Ohio Administrative Code Search

...(A) The pharmacy claims submitted to the Ohio department of medicaid (ODM) or its designee, the pharmacy point-of-sale vendor, must reflect the actual national drug code (NDC) on the container from which the product was dispensed. (B) All records of prescriptions must comply with federal and state regulations and be retained by the provider for a period of six years from the date of payment of th...

...(A) Adults eligible for the medicaid program will pay a three dollar co-payment for prescribed drugs that require prior authorization and a two dollar co-payment for selected trade name prescribed drugs as indicated in the list specified in paragraph (C) of rule 5160-9-03 of the Administrative Code. (B) Rules 5160-1-09 and 5160-1-60 of the Administrative Code establish additional requirements regarding co-payments. ...

...(A) Adults eligible for the medicaid program will pay a three dollar co-payment for prescribed drugs that require prior authorization and a two dollar co-payment for selected trade name prescribed drugs as indicated in the list specified in paragraph (C) of rule 5160-9-03 of the Administrative Code. (B) Rules 5160-1-09 and 5160-1-60 of the Administrative Code establish additional requirements reg...

...(A) This rule sets forth general coverage and payment policies for durable medical equipment (DME), prostheses, orthotic devices, medical/surgical supplies, and supplier services. (1) Additional conditions specific to a particular DMEPOS item or service may be set forth in other rules in this chapter of the Administrative Code. (2) Policies set forth in other rules in this chapter supersede any ...

...(A) Scope. (1) This rule sets forth general coverage and payment policies for durable medical equipment (DME), prostheses, orthotic devices, medical supplies, and supplier services dispensed or rendered by an enrolled DMEPOS provider. (2) Additional conditions specific to a particular DMEPOS item or service may be set forth in other rules in this chapter of the Administrative Code. (3) Policies...

...(A) Definitions and explanations. (1) "Assistance," for purposes of this rule, is help with bathing-related tasks that individuals cannot accomplish by themselves, such as getting into and out of a bathing chair, moving in and out of the bathing area, or fastening and unfastening securements and positioners. The term does not include actual bathing (soaping, shampooing, scrubbing, rinsing). ...

...(A) Definitions and explanations. (1) "Assistance," for purposes of this rule, is help with bathing-related tasks that individuals cannot accomplish by themselves, such as getting into and out of a bathing chair, moving in and out of the bathing area, or fastening and unfastening securements and positioners. The term does not include actual bathing (soaping, shampooing, scrubbing, rinsing). ...

...(A) Provider requirements. A provider of apnea monitors for use in the home must be capable of performing all of the following services: (1) Arranging to have certified individuals provide infant cardiopulmonary resuscitation (CPR) training to caregivers; (2) Providing education and instruction on the mechanical aspects of monitors; and (3) Providing a technician twenty-four hours a day to ...

...(A) Coverage. (1) Initial payment may be made for rental of an apnea monitor for a period not to exceed four months, and after the first four months payment may be made either for additional rental or for purchase, only if the following conditions are satisfied: (a) The monitoring unit meets current United States food and drug administration guidelines. (b) The provider is capable of perfor...

...(A) Definitions and explanations. (1) "Basic equipment package" is the following standard set of parts and accessories that come with a wheelchair at the time of purchase: (a) A sling or solid seat with back, a captain's chair, or a stadium-style seat; (b) Standard casters or wheels with tires; (c) Standard armrests; (d) Standard front rigging, such as non-elevating legrests with footrests or...

...(A) Payment may be made directly to a provider for a pneumatic compression device or a related accessory only if the equipment and supplies are used to treat either lymphedema in the extremities or chronic venous insufficiency (CVI) with venous stasis ulcers. Accessories used for pneumatic compression of the chest or trunk are not covered. Before prescribing a pneumatic compression device, a pract...

...(A) Definitions and explanations. (1) "Group 1," "group 2," and "group 3" are classes of pressure-reducing support surface. (a) Group 1 surfaces are generally non-powered pads or overlays that are designed to be placed on top of a hospital bed or standard mattress. They achieve their effect through the application of, for example, a gel layer, air pressure, natural lamb's wool, or synthetic ...

...(A) Definitions and explanations. (1) "Group 1," "group 2," and "group 3" are classes of pressure-reducing support surface. (a) Group 1 surfaces are generally non-powered pads or overlays that are designed to be placed on top of a hospital bed or standard mattress. They achieve their effect through the application of, for example, a gel layer, air pressure, natural lamb's wool, or synthetic ...

...(A) Condition of provider participation. A provider of in-home use ventilators needs to have available a licensed respiratory care professional (LRCP) twenty-four hours a day to provide respiratory care, technical support, and clinical ventilator services and to perform emergency servicing of equipment on two-hour notice. (B) Coverage. (1) Separate payment may be made for a ventilator furnished ...

...(A) Coverage. (1) Separate payment may be made for a speech-generating device (SGD) furnished to a resident of a long-term care facility (LTCF). (2) The default certificate of medical necessity (CMN) form is the ODM 02924, "Certificate of Medical Necessity: Speech-Generating Devices" (rev. 7/2018). The CMN must include the following elements: (a) A formal, written report of a face-to-face evalu...

...(A) Coverage. (1) Separate payment may be made for a speech-generating device (SGD) furnished to a resident of a long-term care facility (LTCF). (2) The default certificate of medical necessity (CMN) form is the ODM 02924, "Certificate of Medical Necessity: Speech-Generating Devices" (rev. 7/2018). The CMN includes the following elements: (a) A formal, written report of a face-to-face evaluatio...

...(A) Definitions and explanations. (1) "Multiple-user lactation pump" is a lactation pump that is safe for sequential use by multiple individuals. (The term "hospital-grade," which is often applied to such a pump, is not recognized by the United States food and drug administration.) A multiple-user lactation pump comes with a separate set of accessories (e.g., breast shields, tubing) for each ...

...(A) Definitions. (1) "Sensor-augmented insulin pump system" is an insulin infusion pump equipped with a continuous glucose monitoring (CGM) sensor. The pump uses the glucose readings taken by the CGM sensor to modify the amount of insulin infused. (2) "Insulin pump," for purposes of this rule, is a collective term encompassing a portable external insulin infusion pump and a sensor-augmented insu...

...(A) Definitions. (1) "Ambulation aid" is a collective term for a cane, crutch, or walker. (2) "Ambulatory limitation" is an impediment to walking that has either of two effects: (a) It prevents an individual from completing activities of daily living within a reasonable time (or at all); or (b) It places an individual at a demonstrably higher risk of injury, exacerbation of illness, or death w...

...(A) Definitions. (1) "Ambulation aid" is a collective term for a cane, crutch, or walker. (2) "Ambulatory limitation" is an impediment to walking that has either of two effects: (a) It prevents an individual from completing activities of daily living within a reasonable time (or at all); or (b) It places an individual at a demonstrably higher risk of injury, exacerbation of illness, or death w...

...(A) Definitions and explanations that apply to this chapter of the Administrative Code. (1) "Clinical consultation" is the formal evaluation by a physician or other qualified healthcare professional, performed on the written order of a treating practitioner, of test results that appear to be abnormal. Payment for the clinical consultation is based on the physician fee schedule relative value ...

...(A) Providers. An entity may enroll in medicaid as a portable x-ray supplier only if it complies with the conditions set forth in 42 C.F.R. part 486 subpart C (October 1, 2020). (B) Coverage. (1) The radiology procedures performed by a portable x-ray supplier have both a professional component and a technical component. (a) In general, a portable x-ray supplier performs the technical component ...

...(A) Providers. (1) An entity may enroll in medicaid as an independent diagnostic testing facility (IDTF) only if it meets the following criteria: (a) It meets all standards set forth in and provide services in accordance with 42 C.F.R. 410.33 (October 1, 2020); (b) It takes the following measures to establish accountability: (i) It ensures that each supervising practitioner attests in writin...

...(A) "Home health services" includes home health nursing, home health aide services and skilled therapies. (B) Home health services are reimbursable only if a qualifying treating physician, advance practice nurse or physician assistant certifying the need for home health services documents that he or she had a face-to-face encounter with the individual within ninety days prior to the start of ...

...(A) "Private duty nursing (PDN)" is a continuous nursing service that requires the skills of and is performed by either a registered nurse (RN) or a licensed practical nurse (LPN) at the direction of a registered nurse. A service is not considered a PDN service merely because it was performed by a licensed nurse. A covered PDN visit must meet the definition in paragraph (A) of rule 5160-12-04 of t...