Ohio Administrative Code Search

...(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...

...(A) For purposes of this rule, the following definitions apply: (1) "Abuse" has the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1, 2023). (2) "Fraud" has the same meaning as in 42 C.F.R. 455.2 (as in effect on October 1, 2023). (3) "Waste" means any preventable act such as inappropriate utilization of services or misuse of resources that results in unnecessary expenditu...

...(A) "Safeguarded information" includes but is not limited to the following types of information: (1) Names and addresses; and (2) Social security numbers; and (3) Medical services provided; and (4) Social and economic conditions or circumstances; and (5) Agency evaluation of personal information; and (6) Medical data, including diagnosis and past history of disease or disability; and (7) Any information receiv...

...(A) "Safeguarded information" includes but is not limited to the following types of information about individual medicaid applicants, enrollees, or former recipients: (1) Names and addresses; (2) Social security numbers; (3) Medical services provided; (4) Social and economic conditions or circumstances; (5) Agency evaluation of personal information; (6) Medical data, including d...

...(A) In accordance with section 3798.10 of the Revised Code, a standardized authorization form that meets all requirements specified in 45 C.F.R. 164.508 and, where applicable, 42 C.F.R Part 2 as in effect on October 1, 2018, for the use and disclosure of protected health information is found in appendix A to this rule. (B) If the standardized authorization form is properly executed, and adequatel...

...(A) Designation of an authorized representative. (1) ) An individual may designate any person or organization to serve as that individual's authorized representative. Any person serving as an authorized representative must be at least eighteen years or older. (2) Authority for a person or organization to act on behalf of the individual accorded under state law, including but not limited to, a court order establishi...

...(A) Home care service providers, as defined in this paragraph, must have a system as follows. (1) Definitions. (a) "Home care dependent adult" means a consumer who: (i) Resides in a private home or other non-institutional, unlicensed living arrangement without a parent or guardian present; (ii) Requires, due to health and safety needs, regularly scheduled home care services to remain in the home or other living a...

...In accordance with the federal credentialing standards found in 42 CFR 422.204, "provider selection and credentialing" (as in effect on October 1, 2021), this rule details the credentialing and recredentialing process for medicaid providers. (A) For purposes of this rule, the following definitions apply. (1) "Council for affordable quality healthcare (CAQH)" is a non-profit organization which created ...

...(A) The Ohio department of medicaid (ODM) authorizes eligible provider delegates to perform credentialing activities on behalf of individual providers in accordance with rule 5160-1-42 of the Administrative Code. (B) "Delegate" and "Delegation" have the same meaning as in rule 5160-1-42 of the Administrative Code. (C) Entities seeking delegation will be expected to meet the following criteri...

...(A) The medicaid payment for a covered procedure, service, or supply constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ...

...(A) The medicaid payment for a covered procedure, service, or supply constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ...

...(A) The medicaid payment for a covered procedure, service, or supply constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ...

...(A) The medicaid payment for a covered procedure, service, or supply constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ...

...(A) The medicaid payment for a covered procedure, service, or supply constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's submitted charge. A provider may not collect from a medicaid recipient nor bill a medicaid recipient for any difference between the medicaid payment and the provider's submitted charge, nor may a provider ...

...(A) For purposes of this rule only: (1) "Medicaid covered service" is defined as a service that is eligible for coverage by the Ohio medicaid program and is delivered by a medical provider that qualifies for a medicaid provider agreement. (2) "Applicant for reimbursement" is defined as: (a) An individual who has been erroneously determined ineligible for the medicaid program or whose determination was incorrectly ...

...(A) For purposes of this rule: (1) "Applicant for reimbursement" is: (a) An individual who has been determined eligible for a retroactive eligibility period in accordance with rule 5160:1-2-01 of the Administrative Code, and who is seeking reimbursement for medical expenses for which the individual paid for during this approved time period; or (b) An individual who, as a result of an eligibili...

...(A) For the purpose of this rule, the following definitions apply. (1) "Attributed individual" is the Ohio medicaid covered individual for whom a qualified behavioral health entity eligible under this rule has accountability for providing behavioral health care coordination. (2) "Attribution" is the process through which medicaid covered individuals are assigned to a specific qualified behaviora...

...(A) Definitions. (1) "Practitioner," for purposes of this rule, is a collective term for the following professionals: (a) Doctor of medicine or osteopathy; (b) Advanced practice registered nurse; (c) Dentist; (d) Optometrist; (e) Podiatrist; or (f) Chiropractor. (2) "Regular practitioner" is a practitioner enrolled in the Ohio medicaid program who regularly takes care of an individual's health ...

...(A) Definitions. (1) "Practitioner," for purposes of this rule, is a collective term for the following professionals: (a) Doctor of medicine or osteopathy; (b) Advanced practice registered nurse; (c) Dentist; (d) Optometrist; (e) Podiatrist; or (f) Chiropractor. (2) "Regular practitioner" is a practitioner enrolled in the Ohio medicaid program who regularly takes care of an individual's health car...

...The department of medicaid (ODM) will make relief payments available to Ohio medicaid hospitals defined in paragraph (A) of this rule, as authorized under Section 270.15 of Amended Substitute House Bill 45 of the 134th General Assembly: (A) ODM will make available a one-time lump sum payment to the following hospital types: (1) "Critical access hospitals," as defined in rule 5160-2-05 of the Administ...

...(A) The Ohio department of medicaid (ODM) will deposit a portion of the intergovernmental transfers (IGT) that are paid under any state directed payment (SDP) program as authorized under 42 CFR 438.6(c) effective as of July 9, 2024. (B) On or after the effective date of this rule and for each year thereafter: (1) Pursuant to paragraph (A) of this rule, each provider eligible to receive a direc...

...(A) All hospitals, except those excluded in paragraphs (A)(1) and (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R 482 effective as of October 1, 2016, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet the requirements fo...

...(A) All hospitals, except those excluded in paragraphs (A)(1) and (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R 482 effective as of October 1, 2022, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet...

...(A) This rule provides information about the general provisions for covering hospital services. (B) The following words and terms, when used in this chapter have the following meanings, unless the context clearly indicates otherwise: (1) "Inpatient" - A patient who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyond midnight of the day of admi...

...For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise: (A) "Diagnosis related groups (DRGs)" - a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting. The groupings used to assign cases to a DRG for claims ...