Ohio Administrative Code Search

...ndirectly, or in any combination. (2) "Provider" has the same meaning as "eligible provider," as defined in rule 5160-1-17 of the Administrative Code. (3) "Provider Agreement" means an agreement as defined in rule 5160-1-17.2 of the Administrative Code or any rule contained in agency 5160 of the Administrative Code. (B) Termination for long term care nursing facilities and intermediate care facilities for individ...

...ty that at one time was a participating provider in the Ohio medicaid program and whose provider agreement was terminated either voluntarily or involuntarily in accordance with rule 5160-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program. (B) In considering an application for participation in the Oh...

...Code in order to become an eligible provider, a provider must meet the screening requirements described in this rule and in section 5164.34 of the Revised Code and pay an applicable application fee if required in the appendix to this rule. Provider screening and application fees are required at the time of enrollment and revalidation as defined in rule 5160-1-17.4 of the Administrative Code. ...

...f this rule only: (1) A "participating provider" is an active provider who bills the medicaid program for rendered services, or who is an active provider who orders, prescribes, refers, or certifies but does not bill the medicaid program. (2) An "ordering or referring only provider" is a provider who orders, prescribes, refers, or certifies an item or service reported on a claim, and is not a billing provider in th...

...ntity must: (1) Have an active provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code; (2) Read the presumptive eligibility training guide found on the ODM website, www.medicaid.ohio.gov; and (3) Attest that it will meet the terms and conditions as a QE by reading, signing, and sending ODM form 10252 "acknowledgment of terms and conditions governing the presum...

... services rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is defined in rule 5122-29-31 of the Administrative Code. (d) Conversations or electronic communication between practitioners regarding a patient without the patient present is not considered telehealth unless the service would allow billing for practitioner to practitioner commu...

...vices rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is defined in rule 5122-29-31 of the Administrative Code. (d) Conversations or electronic communication between practitioners regarding a patient without the patient present is not considered telehealth unless the service would allow billing for practitioner to practitioner commu...

...e Administrative Code. (2) The ODM provider web portal; or (3) Pharmacy point-of-sale. (B) Claims should be submitted pursuant to the national correct coding initiative and according to the coding standards set forth in the following guides: (1) The healthcare common procedure coding system; (2) The current procedural terminology codebook; (3) The current dental terminology codeb...

...nefits, or coverage. (c) "ANSI X12 274 provider information" is a transaction used to exchange demographic and educational or professional qualifications about health care providers between providers, provider networks, or any other entity that maintains or verifies health care provider information. (d) "ANSI X12 275 patient information" is a transaction used to communicate individual patient in...

...ncounter information, or both, from providers (institutional, professional, or dental) of health care services to payers, either directly or via clearinghouses. (e) "ANSI X12 270 eligibility, coverage, or benefit inquiry" is a transaction used to inquire about the eligibility, benefits or coverage under a subscriber's health care policy. (f) "ANSI X12 271 eligibility, coverage, or benefit inform...

...1 and 5124.41 of the Revised Code, any provider of services or goods contracting with the Ohio department of medicaid (ODM) pursuant to Title XIX of the Social Security Act who, without intent, obtains payment from the medicaid program in excess of the amount to which the provider is entitled becomes liable for payment of interest charged in accordance with this rule on the amount of the overpayment. The interest ra...

...f the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, frequency, extent, duration, and delivery setting of services provided to medicaid recipients, and to document significant business transactions. Medicaid providers are required to provide...

... of medicaid (ODM) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons: (i) In response to allegations of fraud or other willful misrepresentation of claims submission; or (ii) When a provider has been indicted for a criminal offense. (b) ODM shall notify the provider in writing within ten business days that the pr...

...on is used to complement or follow-up a provider or certification or other quality review process; (2) In response to allegations of fraud or willful misrepresentation of claims submission; (3) Upon the request of the office of the attorney general, the office of inspector general, or the auditor of state; (4) When a provider's medicaid provider agreement is subject to termination; (5) When a provider has been ...

... the medicaid program are detected, providers will be subject to a review by ODM and the case will be referred to the attorney general's medicaid fraud control unit and/or the appropriate enforcement officials. If waste and abuse are suspected or apparent, ODM and/or the office of the attorney general will take action to gain compliance and recoup inappropriate or excess payments in accordance...

... the medicaid program are detected, providers will be subject to a review by ODM and the case will be referred to the attorney general's medicaid fraud control unit or the appropriate enforcement officials. If waste and abuse are suspected or apparent, ODM, the office of the attorney general, or both will take action to gain compliance and recoup inappropriate or excess payments in accordance ...

...ained from ODJFS or its designee by the provider before the services are rendered or the items delivered, unless the services meet the provisions in paragraph (F) of this rule. . (B) Services, supplies or prescription drugs that require prior authorization by the department are identified in Chapters 5101:3-2 to 5101:3-56 of the Administrative Code. (C) All prior authorization requests must be submitted through the...

...apply: (1) In situations where the provider considers a delay in providing services or an item requiring prior authorization to be detrimental to the health of the medicaid recipient, the services or item may be rendered or delivered and approval for reimbursement sought after the fact. (2) In cases of emergency, for prescribed drugs requiring prior authorization, the prescribed drug may be...

...) If the authorized representative is a provider or staff member or volunteer of an organization, the authorized representative must affirm that he or she will adhere to the regulations in 42 C.F.R. Part 431 Subpart F (as in effect October 1, 2015), 42 C.F.R. 447.10 (as in effect October 1, 2015), 45 C.F.R. 155.260(f) (as in effect October 1, 2015), as well as other relevant state and federal laws concerning conflict...

...(A) Home care service providers, as defined in this paragraph, must have a system as follows. (1) Definitions. (a) "Home care dependent adult" means a consumer who: (i) Resides in a private home or other non-institutional, unlicensed living arrangement without a parent or guardian present; (ii) Requires, due to health and safety needs, regularly scheduled home care services to remain in the home or other living a...

...g standards found in 42 CFR 422.204, "provider selection and credentialing" (as in effect on October 1, 2021), this rule details the credentialing and recredentialing process for medicaid providers. (A) For purposes of this rule, the following definitions apply. (1) "Council for affordable quality healthcare (CAQH)" is a non-profit organization which created a process allowing ODM to use a single,...

... medicaid (ODM) authorizes eligible provider delegates to perform credentialing activities on behalf of individual providers in accordance with rule 5160-1-42 of the Administrative Code. (B) "Delegate" and "Delegation" have the same meaning as in rule 5160-1-42 of the Administrative Code. (C) Entities seeking delegation will be expected to meet the following criteria to become an authorized ...

...the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments a...

...the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments a...

...the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ask a medicaid recipient to share in the cost through a deductible, coinsurance, copayment, or other similar charge other than medicaid copayments a...