Ohio Administrative Code Search

...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)" is 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 claim ...

...(A) Conditions and limitations applicable to both inpatient and outpatient hospital services. (1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code. (2) Inpatient or outpatient services related to the provision of the services descr...

...(A) Drugs. (1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis for use away from the hospital). (2) Administered inpatient drugs are considered inpatient services and are reimbursed as an inpatient se...

...(A) Drugs. (1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis for use away from the hospital). (2) Administered inpatient drugs are considered inpatient services and are reimburse...

...Effective for services or discharges on or after the effective date of this rule, hospitals shall be classified into mutually exclusive peer groups for purposes of setting rates and making payments under the "All Patient Refined-Diagnosis Related Group" (APR-DRG) inpatient prospective payment system, the "Enhanced Ambulatory Patient Grouping" (EAPG) outpatient prospective payment system or to those hospit...

...This rule describes how hospitals are classified into mutually exclusive peer groups for purposes of setting rates and making payments under the "All Patient Refined-Diagnosis Related Group" (APR-DRG) inpatient prospective payment system, the "Enhanced Ambulatory Patient Grouping" (EAPG) outpatient prospective payment system or to those hospitals excluded from the prospective payment systems. (A) Definitio...

...This rule sets forth the data used to determine assessments and adjustments, and the data policies that are applicable for each program year for all providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Disproportionate share hospital" means a hospital that meets the requirements for disproportionate share st...

...(A) Applicability. The requirements of this rule apply as long as the United States centers for medicare and medicaid services (CMS) determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department of medicaid is informed that the assessment is an impermissible health care-related tax, the department shall promptly ...

...This rule is applicable for each program year for all medicaid-participating providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code. (A) Definitions. (1) "Total fee for service (FFS) medicaid costs" for each hospital means the sum of inpatient program costs reported on ODM 02930, schedule H, section I, columns 1 and 3, line 1 ...

...This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code. (A) Definitions for each psychiatric hospital. (1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from ...

...This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code. (A) Definitions for each psychiatric hospital. (1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from ...

...(A) Appeals. Pursuant to Chapter 5160-70 of the Administrative Code, final settlements that are based upon final audits by the department may be appealed by hospitals under Chapter 119. of the Revised Code. Rule 5160-2-24 of the Administrative Code describes final fiscal audits and final settlements performed by the department. Rules 5160-1-27 and 5160-1-29 of the Administrative Code describe the audits performed b...

...(A) The Ohio department of medicaid (ODM) will perform or contract with a medical review entity to perform utilization review for medicaid inpatient services regardless of the payment methodology used for reimbursement of those services. For the purposes of this rule, "ODM" means ODM or its contracted medical review entity. During the course of its analyses, ODM may request information or records from the hospital an...

...This rule applies to all hospital services excluded from the inpatient hospital and outpatient hospital prospective payment systems. (A) Applicability. (1) Cost-related reimbursement, where payments are made for services to approximate cost based on a historical cost-to-charge ratio, and where no subsequent reconciliation occurs, applies to: (a) All outpatient hospital services provided by hospital...

...(A) For cost-reporting purposes, the medicaid program requires each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in para...

...(A) For cost-reporting purposes, each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, is to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (...

...(A) General provisions. (1) Audits will be conducted by the Ohio department of medicaid for services rendered by the hospital under the medicaid program. The examination of hospital costs and charges will be made in consideration with generally accepted auditing standards necessary to fulfill the scope of the audit. To facilitate this examination, providers are required to make available all records and source docum...

...(A) General provisions. (1) Audits will be conducted by the Ohio department of medicaid for services rendered by the hospital under the medicaid program. The examination of hospital costs and charges will be made in consideration with generally accepted auditing standards necessary to fulfill the scope of the audit. To facilitate this examination, providers will make available all records and sou...

...Rule 5160-1-08 of the Administrative Code sets forth general provisions regarding requirements that the department make payment for covered services only after any available third-party benefits are exhausted. In addition to those general provisions, this rule identifies other requirements applicable to services provided by hospitals. (A) All hospitals are to utilize third-party resources for all services a consumer...

...Rule 5160-1-08 of the Administrative Code sets forth general provisions that the department make payment for covered services only after any available third-party benefits are exhausted. In addition, this rule identifies other provisions applicable to services provided by hospitals. (A) All hospitals are to use third-party resources for all services a consumer receives while in the hospital. If a hos...

...This rule sets forth the assessment rate for the hospital franchise fee program implemented under sections 5168.20 to 5168.28 of the Revised Code. (A) Definitions For purposes of the hospital franchise fee program only, ''total facility costs'' are as defined in section 5168.20 of the Revised Code, and also exclude a hospital's costs associated with providing care to recipients of the medicare progr...

...This rule describes the pre-certification review program for inpatient services. Paragraph (C) of this rule is specific to the medical/surgical pre-certification program. Paragraph (D) of this rule is specific to the psychiatric pre-certification program. (A) Definitions. (1) An "emergency admission" is an admission to treat a condition requiring medical and/or surgical treatment within the next forty-eight hou...

...(A) Definitions. For purposes of this rule, the following definitions apply: (1) A "hospital" is a provider eligible under rule 5160-2-01 of the Administrative Code. (2) "Medical necessity" is as defined in rule 5160-1-01 of the Administrative Code. (3) "Pre-certification" is a process whereby the Ohio department of medicaid (ODM) or its contracted medical review entity assures that covered psychiatric services a...

...Effective for services or discharges on or after the effective date of this rule, payments made to Ohio hospitals under the prospective payment systems or non-diagnostic related groups (DRG) prospective payment system will receive a cost coverage add-on. The provisions of this rule do not apply to the medicaid maximum allowed amount calculation described in rule 5160-2-25 of the Administrative Code. (A) De...

...Effective for services or discharges on or after the effective date of this rule, payments made to Ohio hospitals under the prospective payment systems or non-diagnostic related groups (DRG) and non-ambulatory patient grouping (EAPG) prospective payment systems will receive a cost coverage add-on. The provisions of this rule do not apply to the medicaid maximum allowed amount calculation described in rule 5...