Ohio Administrative Code Search

... (CARES) Act, S.3548 (2020), prior to a provider requesting reimbursement for a service. The plan of care has the same meaning as set forth in rule 5160-51-01 of the Administrative Code and is not the same as an all services plan, individual service plan, or helping Ohioans move expanding choice (HOME choice) service plan. (2) A "registered nurse (RN) assessment" is the medicaid service performed...

... (CARES) Act, S.3548 (2020), prior to a provider requesting reimbursement for a service. The plan of care has the same meaning as set forth in rule 5160-51-01 of the Administrative Code and is not the same as an all services plan, individual service plan, or helping Ohioans move expanding choice (HOME choice) service plan. (2) A "registered nurse (RN) assessment" is the medicaid service performed...

...tment of medicaid (ODM) as a clinic provider: (1) A dialysis center, defined as a "dialysis facility" in 42 C.F.R. 494.10 (October 1, 2022), that meets the following criteria: (a) It is recognized by medicare as a dialysis facility; (b) It operates in accordance with Chapter 3701-83 of the Administrative Code or, if it is located outside of Ohio, operates in accordance with its respective s...

...individual employed by a transportation provider, in addition to the minimum crew of a wheelchair van or a ground ambulance, who aids in the non-emergency transportation of medicaid-eligible individuals who need extra assistance. (4) "County department of job and family services (CDJFS)" is an entity established under section 329.01 of the Revised Code or a group of such entities acting together ...

...dicaid-eligible individuals to and from providers of covered healthcare services. ODM fulfills this obligation in large measure through three-way subgrant agreements with the Ohio department of job and family services (ODJFS) and with each county department of job and family services (CDJFS). This rule sets forth the responsibilities and expectations placed by ODM on each CDJFS in the administrati...

...(A) Definition. "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (B) Transportation-specific criteria. For each entity enrolled as an eligible provider of transportation services, the following conditions are met: (1) The entity, each crew member, and each attendant comply with all applicable local, state, and federal laws, regulations, and rules, inc...

...nditions: (i) The transportation provider is an eligible provider of both wheelchair van services and ground ambulance services; (ii) No wheelchair van is available for one of three reasons: (a) A wheelchair van was originally scheduled for the transport but has been rendered inoperative or unavoidably delayed, and the transportation provider cannot substitute another wheelchair...

...ible individual, and the transportation provider maintains documentation of such necessity. (C) A hospital that is an eligible provider may submit a claim for ground ambulance services on behalf of another entity if two conditions apply: (1) The other entity is an eligible provider of ground ambulance services; and (2) The hospital and the other entity have entered into an appropriate agreement...

... (C) A hospital that is an eligible provider may submit a claim for air ambulance services on behalf of another entity if two conditions apply: (1) The other entity is an eligible provider of air ambulance services; and (2) The hospital and the other entity have entered into an appropriate agreement or contract. (D) Separate payment may be made for critical care services, the provision of w...

...istrative Code. (2) Transportation providers may request manual review of claims for services involving non-exempted combinations of origins and destinations. Transportation providers may also request manual review of a claim for a service involving an origin or destination not listed in paragraph (A) of this rule if they indicate that fact explicitly on the claim. (3) A request for manual r...

...e individual but is not an eligible provider at the time of transport may submit a claim for that service in accordance with Chapter 5160-1 of the Administrative Code after it has become an eligible provider of transportation services. (D) Certain coverage limitations are based on the length of a transport. (1) Mileage payment for a non-emergency transport (either by wheelchair van or by ground ...

...n services furnished by an eligible provider that are automatically deemed to be necessary in accordance with rule 5160-15-22, 5160-15-23, or 5160-15-24 of the Administrative Code. A medicaid managed care organization (MCO) is not obliged to use the practitioner certification process described in paragraph (B) of this rule to certify the necessity of a transportation service furnished to a med...

...on service furnished by an eligible provider on a fee-for-service basis is the lesser of either the provider's submitted charge or the medicaid maximum payment amount for the date of transport. The medicaid maximum payment amounts for transportation services are listed in the appendix to this rule. (B) The amount of payment for a transportation service furnished by an eligible provider under an a...

...on service furnished by an eligible provider on a fee-for-service basis is the lesser of either the provider's submitted charge or the medicaid maximum payment amount for the date of transport. The medicaid maximum payment amounts for transportation services are listed in the appendix to this rule. (B) The amount of payment for a transportation service furnished by an eligible provider under an a...

...le to this rule. (1) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code. (2) "Ground ambulance transport" comprises the following service categories: (a) Basic life support, provided in an emergency (BLS emergency); (b) Basic life support, provided in a non-emergency (BLS non-emergency); (c) Advanced life support, level 1, provided in an emergency...

...33 of the Administrative Code. (B) Provider requirements. Payment may be made to a FBC only if it meets the following criteria: (1) It holds a current license to perform FBC services issued by the appropriate authority in the state in which it is located; (2) It is operated in conformity with rules 3701-83-33 to 3701-83-42 of the Administrative Code; and (3) It is neither a hospital registered...

...r-point injection), skin substitute, or provider-administered pharmaceutical rule 5160-4-12; (c) Applicable durable medical equipment, prostheses, orthoses, and medical supply items Chapter 5160-10; (d) Laboratory service rule 5160-11-11; or (e) Reproductive health service Chapter 5160-21, for which maximum payment amounts are published in appendix DD to rule 5160-1-60.

...le defines coverage and payment for providers who meet the provisions in sections 5103.60, 5103.602, 5103.603, 5103.6010, 5103.6011, 5103.6017 and 5103.6018 of the Revised Code and the provisions described in this rule. (B) Definitions. For the purpose of this rule the following definitions apply: (1) "Clinical Director" is a practitioner of physician services who supervises day-to-day clini...

...xt attribution period following the provider's reinstatement. The following hierarchy will be used in assigning recipients to PCPs under the PCMHCPC and PCMHCPC for kids program: (a) The recipient's choice of provider. (b) Claims data concerning the recipient. (c) Other data concerning the recipient. (2) "CPC attributed medicaid individuals" are Ohio medicaid recipients for whom PCPs h...

...e next attribution period following the provider's reinstatement. The following hierarchy will be used in assigning recipients to PCPs under the CPC and CPC for kids program: (a) The recipient's choice of provider. (b) Claims data concerning the recipient. (c) Other data concerning the recipient. (2) "Baseline year" is a twelve month calendar year, typically two years preceding the performance period ...

...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 Administr...

...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...

...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...