Ohio Administrative Code Search

...(A) Eligible pharmacies in the Ohio medicaid program may bill for medical supplies and durable medical equipment in accordance with Chapter 5160-10 of the Administrative Code, with the following stipulations: (1) The provider must: (a) Apply to, and be approved by, the Ohio department of medicaid (ODM) to be eligible to dispense medical supplies/durable medical equipment; and (b) Use the ...

...(A) Covered prescribed drugs Drugs covered by the Ohio department of medicaid (ODM) pharmacy program, or a managed care plan as defined in rule 5160-26-01 of the Administrative Code, are prescribed drugs as defined in rule 5160-9-05 of the Administrative Code that are dispensed to an eligible patient for use in the patient's residence, including a nursing facility (NF), as defined in section 5165...

...(A) Covered prescribed drugs Drugs covered by the Ohio department of medicaid (ODM) pharmacy program, or a managed care entity as defined in rule 5160-26-01 of the Administrative Code, are prescribed drugs as defined in rule 5160-9-05 of the Administrative Code that are dispensed to an eligible recipient for use in the recipient's residence, including a nursing facility (NF), as defined in sectio...

...(A) Patient profiles, prospective drug utilization review (DUR), and patient counseling (1) Patient profiles, prospective DUR and patient counseling must be performed for medicaid patients by medicaid pharmacy providers in accordance with Chapter 4729-5 of the Administrative Code. (2) Documentation and records required by Chapter 4729-5 of the Administrative Code must be maintained in accordance with rule 5160-1-17...

...(A) Recipient profiles, prospective drug utilization review (DUR), and recipient counseling (1) Recipient profiles, prospective DUR and recipient counseling must be performed for medicaid recipients by medicaid pharmacy providers in accordance with agency 4729 of the Administrative Code. (2) Documentation and records required by - agency 4729 of the Administrative Code must be maintained in ...

...(A) Definitions. (1) "340B ceiling price" means the highest price allowed to be charged by a manufacturer to a 340B covered entity as described in section 340B(a)(4) of the "Public Health Service Act," 42 U.S.C. 256b(a)(4) (in effect as of January 7, 2011). (2) "Actual acquisition cost (AAC)" means the best determination by the Ohio department of medicaid (ODM) of the actual amount the provi...

...(A) Payment for prescribed drugs is the lesser of the provider's billed charges or the calculated allowable, after any coordination of benefits is applied as described in paragraph (E) of this rule. For prescribed drugs that are subject to a co-payment, the amount paid by the Ohio department of medicaid (ODM) is decreased by the amount equal to the co-payment billed to the recipient in accordance ...

...(A) The pharmacy claim 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 shall be retained by the provider for a period of six years from the date of payment of the claim and if an audit i...

...(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 ...