Ohio Administrative Code Search

...s of developmental disabilities and providers of services to individuals with developmental disabilities. (C) Definitions For the purposes of this rule, the following definitions apply: (1) "Administrative investigation" means the gathering and analysis of information related to a major unusual incident in category A as described in paragraph (C)(16)(a) of this rule or a major unusual incid...

...maintained at the community residential provider for a period of three years after the close of the department's fiscal year. The originals are to be submitted on or before the fifth of each month to the department's regional office responsible for the provider's operation for validation. Upon validation, a regional office staff member will sign and forward the originals to the central office bureau of accounting, r...

...ontract with each community residential provider from which residential services are to be purchased. The contract shall: (1) Include all terms of the contract in one instrument, be dated, and be executed by authorized representatives of all parties to the contract, prior to the date of implementation, unless emergency approval is given. (2) Have a definite effective date and a maximum durational term for the provi...

... medications. (iii) The prescribing provider reevaluates a prescription prior to its renewal. (b) Procedures for medication receipt, storage, dispensing, and administration or distribution. (c) Maximum security storage and periodic inventory of all controlled substances, syringes, and needles. (d) Dispensing of medicine in conformance with appropriate federal and state laws. (e) Admi...

... all medications. (c) The prescribing provider reevaluates a prescription prior to its renewal. (2) Procedures for medication receipt, storage, dispensing, and administration or distribution. (3) Maximum security storage and periodic inventory of all controlled substances, syringes, and needles. (4) Dispensing of medicine in conformance with appropriate federal and state laws. (5) Ad...

...edications, and (c) the prescribing provider reevaluates a prescription prior to its renewal. (2) Procedures for medication receipt, storage, dispensing, and administration or distribution. (3) Maximum security storage and periodic inventory of all controlled substances, syringes, and needles. (4) Dispensing of medicine in conformance with appropriate federal and state laws. (5) Admini...

...edications, and (c) the prescribing provider reevaluates a prescription prior to its renewal. (2) Procedures for medication receipt, storage, dispensing, and administration or distribution. (3) Maximum security storage and periodic inventory of all controlled substances, syringes, and needles. (4) Dispensing of medicine in conformance with appropriate federal and state laws. (5) Admini...

...imarily for the economic benefit of the provider nor for the convenience of the provider or anyone else other than the recipient. (D) The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarant...

...imarily for the economic benefit of the provider nor for the sole convenience of the provider or anyone else other than the recipient. (D) The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not gu...

... the scope of practice of the rendering provider as defined by applicable federal, state, and local laws and regulations. (6) The service is rendered by a provider assigned to or selected by the medicaid-covered individual or medicaid-covered individual's authorized representative, with the exception of medicaid-covered individuals enrolled in the coordinated services program as defined in Chapte...

...d medicare managed care plan, preferred provider organization, private fee-for-service plans, or medicare specialty plans. (5) "Medicare Cost Sharing" for the purpose of this rule means the portion of a medicare crossover claim paid by medicaid. (6) "Dual Eligibles or Dually Eligible Individuals" are individuals who are entitled to medicare hospital insurance and SMI and are eligible for medicai...

...as cost sharing the lesser of: (1) The provider's billed charges for the service (except for hospital and nursing facility services); or (2) The deductible, coinsurance and co-payment amount as provided by the medicare part C plan; or (3) The difference between the medicare part C plan's payment to a provider for a service or services identified and the medicaid maximum allowable reimbursement rate for the same id...

... of the following amounts: (1) The provider's billed charges for the service (except for hospital and nursing facility services); or (2) The deductible, coinsurance and co-payment amount as provided by the medicare part C plan; or (3) The difference between the medicare part C plan's payment to a provider for a service or services identified and the medicaid maximum allowable reimbursem...

... not make any additional payment to the provider, or will make a payment of zero dollars, and the service(s) are considered to be paid in full to the provider.

...vice" means the information sent to providers or plan beneficiaries (covered individuals) by any other third party payer, medicare, or medicaid to explain the adjudication of the claim. (4) "Medicare benefits" has the same meaning as in rule 5160-1-05 of the Administrative Code. (5) "Third party" (TP) has the same meaning as in section 5160.35 of the Revised Code. (6) "Third party b...

... payments, the following apply: (1) No provider may deny services to an individual who is eligible for the services on account of the individual's inability to pay the medicaid co-payment. Individuals who are not able to pay their medicaid co-payment may declare their inability to pay for services or medication and receive their services or medication without paying their medicaid co-payment amount. With regard to a...

...(A) Out-of-state providers: (1) Should be licensed, accredited, or certified by their respective states to be considered eligible to receive reimbursement for services provided to Ohio medicaid covered individuals. (2) Should meet any standards applicable to the provision of the service in the state in which the service is being furnished, as well as those standards set forth in the Ohio med...

...hen the payment amount is less than the provider's charge. (1) The provider shall not collect nor bill a medicaid recipient for any difference between the medicaid payment and the provider's charge, nor shall the provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, co-payment, missed appointment fee or other similar charge, other than medicaid co-payments as ...

...31 of the Administrative Code. (B) Providers. Healthchek screening, diagnostic, and treatment services may be rendered by eligible providers in an appropriate discipline, acting within the scope of practice authorized under state law and as set forth in agency 5160 of the Administrative Code. (C) Coverage. For medicaid-eligible individuals younger than twenty-one years of age, healthchek covers ...

...ers, group practices, or organizational providers enrolling with, and seeking reimbursement from, the Ohio medicaid program. (A) Eligible provider means any practitioner, group practice, or organization identified by the Ohio department of medicaid (ODM) as a type of provider eligible to enroll in the medicaid program that: (1) Meets the applicable provider requirements and standards in agency 516...

...Provisions of provider agreements for long term care nursing facilities are defined in Chapter 5160-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5160-26 of the Administrative Code. A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid program. All medicaid provider ap...

...(A) Definitions: (1) "Disclosing provider" means a medicaid provider, managed care entity, or fiscal agent under contract with the department of medicaid (ODM). (2) "Managing employee" means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organiza...

... October 1, 2023). (4) "Disclosing provider" means a medicaid provider, managed care entity, or fiscal agent under contract with the department of medicaid (department) in accordance with 42 C.F.R. 455.101 (as in effect on October 1, 2023). (5) "Indirect ownership interest" means an ownership interest in an entity that has direct or indirect ownership in the disclosing provider. (6) "Managing e...

... Revalidation is the process that a provider is required to follow to renew and revalidate its provider agreement. Provider agreements must be revalidated no later than five years from the effective date of the original or the last revalidated provider agreement, whichever is applicable. In the event the center for medicare and medicaid services (CMS) waives or modifies the deadline, provider agre...

...e Revised Code. (2) "Non-institutional provider" means any person or entity with a medicaid provider agreement other than a hospital, long-term care nursing facility, intermediate care facility for individuals with intellectual disabilities or medicaid contracting managed care plans. (B) The Ohio department of medicaid (ODM) shall suspend a medicaid provider agreement when at least one of the following conditions a...