Ohio Administrative Code Search

... from billed charges from a health care provider. (B) Authority This rule is issued pursuant to the authority vested in the superintendent of insurance under section 3901.041 of the Revised Code, general rule making authority; and sections 3901.19 to 3901.22 of the Revised Code, the unfair and deceptive acts statute. (C) Definitions (1) "Discount" means any negotiated reduction or variation from the schedule of b...

...es its successors. (14) "Other provider" means a supplier of health care services or supplies not meeting the definition of health care practitioner or institutional care practitioner, including but not limited to a pharmacist, physician assistant, nurse aide, or supplier of durable medical equipment. (15) "Third-party payer" is as defined in section 3901.38 of the Revised Code. (D) Applica...

...clinical reviewer(s) or health care provider(s) do not have any prohibited affiliations as outlined in divisions (B) and (C)(1) of section 3922.14 of the Revised Code; (g) A description of the procedures to ensure that no conflict of interest exists in accordance with paragraph (G) of this rule; (h) A description of the quality assurance program as outlined in section 3922.14 of the Revised Code and...

...nt-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans; (b) Medical savings account plans coupled with a contribution into a "Medicare Advantage" medical savings account; and (c) "Medicare Advantage" private fee-for-service plans. (13) "Medicare supplement policy" means a group or individual policy of sickness and accident insurance o...

...nt-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans; (b) Medical savings account plans coupled with a contribution into a "Medicare Advantage" medical savings account; and (c) "Medicare Advantage" private fee-for-service plans. (13) "Medicare supplement policy" means a group or individual policy of sickness and accident insurance o...

...amples include, but are not limited to, provider selection or referral, preadmission certification, length of stay determination and second surgical opinions. (3) "Day" means calendar day. However, when the last day of a time limit stated in this rule falls on a Saturday, Sunday or state or federal holiday, the time limit is extended to the next immediate following day that is not a Saturday, Sun...

...amples include, but are not limited to, provider selection or referral, preadmission certification, length of stay determination and second surgical opinions. (3) "Day" means calendar day. However, when the last day of a time limit stated in this rule falls on a Saturday, Sunday or state or federal holiday, the time limit is extended to the next immediate following day that is not a Saturday, Sun...

...ations or restrictions on access to providers/facilities to enrollees and to potential enrollees prior to enrollment in a particular health plan. (B) Authority This rule is promulgated pursuant to the authority vested in the superintendent under section 3901.041 of the Revised Code, general rule making authority; and section 3901.21 of the Revised Code, the unfair and deceptive acts statute. (C...

... are provided by an out-of- network provider when either of the following conditions applies: (a) The covered person did not have the ability to request such services from an in-network provider. Clinical laboratory services provided by an out-of-network provider, but that are ordered by an in-network provider, shall be considered to have met the condition prescribed in paragraph (E)(7)(a) of ...

...tial licensure as a viatical settlement provider in this state or renewal of a previously-issued license. This rule also provides form filing requirements and fees for licenses, renewals, and form approvals. (B) Authority This rule is promulgated under the authority granted the superintendent of insurance pursuant to sections 3901.011, 3901.041, 3901.19 to 3901.26, 3916.05, and 3916.20 of the Revised Code. (C) Ap...

...rds and procedures and fees for VSE providers, VSE courses and licensed viatical settlement brokers pursuant to Chapter 3916. of the Revised Code. (B) Authority This rule is issued pursuant to the authority vested in the superintendent under sections 3901.011, 3901.041, 3901.19 to 3901.26, 3916.03, and 3916.20 of the Revised Code. (C) Application and scope This rule applies to all persons applying...

...nanced projects, the issuer of bonds or provider of other similar financing shall arrange for the appointment of a prevailing wage coordinator, except where the identity of said coordinator is provided by law. (D) In the event that the public authority does not appoint a prevailing wage coordinator, commerce may appoint a coordinator. The public authority shall reimburse commerce for the cost of such prevailing wage...

...rom the beginning of the unit; (d) The provider utilizes procedures that provide reasonable assurance of participant identity and that the participant receiving the continuing education credit for completing the course actually performed all of the work required to complete the course; and (e) The provider utilizes a clock or timer on each screen that accurately records the course completion ...

...the beginning of the unit; (c) The provider utilizes procedures that provide reasonable assurance of participant identity and that the participant receiving the continuing education credit for completing the course actually performed all of the work required to complete the course; and (d) The provider utilizes a clock or timer on each screen that accurately records the course completion time to...

...eted by the employee, employer, medical provider, or other interested party. If someone other than the employee submits a FROI-1 or equivalent, the bureau may contact the employee to attempt to verify that the employee wishes to pursue the application. To accept or deny the validity of the claim, the employer may complete and sign the form at the designated point or may use a separate writing, tel...

...eted by the employee, employer, medical provider, or other interested party. If someone other than the employee submits a FROI-1 or equivalent, the bureau may contact the employee to attempt to verify that the employee wishes to pursue the application. To accept or deny the validity of the claim, the employer may complete and sign the form at the designated point or may use a separate writing, tel...

...ut is not required to, negotiate with a provider to accept fee bills from the provider for a time period other than as set forth in paragraph (A) of this rule. (C) Paragraph (A) of this rule shall not apply to the following: (1) Requests made by the centers for medicare and medicaid services in the United States department of health and human services for reimbursement of conditional payments made pursuant to secti...

...s not required to, negotiate with a provider to accept fee bills from the provider for a time period other than as set forth in paragraph (A) of this rule. (C) Paragraph (A) of this rule shall not apply to the following: (1) Requests made by the centers for medicare and medicaid services in the United States department of health and human services for reimbursement of conditional payments ma...

...he payment from the claimant or the provider.

...lowed condition. (B) "Bureau certified provider" means: A provider who is approved by the bureau for participation in the health partnership program (HPP) pursuant to this chapter of Administrative Code. (C) "Certification" or "recertification" means: A process by which the bureau approves a provider or managed care organization (MCO) for participation in the HPP. (D) "Credentialing" or "...

...e bureau is authorized to certify a provider who wishes to participate in the HPP. The bureau is authorized to recertify a provider at least every one to three years. The bureau may, but is not required to, recertify providers on a staggered basis, in order of the provider's initial certification date or such other criteria as the bureau determines appropriate. (B) A provider shall be certified o...

...au shall establish minimum criteria for provider certification. Providers must meet all licensing, certification, or accreditation requirements necessary to provide services in Ohio. A provider licensed, certified or accredited pursuant to the equivalent law of another state shall qualify as a provider under this rule in that state. However, a provider will be ineligible to participate in the heal...

...bureau shall make available to each provider a provider certification application and agreement or recertification application and agreement, as applicable, which shall require the provider to furnish documentation as provided in rule 4123-6-02.2 of the Administrative Code. (B) The provider application and agreement or recertification application and agreement shall require the provider to ma...

...tification process by sending certified providers notice and a recertification application and agreement, which must be completed, signed and submitted to the bureau if the provider wishes to be considered for recertification. (B) Except as otherwise provided in paragraph (E) of this rule, if the bureau receives a completed and signed recertification application and agreement from a provider, the...

...(A) A provider not certified or recertified shall cure any defects in the provider application and agreement or recertification application and agreement within thirty days of notice by the bureau. (B) The administrator of the bureau of workers' compensation, pursuant to rule 4123-6-17 of the Administrative Code, may refuse to certify or recertify or may decertify a provider where the provider ha...