Ohio Administrative Code Search

...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...

...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...

...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...

...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...

...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...