Ohio Administrative Code Search

...(A) For nursing facility services the nursing facility provides on or after January 1, 2012, "medicaid maximum allowable amount" means one hundred per cent of the nursing facility's medicaid rate on the date that the service was provided. (B) For qualified medicare beneficiaries (QMB) as defined in rule 5160:1-3-02.1 of the Administrative Code and medicaid consumers admitted to a nursing facility as a medicare part...

...(A) In accordance with section 5165.151 of the Revised Code, the Ohio department of medicaid (ODM) shall determine the initial rate for the fiscal year in which the NF begins participation in the medicaid program for a NF with a first date of licensure and subsequent certification on or after July 1, 2006, including a NF that replaces one or more existing facilities, or a NF with a first date of l...

...(A) The Ohio department of developmental disabilities (DODD), through an interagency agreement with the Ohio department of medicaid (ODM), administers the medicaid program for services provided by intermediate care facilities for individuals with intellectual disabilities (ICFs-IID) on a daily basis in accordance with section 5162.35 of the Revised Code. Pursuant to section 5162.021 of the Revised...

...(A) The Ohio department of developmental disabilities (DODD), through an interagency agreement with the Ohio department of medicaid (ODM), and with oversight by ODM, administers the medicaid program for services provided by intermediate care facilities for individuals with intellectual disabilities (ICFs-IID) in accordance with section 5162.35 of the Revised Code. Pursuant to section 5162.021 of t...

...This rule describes the methodology for calculating payment rates for state-operated intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) operated by the Ohio department of developmental disabilities (DODD) and is effective for periods on or after July 1, 2019. (A) Definitions. (1) "Ancillary care costs" are costs for services other than direct care, incurred by the ...

...This rule describes the methodology for calculating payment rates for state-operated intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) operated by the Ohio department of developmental disabilities (DODD) and is effective for periods on or after July 1, 2024. (A) Definitions. (1) "Ancillary care costs" are costs for services other than direct care, incurred by the state-operated ...

...(A) Payment may be made for a covered service rendered by a physician only if the following conditions are met: (1) The physician is currently enrolled as an Ohio medicaid provider; (2) The service is rendered to a medicaid-eligible Ohio recipient in a state in which the physician is licensed or authorized to practice; and (3) The service is within the scope of practice of the physician's specialty. (B) Separate ...

...(A) Separate payment may be made for covered professional services rendered by a physician employed by or under contract with a facility such as a hospital or long-term care facility (i.e., a "facility-based" physician) only if the following conditions are met: (1) The services contribute directly to the diagnosis or treatment of an individual patient; (2) Any applicable requirements set...

...(A) Definitions that apply to this rule. (1) "Independent practitioner" is a practitioner who, under Ohio law, may provide healthcare services without supervision. (2) "Non-independent practitioner" is a practitioner who, under Ohio law, may provide healthcare services only with supervision. (3) "Supervision" is a collective term encompassing two types of professional oversight: (a) A prac...

...(A) The provisions set forth in paragraph (B) of rule 5160-4-02 of the Administrative Code do not apply when both of the following criteria are met: (1) A healthcare service is provided by a resident participating in an approved graduate medical education (GME) program; and (2) The conditions specified in 42 C.F.R. 415.174 (October 1, 2020) are satisfied. (B) No separate payment will be made fo...

...(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site in which the services are provided. (1) Ambulance. Policies for E&M services provided during ambulance transport by hospital staff members are set forth in rule 5160-2-04 of the Administrative Code. Payment for E&M services provided during ambulance transport by practitione...

...(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site in which the services are provided. (1) Ambulance. Policies for E&M services provided during ambulance transport by hospital staff members are set forth in rule 5160-2-04 of the Administrative Code. Payment for E&M services provided during ambulance transport by practitione...

...(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site in which the services are provided. (1) Ambulance. Policies for E&M services provided during ambulance transport by hospital staff members are set forth in rule 5160-2-04 of the Administrative Code. Payment for E&M services provided during ambulance transport by practitione...

...(A) General provisions. (1) "Current procedural terminology (CPT)" is a comprehensive listing of medical terms and codes published by the American medical association, www.ama-assn.org, for the uniform designation of diagnostic and therapeutic procedures in surgery, medicine, and the medical specialties. "Healthcare common procedure coding system (HCPCS)" is a numeric and alphanumeric code set ma...

...(A) General provisions. (1) A "not otherwise specified," "unlisted," or "miscellaneous" procedure code should be reported on a claim only if no procedure code is available that identifies the particular service or item provided. (2) No separate payment is made for an immunization, injection, infusion, vaccine, toxoid, or provider-administered pharmaceutical as a medical service if it is provide...

...(A) Chemotherapy has two components: administration of a chemotherapeutic agent and the chemotherapeutic agent itself. The administration of chemotherapy includes the preparation of the chemotherapeutic agent and all therapeutic services and medical supplies provided during treatment. (B) Coverage. (1) Chemotherapy provided in a hospital setting (inpatient hospital, outpatient hospital, emergenc...

...(A) Coverage. (1) In general, payment may be made to an eligible provider for performing a medically necessary surgical procedure on an eligible recipient. The following limitations, however, apply. (a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and postoperative care, or any proced...

...(A) Coverage. (1) In general, payment may be made to an eligible provider for performing a medically necessary surgical procedure on a medicaid-eligible individual. The following limitations, however, apply. (a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and post...

...(A) Payment may be made to an ambulatory surgery center (ASC) in the form of a facility fee only for covered ASC surgical procedures, which are procedures that meet the standards set forth in 42 CFR 416.166 (October 1, 2017). Such procedures are listed on the department's website http://www.medicaid.ohio.gov/provider/feeschedulesandrates. (B) Payment may be made to a physician for performing ...

...(A) Payment may be made to an ambulatory surgery center (ASC) in the form of a facility fee only for covered ASC surgical procedures, which are procedures that meet the standards set forth in 42 CFR 416.166 (October 1, 2017). Such procedures are listed on the department's website https://medicaid.ohio.gov/resources-for-providers/billing/fee-schedule-and-rates/fee-schedule-and-rates. (B) Payment m...

...(A) Coverage. (1) Total (global) procedure. Payment may be made to a practitioner for performing both the professional and technical components of a radiology or imaging procedure if two conditions are met: (a) The technical component was not performed in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or a hospital emergency department); and (b) The practitioner who submitted the claim ei...

...(A) Coverage. (1) Total (global) procedure. Payment may be made to a practitioner for performing both the professional and technical components of a radiology or imaging procedure if two conditions are met: (a) The technical component was not performed in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or a hospital emergency department); and (b) The practitioner who su...

...(A) This rule sets forth provisions governing payment for professional, non-institutional dental services. Provisions governing payment for dental services performed as the following service types are set forth in the indicated part of the Administrative Code: (1) Hospital services, Chapter 5160-2; (2) Nursing facility services, Chapter 5160-3; (3) Intermediate care facility services, C...

...(A) This rule sets forth provisions governing payment for professional, non-institutional dental services. Provisions governing payment for dental services performed as the following service types are set forth in : (1) Hospital services, Chapter 5160-2 of the Administrative Code; (2) Nursing facility services, Chapter 5160-3 of the Administrative Code; (3) Intermediate care facility servic...

...(A) This rule sets forth provisions governing payment for professional, non-institutional dental services. Provisions governing payment for dental services performed as the following service types are set forth in the indicated part of the Administrative Code: (1) Hospital services, Chapter 5160-2; (2) Nursing facility services, Chapter 5160-3; (3) Intermediate care facility services, C...