Ohio Administrative Code Search

...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...

...(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 managed care organization (MCO) is responsible for payment of long-term services and supports (LTSS) respite services as defined in rule 5160-26-...

...(A) Provider contracts. (1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule and...

...(A) Provider contracts. (1) A managed care entity (MCE) must provide or arrange for the delivery of covered health care services described in rule 5160-26-03 of the Administrative Code either through the use of employees or through contracts with network providers of health care services ("providers"). All provider contracts must be in writing and in accordance with paragraph (D) of this rule, 42...

...(A) A managed care entity (MCE) must provide the following written information to their contracting providers: (1) The MCE's grievance, appeal and state fair hearing procedures and time frames, including: (a) The member's right to file grievances and appeals and the requirements and time frames for filing; (b) The MCE's toll-free telephone number to file oral grievances and appeals; (c) Th...

...(A) A managed care entity (MCE) must have administrative and management arrangements or procedures, including a mandatory compliance plan, to guard against fraud, waste and abuse as required in the MCE provider agreement or contract with the Ohio department of medicaid (ODM) located at http://medicaid.ohio.gov/. (1) These arrangements or procedures must be made available to ODM upon request. (2)...

...(A) A managed care entity (MCE) must develop and implement written policies in accordance with 42 C.F.R. 438.100 (October 1, 2021), as applicable, to ensure each member has and is informed of his or her right to: (1) Receive all services the MCE is required to provide pursuant to the terms of the MCE provider agreement or contract, as applicable, with the Ohio department of medicaid (ODM). (...

...(A) This rule does not apply to MyCare Ohio plans as defined in rule 5160-58-01 of the Administrative Code. (B) Notice of action (NOA) by a managed care organization (MCO) or the single pharmacy benefit manager (SPBM). (1) When an adverse benefit determination has occurred or will occur, the MCO or SPBM shall provide the affected member with a NOA. (2) The language and format of the NOA sha...

...(A) Tort. (1) Pursuant to sections 5160.37 and 5160.38 of the Revised Code, the Ohio department of medicaid (ODM) maintains all rights of recovery (tort) against the liability of any third party payer (TPP) for the cost of medical services. (2) A managed care entity (MCE) is prohibited from accepting any settlement, compromise, judgment, award, or recovery of any action or claim by a member. (3...

...(A) Tort. (1) Pursuant to sections 5160.37 and 5160.38 of the Revised Code, the Ohio department of medicaid (ODM) maintains all rights of recovery (tort) against the liability of any third party payer (TPP) for the cost of medical services. (2) A managed care entity (MCE) is prohibited from accepting any settlement, compromise, judgment, award, or recovery of any action or claim by a member. (3...

...(A) This rule does not apply to the single pharmacy benefit manager as defined in rule 5160-26-01 of the Administrative Code. (B) If the MCO fails to fulfill its duties and obligations under 42 C.F.R. Part 438 (October 1, 2021), 42 U.S.C. 1396b(m) (as in effect July 1, 2022), 42 U.S.C. 1396u-2 (as in effect July 1, 2022), agency 5160 of the Administrative Code, or the MCO provider agreement, ODM ...

...(A) Non-contracting providers of emergency services must accept as payment in full from a managed care organization (MCO) the lesser of billed charges or one hundred per cent of the Ohio medicaid program reimbursement rate (less any payments for indirect costs of medical education and direct costs of graduate medical education that is included in the Ohio medicaid program reimbursement rate) in effect for the date of...

...(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 managed care organization (MCO) may elect to implement a member co-payment program pursuant to section 5162.20 of the Revised Code for dental ser...

...(A) An "eligible behavioral health provider" for purposes of this chapter is a provider of a mental health or substance use disorder treatment service covered in agency 5160 of the Administrative Code and is one of the following: (1) An entity operating in accordance with section 5119.36 of the Revised Code and Chapters 5122-24 to 5122-29 and Chapter 5160-1 of the Administrative Code and providin...

...(A) For the purposes of this chapter, an "eligible billing provider" is an entity that meets the conditions in paragraph (A)(1) or (A)(2) of this rule. An "eligible rendering provider" is an individual who meets one or more of the conditions stated in paragraphs (A)(3) to (A)(8) of this rule and is employed by or under contract with an eligible billing provider. (1) An entity certified by th...

...(A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified. (1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illne...

...(A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified. (1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illne...

...(A) This rule sets forth the reimbursement requirements and rates for behavioral health services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services will abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Ad...

...(A) This rule sets forth the reimbursement requirements and rates for behavioral health services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code. (B) Providers rendering community behavioral health services shall abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the A...