Ohio Administrative Code Search

...The following costs are not reimbursable to NFs through the NF per diem, except as specified under Chapter 5160-3 of the Administrative Code. Non-reimbursable costs include but are not limited to: (A) Fines or penalties paid under sections 5165.1010, 5165.72 to 5165.77, 5165.83, and 5165.99 of the Revised Code. (B) Disallowances made during the audit of NF cost reports that are sanctioned through adjudication in a...

...(A) As used in this rule: (1) "Annual facility average case mix score" is the score used to calculate the facility's cost per case-mix unit. (2) "Assessment reference date (ARD)" is the last day of the observation (or "look back") period that the MDS 3.0 assessment covers for the resident. (3) "Case mix report" is a report generated by the Ohio department of medicaid (ODM) and distributed t...

...The Ohio department of medicaid (ODM) shall pay each eligible NF a per resident per day rate for direct care costs established prospectively for each facility. The department shall establish each facility's rate for direct care costs semiannually. Each facility's rate for direct care costs shall be based on a case mix payment system. (A) The Ohio medicaid case mix payment system for direct care contains ...

...(A) The definitions of all terms used in this rule are the same as set forth in rules 5160-3-01, 5160-3-43.1, and 5160-3-43.4 of the Administrative Code. (B) To determine resident case mix scores, the Ohio department of medicaid (ODM) shall process resident assessment data submitted by NFs in accordance with rule 5160-3-43.1 of the Administrative Code, and shall classify residents in accordance w...

...(A) Definitions. For purposes of this rule: (1) "Ancillary and support costs," "cost center," "direct care costs," "rebasing" and "tax costs" have the same meaning as in section 5165.01 of the Revised Code. (2) "Cost center report" means a report submitted to the Ohio department of medicaid (ODM) by a nursing facility provider that identifies the amount spent on each cost center included in rebasing. (B) Direct c...

...(A) The Ohio department of medicaid (ODM) shall pay a provider a per medicaid day payment rate for tax costs determined under section 5165.21 of the Revised Code except for the initial rate for new providers. ODM shall determine each new nursing facility's initial per medicaid day payment rate for tax costs in accordance with section 5165.151 of the Revised Code. (B) For purposes of calculating t...

...(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 ...