Ohio Administrative Code Search

...(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...

...(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...