Ohio Administrative Code Search

...le to this rule. (1) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (2) "Lactation consultation" is the development and implementation of management strategies for complex problems related to breastfeeding and human lactation. (3) "International Board-Certified Lactation Consultant (IBCLC)" is a professional member of the healthcare team wh...

...of the Revised Code. (2) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (B) Providers. (1) Rendering provider. The following eligible providers may render a covered acupuncture service: (a) An acupuncturist recognized under section 4762.02 of the Revised Code; or (b) An individual practitioner, other than an acupuncturist, who may render acupunct...

...1 of the Administrative Code. (B) Providers. An individual pharmacist may enroll in medicaid as a pharmacist provider. (C) Coverage. (1) Payment may be made only for a pharmacist service for which the following criteria are met: (a) The service is within a pharmacist's scope of practice; (b) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;...

...individual with diabetes by a qualified provider for the purpose of providing the individual with necessary skills and knowledge to participate in the management of the individual's diabetes, including the self-administration of injectable drugs. (2) "National Diabetes Prevention Program" (NDPP) is an evidence-based, educational and support program administered by the centers for disease control ...

...(A) Provider types eligible for payment for pharmacy services: (1) A "pharmacy provider" designation and provider number can be obtained by a "terminal distributor of dangerous drugs," as defined in section 4729.01 of the Revised Code, who also: (a) Has a valid drug enforcement agency (DEA) registration; and (b) Has a pharmacist as the "responsible person," as defined in rule 4729-5-11 of the Administrative Code;...

...medicaid (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 e.g., Ohio average acquisition cost (OAAC), and published compendia prices, e.g., wholesale acq...

...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...