Ohio Administrative Code Search

...on service furnished by an eligible provider on a fee-for-service basis is the lesser of either the provider's submitted charge or the medicaid maximum payment amount for the date of transport. The medicaid maximum payment amounts for transportation services are listed in the appendix to this rule. (B) The amount of payment for a transportation service furnished by an eligible provider under an a...

...33 of the Administrative Code. (B) Provider requirements. Payment may be made to a FBC only if it meets the following criteria: (1) It holds a current license to perform FBC services issued by the appropriate authority in the state in which it is located; (2) It is operated in conformity with rules 3701-83-33 to 3701-83-42 of the Administrative Code; and (3) It is neither a hospital registered...

...r-point injection), skin substitute, or provider-administered pharmaceutical rule 5160-4-12; (c) Applicable durable medical equipment, prostheses, orthoses, and medical supply items Chapter 5160-10; (d) Laboratory service rule 5160-11-11; or (e) Reproductive health service Chapter 5160-21, for which maximum payment amounts are published in appendix DD to rule 5160-1-60.

...xt attribution period following the provider's reinstatement. The following hierarchy will be used in assigning recipients to PCPs under the PCMHCPC and PCMHCPC for kids program: (a) The recipient's choice of provider. (b) Claims data concerning the recipient. (c) Other data concerning the recipient. (2) "CPC attributed medicaid individuals" are Ohio medicaid recipients for whom PCPs h...

...aid individuals. The following medicaid providers are eligible to participate and receive payment under this rule: (a) Professional medical groups as defined in Chapter 5160-1 of the Administrative Code. (b) Federally qualified health centers (FQHC) and rural health clinics (RHC) as defined in Chapter 5160-28 of the Administrative Code. (c) Clinics as defined in Chapter 5160-13 of the Administr...

...uscle relaxants. (2) "Assigned provider" means a hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed or certified single provider or provider entity that is authorized to and is not excluded from receiving reimbursement for health care services rendered to an individual. The assigned provider is selected in accordance with paragraph (F) of this rule to serve as...

...uscle relaxants. (2) "Assigned provider" means a hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed or certified single provider or provider entity that is authorized to and is not excluded from receiving reimbursement for health care services rendered to an individual. The assigned provider is selected in accordance with paragraph (F) of this rule to serve as...

...service to be used. (3) A medicaid provider must not make the receipt of pregnancy prevention services a prerequisite to eligibility for, receipt of, or participation in any other services offered by the provider. (4) A medicaid recipient must not be denied other medicaid-covered medically necessary services on the basis of fertility or infertility. (B) Coverage. Payment may be made for the...

... The department will reimburse medicaid providers for sterilization services only if all the requirements of this rule and 42 C.F.R. part 441 subpart F (October 1, 2010 edition), are met: (a) The individual is at least twenty-one years old at the time consent is obtained; (b) The individual is not a mentally incompetent individual; (c) The individual is not institutionalized; (d) The individual has voluntarily gi...

...ediatrician or other primary care provider who will subsequently furnish early and continuous well-child and primary care for the newborn and will discuss care of the infant with the individual and, as appropriate, the individual's family. (b) Delivery. Payment may be made for admission to a facility (hospital or freestanding birth center), the taking of a medical history during admission, ...

...ediatrician or other primary care provider who will subsequently furnish early and continuous well-child and primary care for the newborn and will discuss care of the infant with the individual and, as appropriate, the individual's family. (b) Delivery. Payment may be made for admission to a facility (hospital or freestanding birth center), the taking of a medical history during admission, ...

...he Revised Code. (3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (4) "Home visiting" has the same meaning as in Chapter 3701-8 of the Administrative Code. (5) "Nurse home visiting" is home visiting provided by an APRN or RN. Within the package of home visiting services, emphasis is placed on the following services performed within the sc...

... Administrative Code. (B) Eligible ASC providers. (1) All ASCs that have a valid agreement with the centers for medicare and medicaid services (CMS) to provide services in the medicare program are eligible to become medicaid providers upon execution of the "Ohio Medicaid Provider Agreement." (2) ASC providers bill in accordance with rule 5160-1-19 of the Administrative Code. The department will rei...

...ministrative Code: (A) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost ...

...has, the existence of conflicts between provider networks, or access requirements. When this occurs, the effective date of termination of MCO enrollment shall be determined by ODM but in no event shall the termination date be later than the last day of the month in which ODM approves the termination. (6) The member is not eligible for MCO enrollment for one of the reasons set forth in rule 5160-2...

...edicaid from an MCO or SPBM network provider, the MCO or SPBM must adequately and timely cover the services out of network, until the MCO or SPBM is able to provide the services from a network provider. (C) The MCO and SPBM may place appropriate limits on a service: (1) On the basis of medical necessity for the member's condition or diagnosis; or (2) For the purposes of utilization control,...

...sure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member's needs. (1) The MCO must ensure PCPs are in compliance with the following triage requirements: (a) Members with emergency care needs must be triaged and treated immediately on presentation at the PCP site; (b) Members with persistent...

...s not owned, leased, or controlled by a provider of any health-related treatment or support services; (2) Not be a foster child, as defined in Chapter 5101:2-1 of the Administrative Code; (3) Be under twenty-one years of age; (4) Have long-term services and supports (LTSS) needs resulting in the need for respite services as indicated by: (a) Skilled nursing or skilled rehabilitation services at le...

...(A) Provider contracts. (1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule and...

...en information to their contracting providers: (1) The MCE's grievance, appeal and state fair hearing procedures and time frames, including: (a) The member's right to file grievances and appeals and the requirements and time frames for filing; (b) The MCE's toll-free telephone number to file oral grievances and appeals; (c) The member's right to a state fair hearing, the requirements and t...

...te and abuse as required in the MCE provider agreement or contract with the Ohio department of medicaid (ODM) located at http://medicaid.ohio.gov/. (1) These arrangements or procedures must be made available to ODM upon request. (2) The MCE must annually submit to ODM a report that summarizes the MCE's fraud, waste, and abuse activities for the previous year and identifies any proposed changes t...

...rovide pursuant to the terms of the MCE provider agreement or contract, as applicable, with the Ohio department of medicaid (ODM). (2) Be treated with respect and with due consideration for their dignity and privacy. (3) Be ensured of confidential handling of information concerning their diagnoses, treatments, prognoses, and medical and social history. (4) Be provided information about thei...

...ember's authorized representative, or a provider may file an appeal orally or in writing within sixty calendar days from the date that the NOA was issued. An oral appeal filing must be followed with a written appeal. The MCO or SPBM shall: (a) Immediately convert an oral appeal filing to a written appeal on behalf of the member; and (b) Consider the date of the oral appeal filing as the filing d...

...ry against any TPP for costs due to provider fraud, waste, or abuse as defined in rule 5160-26-01 of the Administrative Code related to each member during periods of enrollment in the MCO. In instances when the MCO fails to properly report suspected fraud, waste, or abuse, before the suspected fraud, waste, or abuse is identified by the state of Ohio, any portion of the fraud, waste, or abuse reco...

... the Administrative Code, or the MCO provider agreement, ODM will provide timely written notification to the MCO identifying the violations or deficiencies, and may impose corrective actions or any of the following sanctions in addition to or instead of any actions or sanctions specified in the provider agreement: (1) ODM may require corrective action plans (CAPs) in accordance with the follow...