Ohio Administrative Code Search

...th the following stipulations: (1) The provider must apply to, and be approved by, the Ohio department of medicaid (ODM) to be eligible to dispense medical supplies/durable medical equipment. (2) All products require a prescription written by a practitioner authorized to prescribe. The prescription must be obtained by and kept on file at the pharmacy. (3) The provider must use the same medicaid provider number as ...

...he following stipulations: (1) The provider must: (a) Apply to, and be approved by, the Ohio department of medicaid (ODM) to be eligible to dispense medical supplies/durable medical equipment; and (b) Use the same medicaid provider number as when billing for pharmaceuticals; and (c) Be licensed, registered, or exempt from licensure or registration under Chapter 4761. of the Revised Code ...

...its designee. (a) Only the prescribing provider or a member of the prescribing provider's staff may request prior authorization except as described in paragraph (D)(3)(b) of this rule. (b) A pharmacist may request prior authorization for an alternative dosage form of a drug to be administered through a tube for patients who are tube fed, if no comparable drugs that do not require prior authoriza...

...its designee. (a) Only the prescribing provider or a member of the prescribing provider's staff may request prior authorization except as described in paragraph (D)(3)(b) of this rule. (b) A pharmacist may request prior authorization for an alternative dosage form of a drug to be administered through a tube for recipients who are tube fed, if no comparable drugs that do not require prior authori...

...caid (ODM) of the actual amount the provider paid to purchase the prescribed drug. ODM acquires AAC data through one or more of the following: national survey of retail pharmacy providers, e.g., national average drug acquisition cost (NADAC) rate process, states' surveys of retail pharmacy providers, and published compendia prices, e.g., wholesale acquisition cost (WAC). (3) "Administration f...

...escribed drugs is the lesser of the provider's billed charges or the calculated allowable, after any coordination of benefits is applied as described in paragraph (E) of this rule. For prescribed drugs that are subject to a co-payment, the amount paid by the Ohio department of medicaid (ODM) is decreased by the amount equal to the co-payment billed to the recipient in accordance with rules 5160-1-...

...egulations and shall be retained by the provider for a period of six years from the date of payment of the claim and if an audit is initiated during this time, records must be retained until the audit is resolved. (C) For a pharmacy claim to be eligible for payment by ODM, any prescription executed in written (and non-electronic) format must be executed on a tamper-resistant form. (1) To be considered tamper resist...

...tate regulations and be retained by the provider for a period of six years from the date of payment of the claim and if an audit is initiated during this time, records must be retained until the audit is resolved. (C) For a pharmacy claim to be eligible for payment by ODM, any prescription executed in written (and non-electronic) format must be executed on a tamper-resistant form. (1) To be cons...

... office, emergency department, or other provider setting, that are intended to be used by the individual outside of the provider setting. (E) No provider of pharmacy services may deny a prescribed drug to an individual eligible for medicaid coverage because the individual is unable to pay the co-payment. The provisions of paragraph (B) of rule 5160-1-09 of the Administrative Code apply to co-payments for prescribed ...

... office, emergency department, or other provider setting, that are intended to be used by the individual outside of the provider setting. (E) No provider of pharmacy services may deny a prescribed drug to an individual eligible for medicaid coverage because the individual is unable to pay the co-payment. The provisions of paragraph (B) of rule 5160-1-09 of the Administrative Code apply to co-paym...

...ed on surveys submitted by pharmacy providers enrolled with the Ohio department of medicaid (ODM). (a) The OAAC rate does not account for off-invoice adjustments between pharmacy providers and wholesalers or manufacturers and is reflective of the market conditions specific to enrolled Ohio pharmacy providers. (b) The OAAC rate is recalculated utilizing surveys issued to pharmacy providers semia...

... the department can determine coverage. Providers cannot decide on their own that an item or service is not covered or would not be covered with PA. Providers should submit a PA request to obtain an official decision. (3) "Department" is the Ohio department of medicaid or, when applicable, its designee. The address of the department's web site is http://medicaid.ohio.gov. (4) "DMEPOS item" i...

...d or rendered by an enrolled DMEPOS provider. (2) Additional conditions specific to a particular DMEPOS item or service may be set forth in other rules in this chapter of the Administrative Code. (3) Policies set forth in other rules in this chapter supersede any provisions in this rule with which they conflict. (B) Definitions that apply to rules in this chapter of the Administrative Code....

...(A) Prescribing provider. Only a physician experienced in the management of patients at risk for sudden cardiac death (SCD), such as a cardiologist, electrophysiologist, or cardiac surgeon, may prescribe a wearable cardioverter-defibrillator (WCD). (B) Coverage. (1) Separate payment may be made for a WCD furnished to a resident of a long-term care facility (LTCF). (2) Payment may be made fo...

...ode for medicaid payment purposes. (B) Providers. (1) Prescribing providers. Eligible medicaid providers of the following types, acting within their scope of practice, may prescribe a bathing seat and may certify the medical necessity of a bathing seat when such certification is needed: (a) A physician; (b) An advanced practice registered nurse with a relevant specialty; (c) A physician assis...

... submission of the PA request. (B) Providers. (1) Prescribing providers. Eligible medicaid providers of the following types, acting within their scope of practice, may prescribe a bathing seat and may certify the medical necessity of a bathing seat when such certification is needed: (a) A physician; (b) An advanced practice registered nurse with a relevant specialty; (c) A physician assis...

...(A) Provider requirements. A provider of apnea monitors for use in the home must be capable of performing all of the following services: (1) Arranging to have certified individuals provide infant cardiopulmonary resuscitation (CPR) training to caregivers; (2) Providing education and instruction on the mechanical aspects of monitors; and (3) Providing a technician twenty-four hours a day to ...

...administration guidelines. (b) The provider is capable of performing all of the following services: (i) Arranging to have certified individuals provide infant cardiopulmonary resuscitation (CPR) training to caregivers; (ii) Providing education and instruction on the mechanical aspects of monitors; and (iii) Providing a technician twenty-four hours a day to service monitoring equipment...

...d acceptability of the hearing aid, the provider must attempt to schedule a follow-up visit with the individual within thirty days after delivery. No claim for payment should be submitted during this period. The provider must keep on file, for at least four years, either a confirmation of the follow-up visit signed by the individual or an explanation of why the visit was not conducted. If as a res...

... follow-up visit. In either case, the provider maintains relevant documentation. If the hearing aid is deemed unacceptable by either the provider or the individual, then payment is limited to the cost of the earmold insert and batteries. If payment has already been made for the hearing aid, then the claim is to be adjusted. (6) The following warranty periods apply: (a) For a covered hearing ai...

... concentrator to portable tanks. (B) Providers. (1) The following eligible medicaid providers may prescribe oxygen: (a) A physician; (b) An advanced practice registered nurse with a relevant specialty; or (c) A physician assistant. (2) The following eligible medicaid providers may supply oxygen: (a) A durable medical equipment (DME) provider; (b) A pharmacy; (c) A physician; (d) An advanced pr...

...oncentrator to portable tanks. (B) Providers. (1) The following eligible medicaid providers may prescribe oxygen: (a) A physician; (b) An advanced practice registered nurse with a relevant specialty; or (c) A physician assistant. (2) The following eligible medicaid providers may supply oxygen: (a) A durable medical equipment (DME) provider; (b) A pharmacy; (c) A physician; (d) An advanced pr...

...(A) Provider requirement. A provider of custom-made or custom-fitted compression garments must either employ or contract with a certified fitter and must keep documentation of this relationship on file. (B) Coverage. (1) The default certificate of medical necessity (CMN) form is the ODM 01905, "Certificate of Medical Necessity: Compression Garments" (rev. 7/2018). (2) Payment may be made on...

...For a gradient compression garment, the provider specifies at least one clinical indication such as but not limited to the conditions identified in the following list: (1) Elephantiasis; (2) Lymphedema; (3) Milroy's disease; (4) Orthostatic hypotension; (5) Post-thrombotic syndrome; (6) Stasis dermatitis; (7) Stasis ulcers; (8) Symptomatic chronic venous insufficiency (characterized by, for ex...

...er for rechargeable batteries. (B) Provider requirement. A provider of transcutaneous electrical nerve stimulation (TENS) units must have a physical location available for face-to-face fitting and instruction purposes. (C) Coverage. (1) Payment may be made for a TENS unit on a rental/purchase basis. (2) The default certificate of medical necessity (CMN) form is the ODM 03402, "Certificate ...