payable as a NF bed-hold day or a NF occupied day, th...

...d is managed for the resident by the NF provider. (2) "Letters of administration," also known as letters testamentary, means court papers allowing a person to take charge of the property of a deceased person in order to distribute it. (3) "Surety bond" means an agreement between the principal (i.e., the NF provider), the surety (i.e., the insurance company), and the obligee (i.e., the resident a...

...ion period of up to fourteen days. (C) Provider eligibility. In order to qualify as an ODM NF ventilator program provider and receive an enhanced payment rate for providing ventilator services or ventilator weaning services, a NF shall meet all of the following criteria: (1) Be a licensed and medicaid certified NF and meet the requirements for NFs in accordance with 42 U.S.C. 1396r (10/19/2018...

...provided by an eligible acupuncture provider are paid directly to the provider of acupuncture services in accordance with rule 5160-8-51 of the Administrative Code. (B) Behavioral health services. Costs for behavioral health services are paid directly to the provider of services, not through the NF per diem. (C) Dental services. All covered dental services provided by licensed dentists are paid di...

...ar year, the cost report by the new provider should cover the portion of the calendar year following the change of operator encompassed by the first day of participation up to and including December thirty-first. (3) In the case of a NF that begins participation after January first and ceases participation before December thirty-first of the same calendar year, the reporting period should be the ...

...(A) A nursing facility provider, or a group or association of nursing facility providers, may request a reconsideration of a prospective NF rate on the basis of a possible error in the calculation of the rate as follows: (1) A request for reconsideration shall be filed with the Ohio department of medicaid (ODM) no more than thirty days after the later of the date on the rate setting package n...