Ohio Administrative Code Search

...aid individuals. The following medicaid providers are eligible to participate and receive payment under this rule: (a) Professional medical groups as defined in Chapter 5160-1 of the Administrative Code. (b) Federally qualified health centers (FQHC) and rural health clinics (RHC) as defined in Chapter 5160-28 of the Administrative Code. (c) Clinics as defined in Chapter 5160-13 of the Administrativ...

...uscle relaxants. (2) "Assigned provider" means a hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed or certified single provider or provider entity that is authorized to and is not excluded from receiving reimbursement for health care services rendered to an individual. The assigned provider is selected in accordance with paragraph (F) of this rule to serve as...

...uscle relaxants. (2) "Assigned provider" means a hospital, health care facility, physician, dentist, pharmacy, or otherwise licensed or certified single provider or provider entity that is authorized to and is not excluded from receiving reimbursement for health care services rendered to an individual. The assigned provider is selected in accordance with paragraph (F) of this rule to serve as...

...uded from consideration. (C) "Assigned provider" means a pharmacy provider that is authorized to and is not excluded from receiving reimbursement for health care services rendered to an individual. The assigned pharmacy provider is selected to serve as the pharmacy provider for an individual enrolled in the coordinated services program (CSP). (D) "Coordinated services program" is a program required by section 5164....

...t is assigned a designated pharmacy provider through which pharmacy services are received. Only controlled substances, as defined in 21 U.S.C. 801 as in effect July 6, 2025, are to be received from a designated pharmacy provider. Drugs used for medication assisted treatment (MAT) are excluded. (B) CSP enrollment criteria. The enrollment criteria of this rule are based upon available utilization d...

...service to be used. (3) A medicaid provider must not make the receipt of pregnancy prevention services a prerequisite to eligibility for, receipt of, or participation in any other services offered by the provider. (4) A medicaid recipient must not be denied other medicaid-covered medically necessary services on the basis of fertility or infertility. (B) Coverage. Payment may be made for the...

... The department will reimburse medicaid providers for sterilization services only if all the requirements of this rule and 42 C.F.R. part 441 subpart F (October 1, 2010 edition), are met: (a) The individual is at least twenty-one years old at the time consent is obtained; (b) The individual is not a mentally incompetent individual; (c) The individual is not institutionalized; (d) The individual has voluntarily gi...

...ediatrician or other primary care provider who will subsequently furnish early and continuous well-child and primary care for the newborn and will discuss care of the infant with the individual and, as appropriate, the individual's family. (b) Delivery. Payment may be made for admission to a facility (hospital or freestanding birth center), the taking of a medical history during admission, ...

...ediatrician or other primary care provider who will subsequently furnish early and continuous well-child and primary care for the newborn and will discuss care of the infant with the individual and, as appropriate, the individual's family. (b) Delivery. Payment may be made for admission to a facility (hospital or freestanding birth center), the taking of a medical history during admission, ...

...diatrician, or other primary care provider who will subsequently furnish early and continuous well-child and primary care for the newborn and will discuss care of the infant with the woman and, as appropriate, the woman's family. (b) Delivery. Payment may be made for admission to a facility (hospital or freestanding birth center), the taking of a medical history during admission, phys...

...he Revised Code. (3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (4) "Home visiting" has the same meaning as in Chapter 3701-8 of the Administrative Code. (5) "Nurse home visiting" is home visiting provided by an APRN or RN. Within the package of home visiting services, emphasis is placed on the following services performed within the sc...

...he Revised Code. (3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (4) "Home visiting" has the same meaning as in Chapter 3701-8 of the Administrative Code. (5) "Nurse home visiting" is home visiting provided by an APRN or RN. Within the package of home visiting services, emphasis is placed on the following services performed within the sc...

...he Revised Code. (3) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (4) "Home visiting" has the same meaning as in Chapter 5180-8 of the Administrative Code. (5) "Nurse home visiting" is home visiting provided by an APRN or RN. Within the package of home visiting services, emphasis is placed on the following services performed within the sc...

...d to this rule. (1) "Eligible provider" has the same meaning as defined in rule 5160-1-17 of the Administrative Code. (2) "Family connects" is an evidence-based home visiting model that provides treatment, education, home visits, and training to a postpartum individual to facilitate better birth outcomes and to improve child health and development. family connects comprises of the follo...

... Administrative Code. (B) Eligible ASC providers. (1) All ASCs that have a valid agreement with the centers for medicare and medicaid services (CMS) to provide services in the medicare program are eligible to become medicaid providers upon execution of the "Ohio Medicaid Provider Agreement." (2) ASC providers bill in accordance with rule 5160-1-19 of the Administrative Code. The department will rei...

... Administrative Code. (B) Eligible ASC providers. (1) All ASCs that have a valid agreement with the centers for medicare and medicaid services (CMS) to provide services in the medicare program are eligible to become medicaid providers upon execution of the "Ohio Medicaid Provider Agreement." (2) ASC providers bill in accordance with rule 5160-1-19 of the Administrative Code. ODM will reimburse an A...

... compared to an average case. (B) ASC providers will bill in accordance with rule 5160-1-19 of the Administrative Code. ODM will reimburse an ASC for properly submitted claims for facility services furnished in connection with covered surgical procedures when the services are provided by an eligible ASC provider to an eligible medicaid recipient. Reimbursement for covered ASC facility services will be paid in accor...

...ministrative Code: (A) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost ...

...has, the existence of conflicts between provider networks, or access requirements. When this occurs, the effective date of termination of MCO enrollment shall be determined by ODM but in no event shall the termination date be later than the last day of the month in which ODM approves the termination. (6) The member is not eligible for MCO enrollment for one of the reasons set forth in rule 5160-2...

...edicaid from an MCO or SPBM network provider, the MCO or SPBM must adequately and timely cover the services out of network, until the MCO or SPBM is able to provide the services from a network provider. (C) The MCO and SPBM may place appropriate limits on a service: (1) On the basis of medical necessity for the member's condition or diagnosis; or (2) For the purposes of utilization control,...

...sure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member's needs. (1) The MCO must ensure PCPs are in compliance with the following triage requirements: (a) Members with emergency care needs must be triaged and treated immediately on presentation at the PCP site; (b) Members with persistent...

...t ensure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member's needs. (1) The MCO must ensure PCPs are in compliance with the following triage requirements: (a) Members with emergency care needs must be triaged and treated immediately on presentation at the PCP site; (b) Members with persistent symptoms must b...

...s not owned, leased, or controlled by a provider of any health-related treatment or support services; (2) Not be a foster child, as defined in Chapter 5101:2-1 of the Administrative Code; (3) Be under twenty-one years of age; (4) Have long-term services and supports (LTSS) needs resulting in the need for respite services as indicated by: (a) Skilled nursing or skilled rehabilitation services at le...

...(A) Provider contracts. (1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule and...

...(A) Provider contracts. (1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule, 42...