Ohio Administrative Code Search

...tion, infusion, vaccine, toxoid, or provider-administered pharmaceutical as a medical service if it is provided in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department). (4) A provider-administered pharmaceutical reported on a claim submitted in accordance with Chapter 5160-9 of the Administrative Code is regarded as a pharmacy service rather than a ph...

...njection, infusion, vaccine, toxoid, or provider-administered pharmaceutical as a medical service if it is provided in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department). (3) A provider-administered pharmaceutical reported on a claim submitted in accordance with Chapter 5160-9 of the Administrative Code is regarded as a pharmacy service rather than a ...

...llergen antigen may be made only if the provider prepares the antigen for injection by another entity. (e) The date of service is the date on which the first dose is administered or the date on which the vial is dispensed for future use. (f) Immunotherapy is not considered to be medically necessary for an allergic reaction to common environmental factors (such as dust, house plants, or natural f...

...ral, payment may be made to an eligible provider for performing a medically necessary surgical procedure on an eligible recipient. The following limitations, however, apply. (a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and postoperative care, or any procedure that is performed inci...

... payment may be made to an eligible provider for performing a medically necessary surgical procedure on a medicaid-eligible individual. The following limitations, however, apply. (a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and postoperative care, or any pro...

...ebsite http://www.medicaid.ohio.gov/provider/feeschedulesandrates. (B) Payment may be made to a physician for performing a covered surgical procedure in an ASC even if the surgery is not itself a covered ASC surgical procedure. (C) Payment may be made to a physician for performing the professional component of a covered laboratory, radiologic, diagnostic, or therapeutic service in an ASC only if...

...e component performed by a non-hospital provider, payment is the lesser of the submitted charge or the product of the following two figures: (a) The maximum payment amount listed in appendix DD to rule 5160-1-60 of the Administrative Code; and (b) The relevant percentage indicated by the 'prof/tech split' entry listed in appendix DD to rule 5160-1-60 of the Administrative Code. (2) If more than one advanced imagin...

...mponent performed by a non-hospital provider, payment is the lesser of the submitted charge or the product of the following two figures: (a) The maximum payment amount listed in appendix DD to rule 5160-1-60 of the Administrative Code; and (b) The relevant percentage indicated by the 'prof/tech split' entry listed in appendix DD to rule 5160-1-60 of the Administrative Code (or one hundred per ce...

...lth problems and does not have a dental provider, referral to a dentist or to the county department of job and family services. (C) Payment for the application of fluoride varnish is made separately from payment for a well child visit or a sick child visit.

...the urban areas within the county. (C) Providers of dental services. (1) Rendering providers. The following eligible medicaid providers may render a dental service: (a) A dentist practicing in Ohio; (b) A dental resident acting within their licensure and scope of practice; or (c) A dentist practicing in a state other than Ohio who meets the requirements established by the dental examining board...

...the urban areas within the county. (C) Providers of dental services. (1) Rendering providers. The following eligible medicaid providers may render a dental service: (a) A dentist practicing in Ohio; (b) A dental resident acting within their licensure and scope of practice; or (c) A dentist practicing in a state other than Ohio who meets the requirements established by the dental examining board...

...(A) Definitions. (1) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (2) "Eye care services" is a collective term for the following services and materials involving the health of the eyes: (a) Vision care services, which include the following procedures: (i) Diagnostic and comprehensive examination; (ii) Testing; (iii) Therapeutic treatme...

...h services are paid directly to the provider of services and not through the nursing facility per diem rate. (B) Definitions for the purposes of this rule. (1) "Behavioral health service" is a service or procedure that is performed for the diagnosis and treatment of mental, behavioral, substance use, or emotional disorders by a licensed professional or under the supervision of a licensed ...

...lated diagnostic imaging services. (B) Providers. (1) Rendering providers. The following eligible providers may render a service described in this rule: (a) A chiropractor, defined in Chapter 4734. of the Revised Code. (b) A mechanotherapist, defined in Chapter 4731. of the Revised Code. (2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for su...

... services rendered by the following providers: (a) Service-based ambulatory health care clinics, Chapter 5160-13; or (b) Cost-based clinics, Chapter 5160-28; (7) Medicaid school program services, Chapter 5160-35; and (8) Intermediate care facility services, Chapter 5123:2-7. (B) Definitions. (1) "Audiologist" is a person who holds a valid license as an audiologist under Chapter 4753. of the ...

...(A) Providers. (1) Rendering providers. The following practitioners, defined in Chapter 4759. of the Revised Code, may enroll in medicaid as eligible providers of dietitian services: (a) A licensed dietitian; and (b) A registered dietitian. (2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for submitting a claim for a covered service on behalf ...

...g experience and environment. (B) Providers. (1) Rendering providers. The following eligible providers may render a lactation consultation service: (a) A physician. (b) A physician assistant. (c) An advanced practice registered nurse. (2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for lactation consultation services on behalf of a rendering ...

...of the Revised Code. (2) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (B) Providers. (1) Rendering provider. The following eligible providers may render a covered acupuncture service: (a) An acupuncturist recognized under section 4762.02 of the Revised Code; or (b) An individual practitioner, other than an acupuncturist, who may render acupunct...

...1 of the Administrative Code. (B) Providers. An individual pharmacist may enroll in medicaid as a pharmacist provider. (C) Coverage. (1) Payment may be made only for a pharmacist service for which the following criteria are met: (a) The service is within a pharmacist's scope of practice; (b) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;...

...individual with diabetes by a qualified provider for the purpose of providing the individual with necessary skills and knowledge to participate in the management of the individual's diabetes, including the self-administration of injectable drugs. (2) "National Diabetes Prevention Program" (NDPP) is an evidence-based, educational and support program administered by the centers for disease control ...

...(A) Provider types eligible for payment for pharmacy services: (1) A "pharmacy provider" designation and provider number can be obtained by a "terminal distributor of dangerous drugs," as defined in section 4729.01 of the Revised Code, who also: (a) Has a valid drug enforcement agency (DEA) registration; and (b) Has a pharmacist as the "responsible person," as defined in rule 4729-5-11 of the Administrative Code;...

...th the following stipulations: (1) The provider must apply to, and be approved by, the Ohio department of medicaid (ODM) to be eligible to dispense medical supplies/durable medical equipment. (2) All products require a prescription written by a practitioner authorized to prescribe. The prescription must be obtained by and kept on file at the pharmacy. (3) The provider must use the same medicaid provider number as ...

...its designee. (a) Only the prescribing provider or a member of the prescribing provider's staff may request prior authorization except as described in paragraph (D)(3)(b) of this rule. (b) A pharmacist may request prior authorization for an alternative dosage form of a drug to be administered through a tube for patients who are tube fed, if no comparable drugs that do not require prior authoriza...

...caid (ODM) of the actual amount the provider paid to purchase the prescribed drug. ODM acquires AAC data through one or more of the following: national survey of retail pharmacy providers, e.g., national average drug acquisition cost (NADAC) rate process, states' surveys of retail pharmacy providers, and published compendia prices, e.g., wholesale acquisition cost (WAC). (3) "Administration f...

...egulations and shall be retained by the provider for a period of six years from the date of payment of the claim and if an audit is initiated during this time, records must be retained until the audit is resolved. (C) For a pharmacy claim to be eligible for payment by ODM, any prescription executed in written (and non-electronic) format must be executed on a tamper-resistant form. (1) To be considered tamper resist...