Ohio Administrative Code Search

...agraph (D)(2) of this rule. (a) Active providers. (i) If claims have already been submitted to ODM and processed for dates of service on or after the EFTD, ODM shall offset the amount of overpayment received with the amount of refund due from paragraph (D)(1) of this rule. (ii) If the offset results in amounts owed to the facility, refunds shall be issued. (iii) If the offset results...

...2 of the Administrative Code when a provider fails to furnish invoices or other documentation that ODM requests during an audit. (4) Interest monies owed to ODM pursuant to section 5165.41 of the Revised Code, and to CMS pursuant to 42 C.F.R. 488.442 (October 1, 2015) that CMS has requested ODM to collect. (5) Monies owed ODM and CMS pursuant to sections 5165.52 and 5165.525 of the Revised Code,...

...160-1-19 of the Administrative Code, NF providers shall submit medicare crossover claims and claims for medicaid reimbursement for allowable services that are not included in the NF per diem rate in accordance with the requirements set forth in rule 5160-1-19 of the Administrative Code. (B) Requirements for submitting NF per diem claims. (1) A NF provider submitting a claim for payment, either directly as a trading...

...d to past medicaid payments, the NF provider must submit adjustment claims for as many prior months as are necessary to fully offset the amount of the lump-sum.

...19 of the Revised Code based on the provider's geographical location and the number of licensed beds reported on the provider's annual cost report for the calendar year preceding the fiscal year for which the rate is established. (1) For a provider new to the medicaid program, the Ohio department of medicaid (ODM) shall initially determine the number of beds in the facility from the number of li...

...endix A to this rule is not used by the provider, it is the responsibility of the provider to relate its chart of accounts directly to the cost report. (3) Where a chart of accounts number has sub-accounts that relate directly to a cost report line item, the provider shall capture the information requested so that the information will be broken out for cost reporting purposes. (4) For example,...

... expenditure should be capitalized, NF providers are to refer to the centers for medicare and medicaid services (CMS) publication 15-1, Chapter 1 entitled "Depreciation," (December 15, 2011), available on the internet at http://www.cms.gov/, and shall use the following guidelines: (1) Any expenditure for an item that costs five thousand dollars or more and has a useful life of two or more years ...

...dicaid services (CMS) publication 15-1 "Provider Reimbursement Manual" (rev. 9/28/15) during the audit of NF cost reports. (D) Costs of ancillary services rendered to NF residents by providers who bill medicaid directly. Ancillary services include but are not limited to physicians, legend drugs, radiology, and laboratory. (E) Costs per case-mix units in excess of the applicable peer group ceiling for direct care co...

...dicaid (ODM) and distributed to the provider on the status of all MDS 3.0 assessment data that pertains to the calculation of a quarterly, semiannual, or annual facility average case mix score. (4) "Comprehensive assessment" means an assessment that includes completion of the appropriate MDS 3.0 assessment type listed in paragraph (B)(2) of this rule. (5) "Critical elements" are data items f...

...ty average total case mix score for all providers meeting the following requirements: (1) In accordance with rule 5160-3-43.1 of the Administrative Code, the provider submitted resident assessment information by the filing date, and the data included resident assessments for all residents in medicaid certified beds as of the reporting period end date, and (a) The provider's resident assessment d...

...vel of variance in the calculation of a provider's quarterly facility average medicaid case mix score or an acceptable per cent of the records sampled at exception review that were unverifiable. (5) "Random review" is a type of exception review that examines randomly selected records from any of the RUG major categories listed in paragraph (C) of rule 5160-3-43.2 of the Administrative Code. (6) ...

...of medicaid (ODM) by a nursing facility provider that identifies the amount spent on each cost center included in rebasing. (B) Direct care spending. (1) In accordance with section 5165.36 of the Revised Code, nursing facilities should increase direct care spending by at least seventy percent of any additional dollars received as a result of rebasing. (2) For purposes of determining compliance with section 5165.36...

...tment of medicaid (ODM) shall pay a provider a per medicaid day payment rate for tax costs determined under section 5165.21 of the Revised Code except for the initial rate for new providers. ODM shall determine each new nursing facility's initial per medicaid day payment rate for tax costs in accordance with section 5165.151 of the Revised Code. (B) For purposes of calculating the initial rat...

... service or services. (C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims submitted for payment. Providers submitting medicare part A crossover claims to the medicaid program must be able to provide upon request documentation supporting that the information provided on the claim matches the information on the part A plan's remittance advice.

...(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...

...ces are provided, and interviews of providers and recipients of ICF-IID services. ICF-IID providers shall provide any records related to the administration and/or provision of ICF-IID services to ODM, the centers for medicare and medicaid services (CMS), the medicaid fraud control unit, and any of their designees in accordance with the medicaid provider agreement. (C) ODM will monitor payment mad...

...ces are provided, and interviews of providers and recipients of ICF-IID services. ICF-IID providers will provide any records related to the administration or provision of ICF-IID services to ODM, the centers for medicare and medicaid services (CMS), the medicaid fraud control unit, and any of their designees in accordance with the medicaid provider agreement. (C) ODM will monitor payment made und...

... services (CMS) publications 15-1 ("The Provider Reimbursement Manual - Part 1") and 15-2 ("The Provider Reimbursement Manual - Part 2") as in effect October 16, 2018, available at https://www.cms.gov/ and 45 C.F.R. part 92 in effect as of October 16, 2018. (21) "State-operated intermediate care facility for individuals with intellectual disabilities" means an institution as defined in sectio...

... currently enrolled as an Ohio medicaid provider; (2) The service is rendered to a medicaid-eligible Ohio recipient in a state in which the physician is licensed or authorized to practice; and (3) The service is within the scope of practice of the physician's specialty. (B) Separate payment may be made for covered professional services rendered by a physician employed by or under contract with a facility such as a...

...nts, interns, or fellows; or service on provider committees). Payment for such services may be made only to the employing or contracting provider. (C) For the sole purpose of demonstrating eligibility for incentive payments made in accordance with Section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA, Pub. L. No. 111-5), codified at 42 U.S.C. 1396b (as revised December 27, 2020...

...rently enrolled as an Ohio medicaid provider, payment may be made only if the physician assistant practices under either of the following arrangements: (1) The physician assistant provides services under the supervision, control, and direction of a physician with whom the physician assistant has entered into a supervision agreement under section 4730.19 of the Revised Code; or (2) The physician ...

...rently enrolled as an Ohio medicaid provider; (b) The service is rendered to a medicaid-eligible Ohio recipient in a state in which the APRN is licensed or authorized to practice; (c) The service is within the scope of practice of the APRN's specialty; (d) The APRN personally rendered the service to an individual patient; and (e) The service cannot be performed by someone who lacks the ski...

...or CNP is the lesser of the billing provider's submitted charge or the applicable amount from the following list: (a) For a covered service rendered in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), eighty-five per cent of the medicaid maximum; (b) For a covered service rendered in a non-hospital setting, one hundred per cent of the medicaid maxim...

...cal practitioner enrolled as a medicaid provider. For purposes of this rule, a medical visit initiated by someone other than a licensed medical practitioner (e.g., a patient, a family member, a teacher, a social worker) is not a consultation. (b) The request for a consultation, the need for a consultation, the consultant's opinion, and any services that were ordered or performed in relation to th...

...practitioner enrolled as a medicaid provider requests the consultation. For purposes of this rule, a medical visit initiated by someone other than a licensed medical practitioner (e.g., a patient, a family member, a teacher, a social worker) is not a consultation. (b) The request for a consultation, the need for a consultation, the consultant's opinion, and any services that were ordered or perfo...