Ohio Administrative Code Search

...(A) The Ohio department of aging (ODA) is responsible for the daily administration of the assisted living HCBS waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM), in accordance with section 5162.35 of the Revised Code. (B) The assisted living HCBS waiver is an alternative to nursing facility placement for persons age twenty-one ...

...(A) Definitions. (1) "Coordination of benefits" (COB) means the process of determining which health plan or insurance policy will pay first or determining the payment obligations of each health plan, medical insurance policy, or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits for a medicaid covered individual. (2) "Coordinat...

...This rule sets forth requirements regarding co-payments by individuals for medicaid-covered services. (A) Certain medicaid services are subject to individual co-payments. Information regarding these services and co-payment amounts can be found in the following Administrative Code rules: (1) Co-payments for dental services are described in rule 5160-5-01 of the Administrative Code. (2) Co-payments for vision servic...

...(A) Out-of-state providers: (1) Should be licensed, accredited, or certified by their respective states to be considered eligible to receive reimbursement for services provided to Ohio medicaid covered individuals. (2) Should meet any standards applicable to the provision of the service in the state in which the service is being furnished, as well as those standards set forth in the Ohio med...

...(A) In accordance with 42 C.F.R. 447.15 (as in effect October 1, 2018), the medicaid payment for a covered service constitutes payment-in-full. It shall not be construed as a partial payment even when the payment amount is less than the provider's charge. (1) The provider shall not collect nor bill a medicaid recipient for any difference between the medicaid payment and the provider's charge,...

...(A) Definitions. (1) "Healthchek" is Ohio's early and periodic screening, diagnostic, and treatment (EPSDT) benefit for all medicaid recipients younger than twenty-one years of age, described in 42 U.S.C. 1396d(r) (as in effect 10/2017). (2) "Bright futures guidelines" are the American academy of pediatrics bright futures guidelines for preventive health care (rev. 2/2017), available at http://w...

...This rule sets forth eligibility requirements for practitioners, group practices, or organizational providers enrolling with, and seeking reimbursement from, the Ohio medicaid program. (A) Eligible provider means any practitioner, group practice, or organization identified by the Ohio department of medicaid (ODM) as a type of provider eligible to enroll in the medicaid program that: (1) Meets the ap...

...Provisions of provider agreements for long term care nursing facilities are defined in Chapter 5160-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5160-26 of the Administrative Code. A valid provider agreement with medicaid will act as a provider agreement for participation in the medicaid program. All medicaid provider ap...

...(A) For the purposes of this rule, the following definitions apply: (1) "Affiliation" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (2) "Agent" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (3) "Disclosable event" has the same meaning as in 42 C.F.R. 455.101 (as in effect on October 1, 2023). (4) "Disclosing provider" ...

...(A) Revalidation is the process that a provider is required to follow to renew and revalidate its provider agreement. Provider agreements must be revalidated no later than five years from the effective date of the original or the last revalidated provider agreement, whichever is applicable. In the event the center for medicare and medicaid services (CMS) waives or modifies the deadline, provider a...

...(A) For purposes of this rule, the following definitions apply: (1) "Ownership or control interest" means having at least five per cent ownership, or interest, either directly, indirectly, or in any combination. (2) "Provider" has the same meaning as "eligible provider," as defined in rule 5160-1-17 of the Administrative Code. (3) "Provider Agreement" means an agreement as defined in rule 5160-1-17.2 of the Admin...

...(A) An individual or entity that at one time was a participating provider in the Ohio medicaid program and whose provider agreement was terminated either voluntarily or involuntarily in accordance with rule 5160-1-17.6 of the Administrative Code must complete a new application for enrollment if that individual or entity wants to resume participation in the Ohio medicaid program. (B) In considering an application fo...

...(A) In accordance with 42 C.F.R. 455.410 (as in effect October 1, 2019) and rule 5160-1-17 of the Administrative Code in order to become an eligible provider, a provider must meet the screening requirements described in this rule and in section 5164.34 of the Revised Code and pay an applicable application fee if required in the appendix to this rule. Provider screening and application fees are req...

...(A) Definitions for purposes of this rule only: (1) A "participating provider" is an active provider who bills the medicaid program for rendered services, or who is an active provider who orders, prescribes, refers, or certifies but does not bill the medicaid program. (2) An "ordering or referring only provider" is a provider who orders, prescribes, refers, or certifies an item or service reported on a claim, and i...

...The Ohio department of medicaid (ODM) authorizes qualified entities (QEs) to determine presumptive eligibility (PE) based on self-attested information to grant immediate medicaid coverage to certain individuals seeking medicaid covered services. This rule sets forth eligibility requirements and responsibilities to maintain designation as a QE. (A) For the purposes of this rule, "qualified entity" has the...

...(A) For the purposes of this rule, the following definitions apply: (1) "Patient site" is the physical location of the patient at the time a health care service is provided through the use of telehealth. (2) "Practitioner site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth. (3) "Telehealth" is the direct deliver...

...(A) For the purposes of this rule, the following definitions apply: (1) "Patient site" is the physical location of the patient at the time a health care service is provided through the use of telehealth. (2) "Practitioner site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth. (3) "Telehealth" is the direct deliver...

...(A) Unless otherwise directed by the Ohio department of medicaid (ODM), paper claims will not be accepted. Except as otherwise provided in section 5164.46 of the Revised Code or a state agency's interagency agreement, claims are to be submitted directly to ODM through one of the following formats: (1) Electronic data interchange (EDI), in accordance with rule 5160-1-20 of the Administrative C...

...(A) For purposes of this rule, the following definitions apply: (1) "Covered entity" has the same meaning as in 45 C.F.R. 160.103 (as in effect on October 1, 2021). (2) "Electronic data interchange (EDI) transactions" are transactions developed by standards development organizations recognized by the federal centers for medicare and medicaid services (CMS) and adopted by the Ohio department ...

...(A) For purposes of this rule, the following definitions apply: (1) "Covered entity," has the same meaning as in 45 C.F.R. 160.103 (as in effect on October 1, 2018). (2) "Electronic data interchange (EDI) transactions" are transactions developed by standards development organizations recognized by the federal centers for medicare and medicaid services (CMS) and adopted by the Ohio department...

...(A) Except for medicaid contracting managed care plans (MCPs), and nursing facilities and intermediate care facilities for individuals with intellectual disabilities (ICF/IID) rate recalculations performed in accordance with sections 5165.41 and 5124.41 of the Revised Code, any provider of services or goods contracting with the Ohio department of medicaid (ODM) pursuant to Title XIX of the Social Security Act who, ...

...(A) As specified in Chapter 5160-1 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, frequency, extent, duration, and delivery setting of services provided to medicaid recipients, and to document significant business transactions. Medic...

...(A) "Hold and Review" is defined in accordance with rule 5160-1-27 of the Administrative Code. (1) Hold and review without prior notification. (a) The Ohio department of medicaid (ODM) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons: (i) In response to allegations of fraud or other willful misrepresentation of ...

...(A) "Medicaid administrative agency" means a state agency other than the Ohio department of medicaid that: (1) Administers a component of the medicaid program under the terms of a contract with ODM under section 5162.35 of the Revised Code; and (2) Pays claims for medicaid services or reimburses local entities for claims paid for medicaid services. (B) "Hold and Review" is defined in accordance with rule 5160-1-2...

...(A) For purposes of this rule, the following definitions apply: (1) "Fraud" is defined as an intentional deception, false statement, or misrepresentation made by a person with the knowledge that the deception, false statement, or misrepresentation could result in some unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or sta...