Ohio Administrative Code Search

... office, emergency department, or other provider setting, that are intended to be used by the individual outside of the provider setting. (E) No provider of pharmacy services may deny a prescribed drug to an individual eligible for medicaid coverage because the individual is unable to pay the co-payment. The provisions of paragraph (B) of rule 5160-1-09 of the Administrative Code apply to co-payments for prescribed ...

... the department can determine coverage. Providers cannot decide on their own that an item or service is not covered or would not be covered with PA. Providers should submit a PA request to obtain an official decision. (3) "Department" is the Ohio department of medicaid or, when applicable, its designee. The address of the department's web site is http://medicaid.ohio.gov. (4) "DMEPOS item" i...

...(A) Prescribing provider. Only a physician experienced in the management of patients at risk for sudden cardiac death (SCD), such as a cardiologist, electrophysiologist, or cardiac surgeon, may prescribe a wearable cardioverter-defibrillator (WCD). (B) Coverage. (1) Separate payment may be made for a WCD furnished to a resident of a long-term care facility (LTCF). (2) Payment may be made fo...

...ode for medicaid payment purposes. (B) Providers. (1) Prescribing providers. Eligible medicaid providers of the following types, acting within their scope of practice, may prescribe a bathing seat and may certify the medical necessity of a bathing seat when such certification is needed: (a) A physician; (b) An advanced practice registered nurse with a relevant specialty; (c) A physician assis...

...(A) Provider requirements. A provider of apnea monitors for use in the home must be capable of performing all of the following services: (1) Arranging to have certified individuals provide infant cardiopulmonary resuscitation (CPR) training to caregivers; (2) Providing education and instruction on the mechanical aspects of monitors; and (3) Providing a technician twenty-four hours a day to ...

...d acceptability of the hearing aid, the provider must attempt to schedule a follow-up visit with the individual within thirty days after delivery. No claim for payment should be submitted during this period. The provider must keep on file, for at least four years, either a confirmation of the follow-up visit signed by the individual or an explanation of why the visit was not conducted. If as a res...

... concentrator to portable tanks. (B) Providers. (1) The following eligible medicaid providers may prescribe oxygen: (a) A physician; (b) An advanced practice registered nurse with a relevant specialty; or (c) A physician assistant. (2) The following eligible medicaid providers may supply oxygen: (a) A durable medical equipment (DME) provider; (b) A pharmacy; (c) A physician; (d) An advanced pr...

...(A) Provider requirement. A provider of custom-made or custom-fitted compression garments must either employ or contract with a certified fitter and must keep documentation of this relationship on file. (B) Coverage. (1) The default certificate of medical necessity (CMN) form is the ODM 01905, "Certificate of Medical Necessity: Compression Garments" (rev. 7/2018). (2) Payment may be made on...

...er for rechargeable batteries. (B) Provider requirement. A provider of transcutaneous electrical nerve stimulation (TENS) units must have a physical location available for face-to-face fitting and instruction purposes. (C) Coverage. (1) Payment may be made for a TENS unit on a rental/purchase basis. (2) The default certificate of medical necessity (CMN) form is the ODM 03402, "Certificate ...

...lchair or a power mobility device. (B) Providers. (1) Prescribing providers. Eligible medicaid providers of the following types, acting within their scope of practice, may certify the medical necessity of a wheelchair: (a) A physician; (b) An advanced practice registered nurse with a relevant specialty; (c) A physician assistant; or (d) A podiatrist. (2) Evaluators. The following profession...

...) Payment may be made directly to a provider for a pneumatic compression device or a related accessory only if the equipment and supplies are used to treat either lymphedema in the extremities or chronic venous insufficiency (CVI) with venous stasis ulcers. Accessories used for pneumatic compression of the chest or trunk are not covered. Before prescribing a pneumatic compression device, a practit...

... mattress) does not require PA. The provider, however, must keep on file a completed CMN. The default form is the ODM 02910. (2) If an accessory is to be used with a hospital bed, then the medical necessity of the hospital bed must also have been established. (D) Coverage of pressure-reducing support surfaces. (1) The default CMN form is the ODM 02904, "Certificate of Medical Necessity: Pre...

...vice is effective. (C) Constraint. The provider of a positive airway pressure device cannot perform the qualifying respiratory study.

...ties representing one month's supply. A provider must not dispense additional incontinence items to an individual who already has at least a month's supply on hand. Before dispensing additional items, therefore, providers must make contact, either orally or in writing, with each individual (or the individual's authorized representative) to verify the current need. Providers must keep on file a sum...

...(A) Condition of provider participation. A provider of in-home use ventilators needs to have available a licensed respiratory care professional (LRCP) twenty-four hours a day to provide respiratory care, technical support, and clinical ventilator services and to perform emergency servicing of equipment on two-hour notice. (B) Coverage. (1) Separate payment may be made for a ventilator furnished ...

...et the individual's needs, then the provider may choose to submit a request for payment of one month's rental. (5) The department will consider coverage of SGDs in any of several forms, including but not limited to the following examples: (a) A standalone unit running dedicated, proprietary software; (b) Commercially available software and, if necessary, hardware to run it (e.g., a portable...

.... During the initial rental period, the provider must obtain a revised copy of the previously completed CMN, on which the prescriber includes the following information: (a) A description, including approximate age and ownership, of any similar equipment currently in the individual's possession; (b) An explanation of why additional rental of the multiple-user lactation pump is warranted; and (c)...

...be made only to a medicaid-enrolled provider that is a member in good standing of the human milk banking association of North America. (b) The provider must keep on file the following documents: (i) An explanation by a prescriber of the medical necessity of human milk for the recipient; (ii) An attestation that the prescriber has given the recipient's parent or guardian information ...

... for at least three months, which the provider substantiates with the following documentation: (i) At least two sets of images including multiple views of the fracture site, the first and last of which were taken at least ninety days apart; and (ii) A written statement by a qualified interpreting practitioner that there has been no clinically significant evidence of fracture healing du...

...ring the initial rental period, the provider obtains a revised copy of the previously completed CMN, on which the prescriber attests that the individual (or someone assisting the individual) is capable of managing the pump and that the desired improvement in metabolic control can be achieved. (C) Constraints and limitations. (1) The use of an insulin pump is contraindicated by either of the foll...

...iting to the medical necessity, and the provider keeps a copy of this document in the individual's file. (d) For a trunk-support walker, the prescriber describes and attests in writing to the medical necessity, and the provider keeps a copy of this document in the individual's file. (e) For walker leg extensions, the individual stands at least six feet tall. (f) For a white cane that is to be used ...

...mity must be well documented in the provider's records. If there is insufficient evidence of need for a custom-molded shoe, then payment will be limited to the cost of the least expensive medically appropriate alternative. (6) No payment is made for the following items: (a) Inserts that are compression-molded to the foot over time by the heat and pressure of being worn inside a shoe; (b) Insert...

...nd performed by a qualified health care provider. Frequent evaluation is expected if a wound is heavily draining or infected. The evaluation report must include wound type; wound location; wound length, width, and depth; the amount of drainage; and any other relevant clinical information. Any such report must be made available to the department on request. (2) The provider must keep the prescript...

...Before dispensing additional units, the provider makes contact, either verbally or in writing, with the individual (or the individual's authorized representative) to verify the current need. The provider keeps on file a summary of this contact. If the individual has one unit or less, the provider may dispense up to three units.

... procedure code.) (3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (4) "Global procedure" or "total procedure" is a procedure, in its entirety, that comprises both a technical component (the part of a laboratory procedure that relies on the technical skill of a trained individual to secure a specimen and prepare it for analysis) and a professio...