Ohio Administrative Code Search

...(A) Definitions. (1) "Freestanding birth center (FBC)" has the same meaning as in 42 U.S.C. 1396d(l)(3)(B) (October 1, 2016). (2) "Independent practitioner" and "non-independent practitioner" have the same meaning as in rule 5160-4-02 of the Administrative Code. (3) "Low-risk expectant mother" has the same meaning as in rule 3701-83-33 of the Administrative Code. (B) Provider requirements....

...(A) Definitions. (1) "Freestanding birth center (FBC)" is an entity defined in 42 U.S.C. 1396d(l)(3)(B) (in effect as of January 1, 2023) that is operated in conformity with rules 3701-83-33 to 3701-83-42 of the Administrative Code. (2) "Independent practitioner" and "non-independent practitioner" have the same meaning as in rule 5160-4-02 of the Administrative Code. (3) "Low-risk expectant...

...(A) This rule defines coverage and payment for providers who meet the provisions in sections 5103.60, 5103.602, 5103.603, 5103.6010, 5103.6011, 5103.6017 and 5103.6018 of the Revised Code and the provisions described in this rule. (B) Definitions. For the purpose of this rule the following definitions apply: (1) "Clinical Director" is a practitioner of physician services who supervises day-t...

...(A) For purposes of rules 5160-19-01 and 5160-19-02 of the Administrative Code, the following definitions apply: (1) "Attribution" is the process through which medicaid recipients are assigned to specific PCPs who are able to participate in the medicaid program in accordance with rule 5160-1-17.2 of the Administrative Code. ODM is responsible for attributing fee-for-service recipients; MCOs are r...

...(A) For purposes of rules 5160-19-01 and 5160-19-02 of the Administrative Code, the following definitions apply: (1) "Attribution" is the process through which medicaid recipients are assigned to specific primary care practitioners (PCPs) who are able to participate in the medicaid program in accordance with rule 5160-1-17.2 of the Administrative Code. The Ohio department of medicaid (ODM) is res...

...(A) A comprehensive primary care (CPC) entity has to be enrolled and meet the provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for patient centered medical home (PCMH) payments. (B) A CPC entity participating in the CPC for kids program has to be enrolled as a CPC entity and meet all provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible...

...(A) A comprehensive primary care (CPC) entity has to be enrolled and meet the provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible for patient centered medical home (PCMH) payments. (B) A CPC entity participating in the CPC for kids program has to be enrolled as a CPC entity and meet all provisions set forth in rule 5160-19-01 of the Administrative Code to be eligible...

...The "comprehensive maternal care (CMC) program" is a maternal and infant support program that utilizes a comprehensive care coordination and service model incorporating supportive services for expectant and postpartum medicaid eligible individuals to reduce adverse birth and infant outcomes. (A) For purposes of Chapter 5160-19 of the Administrative Code, the following definitions apply: (1) "Attribution...

...The "comprehensive maternal care (CMC) program" is a maternal and infant support program that utilizes a comprehensive care coordination and service model incorporating supportive services for expectant and postpartum women to reduce adverse birth and infant outcomes. (A) For purposes of Chapter 5160-19 of the Administrative Code, the following definitions apply: (1) "Attribution" is the process thr...

...(A) Definitions. (1) "Abuse potential drug" as used in the appendix to this rule, means any drug that contains substances which have a potential for abuse because of depressant or stimulant effects on the central nervous system or hallucinogenic effects. Abuse potential drugs include any drug that is reportable to Ohio automated RX reporting system (OARRS) as described in rules 4729:8-2-01 and 47...

...(A) Definitions. (1) "Abuse potential drug" as used in the appendix to this rule, means any drug that contains substances which have a potential for abuse because of depressant or stimulant effects on the central nervous system or hallucinogenic effects. Abuse potential drugs include any drug that is reportable to Ohio automated RX reporting system (OARRS) as described in rules 4729:8-2-01 and 47...

...(A) Definitions. (1) For the purposes of this rule, "hysterectomy" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), a medical procedure or operation for the purpose of removing the uterus. (2) For the purposes of this rule, "institutionalized individual" means, in accordance with 42 C.F.R. 441.251 (October 1, 2010 edition), an individual who is: (a) Involuntarily confined or detained, under a...

...(A) Coverage. (1) Unless a different time period is specified, services described in this rule are covered through the pregnancy and the delivery. (2) Basic pregnancy-related services include but are not limited to antepartum care, delivery, outpatient postpartum care, and family planning services. (a) Antepartum care. Payment for a visit may be made for either of two purposes: (i) Basic...

...(A) Coverage. (1) Unless a different time period is specified, services described in this rule are covered through the pregnancy and the delivery. (2) Basic pregnancy-related services include but are not limited to antepartum care, delivery, outpatient postpartum care, and family planning services. (a) Antepartum care. Payment for a visit may be made for either of two purposes: (i) Basic...

...(A) Coverage. (1) Unless a different time period is specified, services described in this rule are covered through the pregnancy and the delivery. (2) Basic pregnancy-related services include but are not limited to antepartum care, delivery, outpatient postpartum care, and family planning services. (a) Antepartum care. Payment for a visit may be made for either of two purposes: (i) Basic...

...(A) Unless otherwise noted, any limitations or requirements specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule. (B) Definitions. (1) "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. (2) "Registered nurse (RN)" has the same meaning as in Chapter 4723. of the Revised ...

...(A) Unless otherwise noted, any limitations or conditions specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule. (B) Definitions. (1) "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. (2) "Registered nurse (RN)" has the same meaning as in Chapter 4723. of the Revised ...

...(A) Unless otherwise noted, any limitations or conditions specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule. (B) Definitions applied to this rule. (1) "Eligible provider" has the same meaning as defined in rule 5160-1-17 of the Administrative Code. (2) "Family connects" is an evidence-based home visiting model that provides...

...Effective for dates of service on or after the effective date of this rule, eligible ambulatory surgery centers as defined in paragraphs (A)(1) and (B) of this rule are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective payment methodology utilized by the Ohio department of medicaid as described in this rule. (A) Definitions, for the purposes of this rule the following mean...

...Effective for dates of service on or after the effective date of this rule, eligible ambulatory surgery centers as defined in paragraphs (A)(1) and (B) of this rule are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rule. (A) Definitions, for the purposes of this rule the following ...

...As used in Chapter 5160-26 of the Administrative Code: (A) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practi...

...(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) Eligibility for managed care organization (MCO) enrollment. (1) Except as specified in paragraphs (B)(3) to (B)(5) of this rule, in mandatory servic...

...(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) The Ohio department of medicaid (ODM) will terminate a member from enrollment in a managed care organization (MCO) for any of the following reasons: ...

...(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) Except as otherwise provided in this rule, a managed care organization (MCO) and the single pharmacy benefit manager (SPBM) must ensure members have ...

...(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code or the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. (B) A managed care organization (MCO) must ensure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and a...