Ohio Administrative Code Search

...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...

...d program and is delivered by a medical provider that qualifies for a medicaid provider agreement. (2) "Applicant for reimbursement" is defined as: (a) An individual who has been erroneously determined ineligible for the medicaid program or whose determination was incorrectly delayed, and who is seeking reimbursement for medical expenses incurred during the time period when the individual should have been covered b...

...ive Code; (b) Delivered by an eligible provider who qualifies for one of the following: (i) A medicaid provider agreement as described in rule 5160-1-17.12 of the Administrative Code; or (ii) An approved contract or single case agreement with a medicaid managed care entity (MCE); (c) A reimbursable medical service as defined in rule 5160-1-02 of the Administrative Code. (d) A phys...

... procedure, service, or supply, the provider may submit a new claim with the appropriate code. The new claim must not be submitted for by-report consideration.

...tive Code if an outpatient hospital provider; and (3) Within ninety calendar days of approval to participate as a QBHE, have an active provider contract with each medicaid managed care plan (MCP); (4) Submit an application to become a QBHE. ODM reserves the right to deny any QBHE enrollment application it determines is not in compliance with the requirements of this rule. A QBHE may seek rec...

...itute practitioner meets the applicable provider screening requirements described in rule 5160-1-17.8 of the Administrative Code; (e) The substitute practitioner has not been sanctioned under medicare, medicaid, or Title XX and is not otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries; and (f) The substitute practitioner receives payment from the re...

...e practitioner meets the applicable provider screening requirements described in rule 5160-1-17.8 of the Administrative Code; (5) The substitute practitioner has not been sanctioned under medicare, medicaid, or Title XX and is not otherwise prohibited from providing services to medicare, medicaid, or Title XX beneficiaries; and (6) The substitute practitioner receives payment from the regula...

...ata to be utilized for establishing provider payment amounts are fee-for-service (FFS) payments for state fiscal year 2022 and reflected in the ODM management information technology system (MITS) on January 31, 2023. (b) Each payment is the product of the ratio of each hospital's total FFS payments to the total FFS payments for all eligible hospitals as defined in paragraph (A) of this rule, mult...

...to paragraph (A) of this rule, each provider eligible to receive a directed SDP program payment will submit to ODM an additional IGT which is to be four per cent of the provider's computed IGT amount. (2) In subsequent SDP program years, ODM may establish a rate higher or lower than the rate described in paragraph (B)(1) of this rule as approved by the medicaid director.

...(Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet the requirements for Title XVIII participation and has in effect a hospital utilization review plan applicable to all patients who receive medical assistance under Title XIX. The following hospitals are excluded from participation: (1) Tuberculosis hospitals, and (2) Hospital...

...le XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet the established criteria for Title XVIII participation and has in effect a hospital utilization review plan applicable to all patients who receive medical assistance under Title XIX. The following hospitals are excluded from participation: (1) Tuberculosis ...

...ent hospital services. (1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code. (2) Inpatient or outpatient services related to the provision of the services described in this rule are not covered: (a) Abortions other than those tha...

...hospital services. (1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code. (2) The following inpatient or outpatient services related to the provision of the services described in this rule are not covered: (...

...ty-five beds and enrolled as a medicaid provider on or after January 1, 2011 shall: (a) For the purposes of setting base rates, for inpatient services as described in rule 5160-2-65 of the Administrative Code and outpatient services as described in rule 5160-2-75 of the Administrative Code, be grouped into its natural urban or rural hospital peer group as described in paragraph (A)(2) or (A)(5) o...

...ive beds and enrolled as a medicaid provider on or after January 1, 2011, will: (a) For the purposes of setting base rates, for inpatient services as described in rule 5160-2-65 of the Administrative Code and outpatient services as described in rule 5160-2-75 of the Administrative Code, be grouped into its natural rural or urban hospital peer group as described in paragraph (A)(7) or (A)(9) of th...

...licable for each program year for all providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Disproportionate share hospital" means a hospital that meets the requirements for disproportionate share status as defined in rule 5160-2-09 of the Administrative Code. (2) "Governmental hospital" means a county...

...m year for all medicaid-participating providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Total fee for service (FFS) medicaid costs" for each hospital means the sum of inpatient program costs reported on ODM 02930, schedule H, section I, columns 1 and 3, line 1 and outpatient medicaid program costs a...

...tional information that may support the provider's position. (2) If the submitted request for a reconsideration is incomplete, the department or the medical review entity will notify the provider of missing documentation. The notice will give the provider two business days to submit the missing documentation. (3) The department will conduct an administrative review of the reconsideration decision if the provider su...

...eny payment to or recoup payment from a provider who has transferred patients inappropriately. (2) ODM may review readmissions to determine if the readmission as defined in rule 5160-2-02 of the Administrative Code is appropriate. (a) If the readmission is related to the first hospitalization, ODM will determine if the readmission resulted from complications or other circumstances that arose because of an early dis...

...d delivered at a hospital where the provider has clinical privileges, and where such services are permissible to be provided by the hospital under its certificate of authority granted under Chapters 3711., 3727., and 5119. of the Revised Code. Hospitals will be responsible for providing basic, medically necessary hospital-level services to those persons described in paragraph (C) of this rule. (2...

...medicaid program requires each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (A)(7) of this rule. Effective...

...t-reporting purposes, each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, is to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (A)(7) of th...

... audit. To facilitate this examination, providers are required to make available all records and source documents necessary to fully disclose the extent of services provided to program recipients, the corresponding costs and charges made and payments received for such services, for the period corresponding to the cost-reporting period. The principle objective of the audit is to enable the department to determine that...

...it. To facilitate this examination, providers will make available all records and source documents necessary to fully disclose the extent of services provided to program recipients, the corresponding costs and charges made and payments received for such services, for the period corresponding to the cost-reporting period. The principle objective of the audit is to enable the department to determine...