Ohio Administrative Code Search

...en information to their contracting providers: (1) The MCE's grievance, appeal and state fair hearing procedures and time frames, including: (a) The member's right to file grievances and appeals and the requirements and time frames for filing; (b) The MCE's toll-free telephone number to file oral grievances and appeals; (c) The member's right to a state fair hearing, the requirements and t...

...te and abuse as required in the MCE provider agreement or contract with the Ohio department of medicaid (ODM) located at http://medicaid.ohio.gov/. (1) These arrangements or procedures must be made available to ODM upon request. (2) The MCE must annually submit to ODM a report that summarizes the MCE's fraud, waste, and abuse activities for the previous year and identifies any proposed changes t...

...rovide pursuant to the terms of the MCE provider agreement or contract, as applicable, with the Ohio department of medicaid (ODM). (2) Be treated with respect and with due consideration for their dignity and privacy. (3) Be ensured of confidential handling of information concerning their diagnoses, treatments, prognoses, and medical and social history. (4) Be provided information about thei...

...ember's authorized representative, or a provider may file an appeal orally or in writing within sixty calendar days from the date that the NOA was issued. An oral appeal filing must be followed with a written appeal. The MCO or SPBM shall: (a) Immediately convert an oral appeal filing to a written appeal on behalf of the member; and (b) Consider the date of the oral appeal filing as the filing d...

...ry against any TPP for costs due to provider fraud, waste, or abuse as defined in rule 5160-26-01 of the Administrative Code related to each member during periods of enrollment in the MCO. In instances when the MCO fails to properly report suspected fraud, waste, or abuse, before the suspected fraud, waste, or abuse is identified by the state of Ohio, any portion of the fraud, waste, or abuse reco...

...covery against any TPP for costs due to provider fraud, waste, or abuse as defined in rule 5160-26-01 of the Administrative Code related to each member during periods of enrollment in the MCE. In instances when the MCE fails to properly report suspected fraud, waste, or abuse, before the suspected fraud, waste, or abuse is identified by the state of Ohio, any portion of the fraud, waste, or abuse ...

... the Administrative Code, or the MCO provider agreement, ODM will provide timely written notification to the MCO identifying the violations or deficiencies, and may impose corrective actions or any of the following sanctions in addition to or instead of any actions or sanctions specified in the provider agreement: (1) ODM may require corrective action plans (CAPs) in accordance with the follow...

...(A) Non-contracting providers of emergency services must accept as payment in full from a managed care organization (MCO) the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of...

... (October 1, 2021); (4) Specify in provider contracts governed by rule 5160-26-05 of the Administrative Code the circumstances under which member co-payment amounts can be requested. If the MCO or SPBM implements a co-payment program, no provider can waive a member's obligation to pay the provider a co-payment except as described in paragraph (I) of this rule; (5) Ensure that the member ...

...BM), ODM or its designees will accept provider claim submissions for pharmaceuticals through ODM's managed care entities (MCEs) in the following manner: (A) Claims for pharmaceuticals that are dispensed by pharmacy providers are billed through ODM's SPBM. (B) For all other provider types, claims for pharmaceuticals are billed through an MCO, or in accordance with rule 5160-59-03 of the Administ...

...(A) An "eligible behavioral health provider" for purposes of this chapter is a provider of a mental health or substance use disorder treatment service covered in agency 5160 of the Administrative Code and is one of the following: (1) An entity operating in accordance with section 5119.36 of the Revised Code and Chapters 5122-24 to 5122-29 and Chapter 5160-1 of the Administrative Code and providin...

... this chapter, an "eligible billing provider" is an entity that meets the conditions in paragraph (A)(1) or (A)(2) of this rule. An "eligible rendering provider" is an individual who meets one or more of the conditions stated in paragraphs (A)(3) to (A)(8) of this rule and is employed by or under contract with an eligible billing provider. (1) An entity certified by the Ohio department of me...

...aid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified. (1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illness or substance use disorder. The list of recognized diagnoses can be accessed at www.medicaid...

...aid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified. (1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illness or substance use disorder. The list of recognized diagnoses can be accessed at www.medicaid...

... Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services will abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code. (C) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, ...

... Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services shall abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code. (C) Records related to services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456....

... Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services shall abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code. (C) Records related to services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456....

... the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services will abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code. (C) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, medicaid reimburs...

... Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) With the exception of pharmacists as described in paragraph (A)(7) of rule 5160-27-01 of the Administrative Code, medicaid reimbursement rates for services and practitioners described in Chapter 5160-27 of the Administrative Code are listed in the appendix to this rule. Ohio medicaid ...

...ecipient. (C) The ACT team is the sole provider to ACT recipients of outpatient behavioral health services, including level one outpatient services as defined by the American society of addiction medicine. (D) ACT services include but are not limited to the following: (1) Psychiatry and primary care as related to the mental health or substance use disorder diagnoses; (2) Service coordinati...

... made on the same day with the same provider for the same individual. (4) Other behavioral health individual services may be reimbursed on the same day as therapeutic behavioral group service-hourly and therapeutic behavioral group service per diem. (5) A medicaid recipient can receive one therapeutic behavioral group service per diem service per day. Prior authorization may be approved for a di...

...on the same day by the same billing provider for the same individual. (4) A medicaid recipient can receive one therapeutic behavioral group service per diem service per day per provider. Reimbursement of therapeutic behavioral group service per diem and therapeutic behavioral service hourly by more than one billing provider to the same individual on the same day is allowable with prior authorizat...

...n medicine. Medicaid will reimburse providers of these services outside the per diem rate paid to residential treatment programs. All treatment services, regardless of whether they are rendered by the residential treatment program or unaffiliated billing practitioners or agencies must be documented in the client's treatment plan maintained by the residential treatment provider. (D) The entity pr...

... the Administrative Code. (B) Eligible providers. (1) Providers certified by OhioMHAS in accordance with rule 5122-29-14 of the Administrative Code are eligible for MRSS reimbursement. (2) Services rendered by MRSS team staff described in rule 5122-29-14 of the Administrative Code that are eligible providers of behavioral health services in accordance with rule 5160-27-01 of the Administrative ...

... the Administrative Code. (B) Eligible providers. (1) Providers eligible to provide MRSS in accordance with rule 5122-29-14 of the Administrative Code and designated by OhioMHAS as regional MRSS providers are eligible for MRSS reimbursement. (2) Eligible rendering providers are MRSS team staff described in rule 5122-29-14 of the Administrative Code that are eligible providers of behavioral heal...