Ohio Administrative Code Search

...waiver services from any combination of providers on the provider panel of the MyCare Ohio plan selected by the member pursuant to paragraph (B) of rule 5160-58-04 of the Administrative Code. (B) A member receiving waiver services from any MyCare Ohio waiver provider will: (1) Participate with the waiver service coordinator in the development of the person-centered services plan as defined in r...

... services (HCBS) waiver program and the providers eligible to furnish those services to members enrolled in the MyCare Ohio waiver. (B) Providers seeking to furnish services in the MyCare Ohio waiver program shall meet the requirements in Chapter 173-39, 5160-45 or 5160-44 of the Administrative Code, as appropriate. Prior to furnishing services to MyCare Ohio waiver recipients, the services must be ...

... services (HCBS) waiver program and the providers eligible to furnish those services to members enrolled in the MyCare Ohio waiver. (B) Providers seeking to furnish services in the MyCare Ohio waiver program shall meet the requirements in Chapter 173-39, 5160-45 or 5160-44 of the Administrative Code, as appropriate. Prior to furnishing services to MyCare Ohio waiver recipients, the services must be ...

...or participant-directed waiver services provider pursuant to paragraph (G) of rule 5160-58-03.2 of the Administrative Code; (e) Failure to provide services in a timely manner as specified in rules 5160-26-03.1 and 5160-58-01.1 of the Administrative Code; (f) Failure to act within the resolution time frames specified in this rule; or (g) Denial of a member's request to dispute a financial liabil...

...ary. (d) For denial of a request for a provider pursuant to paragraph (A)(1)(d) of this rule, the MCOP shall give notice simultaneously with the MCOP's decision. (e) For untimely prior authorization, appeal, or grievance resolution, the MCOP shall give notice simultaneously with the MCOP becoming aware of the untimely resolution. Service authorization decisions not reached within the time frames...

...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 by a written appeal. An MCOP 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 date. (2) ...

...5(c) waiver services for a youth when a provider is unable to or unresponsive in providing scheduled services. A back-up plan can include natural supports or other certified providers as the substitute of coverage. The child and family team identifies possible back-up options and includes them in the child and family-centered care plan. (2) "Care coordination" means the model described in rule 51...

...s network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk; (d) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or (e) The youth cannot access medically necessary medicaid-covered services or cannot access ...

... network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk; (d) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or (e) The youth cannot access medically necessary medicaid-covered services or cannot access ...

... network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk; (d) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or (e) The youth cannot access medically necessary medicaid-covered services or cannot access ...

...s network, and the youth's primary care provider or another provider determines that receiving services separately would subject the youth to unnecessary risk; (c) The youth has experienced poor quality of care and the services are not available from another provider within the OhioRISE plan's network; or (d) The youth cannot access medically necessary medicaid-covered services or cannot access ...

...le through an OhioRISE plan network provider, the OhioRISE plan has to adequately and timely cover the services out of network, until the OhioRISE plan is able to provide the services from a network provider. (6) Providers delivering services in the OhioRISE program will adhere to the incident management criteria set forth in rule 5160-44-05 of the Administrative Code. (B) The OhioRISE plan has ...

...to both contracting and non-contracting providers; and (d) A description of how the OhioRISE plan will monitor the impact of the UM program to detect and correct potential under-and over-utilization. (3) The OhioRISE plan's UM program has to ensure and document the following: (a) An annual review and update of the UM program; (b) The involvement of a designated senior physician in the UM pr...

... (a) Maintain an active, valid medicaid provider agreement as defined and set forth in rule 5160-1-17.2 of the Administrative Code; (b) Comply with all applicable provider requirements set forth in this rule; (c) Participate in initial and ongoing training, coaching, and supports from an independent validation entity recognized by the Ohio department of medicaid (ODM) to ensure consistency in delivering care coordi...

... (a) Maintain an active, valid medicaid provider agreement as defined and set forth in rule 5160-1-17.2 of the Administrative Code; (b) Comply with all applicable provider requirements set forth in this rule; (c) Participate in initial and ongoing training, coaching, and supports from an independent validation entity recognized by the Ohio department of medicaid (ODM) to ensure consistency in de...

... the Administrative Code. (C) Eligible providers of IHBT services. (1) Providers eligible for medicaid payment for IHBT will: (a) Meet the criteria in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and (b) Provide the service in accordance with rule 5122-29-28 of the Administrative Code. (D) Coverage. (1) Payment may be made for IHBT services rendered face-to-face in person or via tel...

... the Administrative Code. (C) Eligible providers of IHBT services. (1) Providers eligible for medicaid payment for IHBT will: (a) Meet the criteria in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and (b) Provide the service in accordance with rule 5122-29-28 of the Administrative Code. (D) Coverage. (1) Payment may be made for IHBT services rendered face-to-face ...

... the Administrative Code. (C) Eligible providers of OhioRISE respite services. (1) Behavioral health respite services can be provided by the following individuals or organizations: (a) Behavioral health entities operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Rendering practitioners will meet the critera to be an eligible provider of behavioral health services...

... Administrative Code. (C) Eligible providers of OhioRISE respite services. (1) Behavioral health respite services can be provided by the following individuals or organizations: (a) Behavioral health entities operating in accordance with paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code. Rendering practitioners will meet the criteria to be an eligible provider of b...

...der the OhioRISE program. (C) Eligible providers and conditions of participation. (1) The provider of primary flex funds will be the FMS entity under contract with the OhioRISE plan to complete the purchase and reimbursement of primary flex funds approved by the OhioRISE plan. (2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, the provider will comply with conditions of par...

...der the OhioRISE program. (C) Eligible providers and conditions of participation. (1) The provider of primary flex funds will be the FMS entity under contract with the OhioRISE plan to complete the purchase and reimbursement of primary flex funds approved by the OhioRISE plan. (2) With the exception of paragraph (B)(14) of rule 5160-44-31 of the Administrative Code, the provider will compl...

... transition planning. (C) Eligible providers. (1) A "PRTF provider" for purposes of Chapter 5160-59 of the Administrative Code is an entity covered in agency 5160 of the Administrative Code that provides psychiatric services to individuals twenty years of age or younger in an inpatient setting; and (a) Meets the provisions in 42 CFR Part 441 Subpart D and 42 CFR Part 483 Subpart G (October ...

...titutional services; and (b) Choice of providers who meet provider qualifications as described in Chapter 5160-59 of the Administrative Code to provide services under the waiver. (7) Have needs that can be safely met in an HCBS setting through the waiver as determined by ODM or its designee. (8) Meet the following age criteria: (a) Be between the ages of birth and twenty years of age at the time of initial enroll...

...ed clinician that is the treating provider dated no more than two years prior to the date of application for the OhioRISE waiver, accompanied by the diagnostic assessment that resulted in the applicable SED diagnosis performed by a licensed clinician. (d) Have documented functional impairment and behaviors that substantially interfere with or limit the youth's role or functioning in ...

...licensed clinician that is the treating provider dated no more than two years prior to the date of application for the OhioRISE waiver, accompanied by the diagnostic assessment that resulted in the applicable SED diagnosis performed by a licensed clinician. (d) Have documented functional impairment and behaviors that substantially interfere with or limit the youth's role or functioning in family, school, or communi...