Ohio Administrative Code Search

...to both contracting and non-contracting providers; and (d) A description of how the OhioRISE plan will monitor the impact of the UM program to detect and correct potential under-and over-utilization. (3) The OhioRISE plan's UM program has to ensure and document the following: (a) An annual review and update of the UM program; (b) The involvement of a designated senior physician in the UM pr...

... (a) Maintain an active, valid medicaid provider agreement as defined and set forth in rule 5160-1-17.2 of the Administrative Code; (b) Comply with all applicable provider requirements set forth in this rule; (c) Participate in initial and ongoing training, coaching, and supports from an independent validation entity recognized by the Ohio department of medicaid (ODM) to ensure consistency in delivering care coordi...

... the Administrative Code. (C) Eligible providers of IHBT services. (1) Providers eligible for medicaid payment for IHBT will: (a) Meet the criteria in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and (b) Provide the service in accordance with rule 5122-29-28 of the Administrative Code. (D) Coverage. (1) Payment may be made for IHBT services rendered face-to-face in person or via tel...

... the Administrative Code. (C) Eligible providers of OhioRISE respite services. (1) Behavioral health respite services can be provided by the following individuals or organizations: (a) Behavioral health entities operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Rendering practitioners will meet the critera to be an eligible provider of behavioral health services...

...der the OhioRISE program. (C) Eligible providers and conditions of participation. (1) The provider of primary flex funds will be the FMS entity under contract with the OhioRISE plan to complete the purchase and reimbursement of primary flex funds approved by the OhioRISE plan. (2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, the provider will comply with conditions of par...

...titutional services; and (b) Choice of providers who meet provider qualifications as described in Chapter 5160-59 of the Administrative Code to provide services under the waiver. (7) Have needs that can be safely met in an HCBS setting through the waiver as determined by ODM or its designee. (8) Meet the following age criteria: (a) Be between the ages of birth and twenty years of age at the time of initial enroll...

...ed clinician that is the treating provider dated no more than two years prior to the date of application for the OhioRISE waiver, accompanied by the diagnostic assessment that resulted in the applicable SED diagnosis performed by a licensed clinician. (d) Have documented functional impairment and behaviors that substantially interfere with or limit the youth's role or functioning in ...

...U.S.C. 1396n (January 1, 2022), and the providers eligible to deliver those services to youth enrolled on the waiver. (B) Providers seeking to deliver services in the waiver program will meet the criteria in Chapter 5160-59 and set forth in rules 5160-44-02 and 5160-44-31 of the Administrative Code, as appropriate. Providers that have responsibility for developing the child and family-centered care plan cannot prov...

... the Administrative Code. (C) Eligible providers and conditions of participation. (1) The following providers are eligible to provide the out-of-home respite service available under the waiver program: (a) An ICF/IID who is certified by the Ohio department of health (ODH), holds certification as a residential respite provider, and has an active license with the Ohio department of developmental disabilities (DODD)....

... the Administrative Code. (C) Eligible providers and conditions of participation. (1) The following providers are eligible to provide TSS under the waiver program: (a) An entity operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Eligible rendering practitioners employed by or under contract with the entity include those described in paragraph (A)(3), (A)(4), (A)(...

...society or association. (15) "Medicaid provider" or "provider" means a person or governmental entity with a valid provider agreement to provide medical services or supplies to medicaid recipients. To the extent appropriate in the context, "medicaid provider" or "provider" includes a person or governmental entity applying for a provider agreement, a former medicaid provider, or both. (16) "Notice by ordinary mail" m...

...procedures to be followed when medicaid providers seek review of actions or proposed actions of the department, except for any action taken or decision made by the department with respect to entering into or refusing to enter into a contract with a managed care organization pursuant to section 5167.10 of the Revised Code and any action taken under section 5165.60 to 5165.89 of the Revised Code. The rules in Chapter 5...

...e documentation or information that the provider failed, upon request, to furnish to ODM or its contractor during the final fiscal audit process unless ODM agrees to the admissibility of such post final fiscal audit production of documentation or information; (4) The authority to hold pre-hearing conferences for the purpose of resolving issues that can be resolved by the participants in the hearing, including facili...

...Is created or received by a health care provider, health plan, employer or health care clearinghouse; and (b) Relates to the past, present, or future physical condition or mental health condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual and either: (i) Identifies the individual; or (ii) There is a reas...

...ormation, and to uniformly identify providers. (37) "Immigrant" means a person who comes to the United States (U.S.) with plans to live in the country permanently. This term includes, but is not limited to, an individual who is a refugee, asylee, parolee, or other entrant regardless of whether he or she is residing in the U.S. legally. (38) "Income" means cash, in-kind income as defined in p...

...ormation, and to uniformly identify providers. (38) "Immigrant" means a person who comes to the United States (U.S.) with plans to live in the country permanently. This term includes, but is not limited to, an individual who is a refugee, asylee, parolee, or other entrant regardless of whether he or she is residing in the U.S. legally. (39) "Income" means cash, in-kind income as defined in p...

...a) The agency may use county employees, provider or contractor employees, or volunteers who have been properly trained to staff outstation locations under the following conditions: (i) County outstation intake workers may perform all eligibility processing functions, including the eligibility determination, if the worker is authorized to do so at the regular intake office. (ii) Provider or...

...insurance company. (b) From a medicaid provider, managed care plan, or a managed care plan's contracted provider to provide additional information that is required for the provider or plan to obtain payments from a third-party insurance company for medicaid covered services. (c) From a third-party insurance company, medicaid provider, managed care plan, or a managed care plan's contracted provider t...

...rted by the individual's medicaid provider; (b) The prior authorization requirement for some services, products, or procedures applies even when the individual is under twenty-one years of age; (c) The prior authorization process may enable individuals under twenty-one years of age to receive services not available to adults, including services that are limited in number for adul...

... (ix) A list of medicaid prenatal care providers, if requested, available to the community and/or information about medicaid-contracting MCPs. (2) Inform individuals enrolled in a MCP that they should contact the MCP for medical care options and referrals. (3) Re-inform the individual of the benefits of healthchek services as soon as possible after the infant's birth. (4) Refer the individual to support services ...

...y to a third party, generally a funeral provider. The purpose of the assignment is to fund a burial contract. (a) Assignment of ownership. (i) Revocable assignment of ownership. (a) The burial space exclusion described in rule 5160:1-3-05.7 of the Administrative Code does not apply because the funeral provider has not received payment and no purchase of burial spaces has been made. The provider has no obligation t...

...ule, means a contract with a burial provider for a burial space held for the individual or a member of the individual's immediate family. (2) "Burial space," means a burial plot, gravesite, crypt, mausoleum, casket, urn, niche, or other repository customarily and traditionally used for the deceased's bodily remains. The term also includes a contract for care and maintenance of the gravesite, ...

...institution, a hospital which has a provider agreement with the Ohio department of medicaid, or a Title XIX certified long-term care facility (LTCF). (5) "OhioMHAS" means the Ohio department of mental health and addiction services or the entity designated by OhioMHAS pursuant to division (A) of section 5119.41 of the Revised Code. (6) "RSS living arrangement" means an arrangement listed in p...

...reast and cervical cancer screening provider" means an entity which has entered into a written agreement with the ODH BCCP to provide specified breast and cervical cancer screening and diagnostic services for ODH BCCP enrollees. (b) "ODH BCCP designated local agency or subgrantee" means an entity which has received a grant from ODH to implement specified activities of the ODH BCCP. (c) "ODH BCCP...

... ODM 07161 and ODM 7160 "Healthcare Provider's Treatment Plan" (rev. 9/2017) within five business days of receipt of the diagnostic information when: (i) The ODH BCCP enrollee has submited the ODM 07161; and (ii) The ODH BCCP screening provider notifies the designated ODH BCCP regional case manager that, as a result of the NBCCEDP funded screening, a treating health professional has ...