Ohio Administrative Code Search

...(A) Providers. An entity may enroll in medicaid as a portable x-ray supplier only if it complies with the conditions set forth in 42 C.F.R. part 486 subpart C (October 1, 2020). (B) Coverage. (1) The radiology procedures performed by a portable x-ray supplier have both a professional component and a technical component. (a) In general, a portable x-ray supplier performs the technical component ...

...(A) Providers. (1) An entity may enroll in medicaid as an independent diagnostic testing facility (IDTF) only if it meets the following criteria: (a) It meets all standards set forth in and provide services in accordance with 42 C.F.R. 410.33 (October 1, 2020); (b) It takes the following measures to establish accountability: (i) It ensures that each supervising practitioner attests in writin...

...in accordance with the individual's provider of hospice services when the individual has elected the hospice benefit. (6) Access home health services in accordance with the individual's managed care plan when the individual is enrolled in a medicaid managed care plan. (G) Covered home health services: (1) "Home health nursing" is a nursing service that requires the skills of and is performed ...

...rovided by more than one non-agency provider. (B) For PDN to be covered, the service: (1) Must be performed within the nurse's scope of practice as defined in Chapter 4723. of the Revised Code and rules adopted thereunder; (2) Must be provided and documented in accordance with the individual's plan of care in accordance with rule 5160-12-03 of the Administrative Code; (3) Must be medically...

...ed services (HCBS) waiver. (1) The PDN provider shall submit a referral for PDN authorization to ODM using the ODM 02374, "Private Duty Nursing (PDN) Services Request" (3/2015), along with any additional supporting documentation requested by ODM. (2) ODM shall conduct an in-person assessment and/or perform a desk review to determine if, in accordance with rule 5160-12-02 of the Administrative Code, the individual h...

...io medicaid program upon execution of a provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code. (B) MCHHAs are required to: (1) Be certified for medicare participation by the Ohio department of health (ODH) in accordance with Chapter 3701-60 of the Administrative Code. (2) Meet the conditions of participation in accordance with 42 C.F.R. Part 484 (October 1, 2014). (3) Implement policy ...

...io medicaid program upon execution of a provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code. A non-agency nurse is required to: (1) Be a registered nurse or licensed practical nurse at the direction of a registered nurse practicing within the scope of his or her nursing license pursuant to Chapter 4723. of the Revised Code as an independent provider. (2) Comply with the requirements of...

...ons that apply to its provision and the provider who renders the service(s). (C) Each covered visit must be billed as a separate line item. The number of lines /procedure codes must reflect the number of visits provided with one line equaling one visit. (D) A "group visit" is a visit where the service(s) is provided to more than one person. During a group visit: (1) The ratio of provider to...

...th visit shall be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and/or unit rate found in appendix A as applicable to this rule using the number of units of service that were provided during a visit in accordance with this chapter as follows: (1) Each visit must be less than or equal to ...

...th visit shall be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and/or unit rate found in appendix A as applicable to this rule using the number of units of service that were provided during a visit in accordance with this chapter as follows: (1) Each visit must be less than or equal to ...

... a PDN visit shall be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and unit rate found in appendix A to this rule using the number of units of service that were provided during a visit in accordance with this chapter. (D) The amount of reimbursement for a PDN visit shall be the lesser of the provider's billed ...

...DN visit shall be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and unit rate found in appendix A to this rule using the number of units of service that were provided during a visit in accordance with this chapter. (D) The amount of reimbursement for a PDN visit shall be the lesser of the pr...

... and private duty nursing (PDN) service providers may be reimbursed when any of the exceptions set forth in this rule apply through no fault of the provider: (A) Requirements of paragraphs (D)(2) of rule 5160-12-01 and (E)(2) of rule 5160-12-02 of the Administrative Code are not met due to any of the following: (1) Services are not identified on the all services plan when the individual is enrolled on an Ohio depar...

... (CARES) Act, S.3548 (2020), prior to a provider requesting reimbursement for a service. The plan of care has the same meaning as set forth in rule 5160-51-01 of the Administrative Code and is not the same as an all services plan, individual service plan, or helping Ohioans move expanding choice (HOME choice) service plan. (2) A "registered nurse (RN) assessment" is the medicaid service performed...

... (CARES) Act, S.3548 (2020), prior to a provider requesting reimbursement for a service. The plan of care has the same meaning as set forth in rule 5160-51-01 of the Administrative Code and is not the same as an all services plan, individual service plan, or helping Ohioans move expanding choice (HOME choice) service plan. (2) A "registered nurse (RN) assessment" is the medicaid service performed...

...tment of medicaid (ODM) as a clinic provider: (1) A dialysis center, defined as a "dialysis facility" in 42 C.F.R. 494.10 (October 1, 2022), that meets the following criteria: (a) It is recognized by medicare as a dialysis facility; (b) It operates in accordance with Chapter 3701-83 of the Administrative Code or, if it is located outside of Ohio, operates in accordance with its respective s...

...individual employed by a transportation provider, in addition to the minimum crew of a wheelchair van or a ground ambulance, who aids in the non-emergency transportation of medicaid-eligible individuals who need extra assistance. (4) "County department of job and family services (CDJFS)" is an entity established under section 329.01 of the Revised Code or a group of such entities acting together ...

...dicaid-eligible individuals to and from providers of covered healthcare services. ODM fulfills this obligation in large measure through three-way subgrant agreements with the Ohio department of job and family services (ODJFS) and with each county department of job and family services (CDJFS). This rule sets forth the responsibilities and expectations placed by ODM on each CDJFS in the administrati...

...(A) Definition. "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (B) Transportation-specific criteria. For each entity enrolled as an eligible provider of transportation services, the following conditions are met: (1) The entity, each crew member, and each attendant comply with all applicable local, state, and federal laws, regulations, and rules, inc...

...nditions: (i) The transportation provider is an eligible provider of both wheelchair van services and ground ambulance services; (ii) No wheelchair van is available for one of three reasons: (a) A wheelchair van was originally scheduled for the transport but has been rendered inoperative or unavoidably delayed, and the transportation provider cannot substitute another wheelchair...

...ible individual, and the transportation provider maintains documentation of such necessity. (C) A hospital that is an eligible provider may submit a claim for ground ambulance services on behalf of another entity if two conditions apply: (1) The other entity is an eligible provider of ground ambulance services; and (2) The hospital and the other entity have entered into an appropriate agreement...

... (C) A hospital that is an eligible provider may submit a claim for air ambulance services on behalf of another entity if two conditions apply: (1) The other entity is an eligible provider of air ambulance services; and (2) The hospital and the other entity have entered into an appropriate agreement or contract. (D) Separate payment may be made for critical care services, the provision of w...

...istrative Code. (2) Transportation providers may request manual review of claims for services involving non-exempted combinations of origins and destinations. Transportation providers may also request manual review of a claim for a service involving an origin or destination not listed in paragraph (A) of this rule if they indicate that fact explicitly on the claim. (3) A request for manual r...

...e individual but is not an eligible provider at the time of transport may submit a claim for that service in accordance with Chapter 5160-1 of the Administrative Code after it has become an eligible provider of transportation services. (D) Certain coverage limitations are based on the length of a transport. (1) Mileage payment for a non-emergency transport (either by wheelchair van or by ground ...

...n services furnished by an eligible provider that are automatically deemed to be necessary in accordance with rule 5160-15-22, 5160-15-23, or 5160-15-24 of the Administrative Code. A medicaid managed care organization (MCO) is not obliged to use the practitioner certification process described in paragraph (B) of this rule to certify the necessity of a transportation service furnished to a med...