Ohio Revised Code Search

...In any action taken by the department of medicaid under section 5164.38 or 5164.57 of the Revised Code or any other state statute governing the medicaid program that requires the department to give notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code, if the department gives notice of the opportunity for a hearing but the medicaid provider or other entity subject to the not...

...(A) As used in this section: (1) "Aide services" means all of the following: (a) Home health aide services covered by the medicaid program as part of the home health services benefit pursuant to 42 C.F.R. 440.70(b)(2); (b) Home care attendant services covered by a participating medicaid waiver component, as defined in section 5166.30 of the Revised Code; (c) Any of the following covered by a home and communit...

...(A) The department of medicaid may contract with any person or persons as a fiscal agent for the examination, processing, and determination of medicaid claims. The contracting party may provide any of the following services, as required by the contract: (1) Design and operate medicaid management information systems, including the provision of data processing services; (2) Determine the amounts of payments to ...

...(A) As used in this section, "electronic claims submission process" means any of the following: (1) Electronic interchange of data; (2) Direct entry of data through an internet-based mechanism implemented by the department of medicaid; (3) Any other process for the electronic submission of claims that is specified in rules adopted under section 5162.02 of the Revised Code. (B) Not later than January 1, 2013,...

...(A) As used in this section, "OCHSPS" means the private, not-for-profit corporation known as the Ohio children's hospital solutions for patient safety, which was formed for the purpose of improving pediatric patient care in this state, which performs functions that are included within the functions of a peer review committee as defined in section 2305.25 of the Revised Code, and which consists of all of the fol...

...Not less than once each year and in accordance with all state and federal laws governing the confidentiality of patient-identifying information, the department of medicaid shall make summary data regarding perinatal services available on request to local organizations concerned with infant mortality reduction initiatives and recipients of grants administered by the division of family and community health services in...

...The medicaid director may implement a system under which medicaid payments for medicaid services are made to an organization on behalf of medicaid providers. The system may not provide for an organization to receive an amount that exceeds, in aggregate, the amount the medicaid program would have paid directly to medicaid providers if not for this section.

...The department of medicaid may conduct final fiscal audits of medicaid providers in accordance with the applicable requirements set forth in federal laws and regulations and determine any amounts the provider may owe the state. When conducting final fiscal audits, the department shall consider generally accepted auditing standards, which include the use of statistical sampling.

...Under the medicaid program, any amount determined to be owed the state by a final fiscal audit conducted pursuant to section 5164.55 of the Revised Code, upon the issuance of an adjudication order pursuant to Chapter 119. of the Revised Code that contains a finding that there is a preponderance of the evidence that a medicaid provider will liquidate assets or file bankruptcy in order to prevent payment of the a...

...(A)(1) Except as provided in division (A)(2) of this section, the department of medicaid may recover a medicaid payment or portion of a payment made to a medicaid provider to which the provider is not entitled if the department notifies the provider of the overpayment during the five-year period immediately following the end of the state fiscal year in which the overpayment was made. (2) In the case of a hospital me...

...(A) If a state agency that enters into a contract with the department of medicaid under section 5162.35 of the Revised Code identifies that a medicaid overpayment has been made to a medicaid provider, the state agency may commence actions to recover the overpayment on behalf of the department. (B) In recovering an overpayment pursuant to this section, a state agency shall comply with the following procedures: ...

...The department of medicaid may deduct from medicaid payments for medicaid services rendered by a medicaid provider any amounts the provider owes the state as the result of incorrect medicaid payments the department has made to the provider.

...Any medicaid provider who, without intent, obtains payments under the medicaid program in excess of the amount to which the provider is entitled is liable for payment of interest on the amount of the excess payments for a period determined by the department, but not to exceed the period from the date on which payment was made to the date on which repayment is made to the state. The interest shall be paid at the avera...

...The authority, under state and federal law, of the department of medicaid or a county department of job and family services to recover excess medicaid payments made to a medicaid provider is not limited by the availability of remedies under sections 5162.21 and 5162.23 of the Revised Code for recovering benefits paid on behalf of medicaid recipients.

...Except as otherwise required by federal statute or regulation, no medicaid payment for any medicaid service provided by a hospital, nursing facility, or ICF/IID shall exceed the limits established under Subpart C of 42 C.F.R. Part 447.

...Medicaid payments for freestanding medical laboratory charges shall not exceed the customary and usual fee for laboratory profiles.

...The number of days of inpatient hospital care for which a medicaid payment is made on behalf of a medicaid recipient to a hospital that is not paid under a diagnostic-related-group prospective payment system shall not exceed thirty days during a period beginning on the day of the recipient's admission to the hospital and ending sixty days after the termination of that hospital stay, except that the department of medi...

...A hospital or freestanding birthing center that is a medicaid provider may submit to the department of medicaid or the department's fiscal agent a medicaid claim that is both of the following: (A) For a long-acting reversible contraceptive device that is covered by medicaid and provided to a medicaid recipient during the period after the recipient gives birth in the hospital or center and before the recipient is di...

...The division of any medicaid payment between a collaborating physician or podiatrist and a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner for services performed by the nurse shall be determined and agreed on by the nurse and collaborating physician or podiatrist. In no case shall the medicaid payment exceed the medicaid payment that the physician or podiatrist would have re...

...The medicaid director shall adopt rules under section 5164.02 of the Revised Code governing the calculation and payment of, and the allocation of payments for, graduate medical education costs associated with medicaid services rendered to medicaid recipients. Subject to section 5164.741 of the Revised Code, the rules shall provide for payment of graduate medical education costs associated with medicaid services...

...(A) Except as provided in division (B) of this section, the department of medicaid may deny medicaid payment to a hospital for direct graduate medical education costs associated with the delivery of medicaid services to any medicaid recipient if the hospital refuses without good cause to contract with a medicaid managed care organization that serves the area in which the hospital is located. (B) A hospital is...

...As used in this section, "federal upper reimbursement limit" means the limit established pursuant to the "Social Security Act," section 1927(e), 42 U.S.C. 1396r-8(e). The medicaid payment for a drug that is subject to a federal upper reimbursement limit shall not exceed, in the aggregate, the federal upper reimbursement limit for the drug.

...(A) As used in this section, "state maximum allowable cost" means the per unit amount the medicaid program pays a terminal distributor of dangerous drugs for a prescribed drug included in the state maximum allowable cost program established under division (B) of this section. "State maximum allowable cost" excludes dispensing fees and copayments, coinsurance, or other cost-sharing charges, if any. (B) Subject to se...

...In July of every even-numbered year, the department of medicaid shall initiate a confidential survey of the cost of dispensing drugs incurred by terminal distributors of dangerous drugs in this state. The survey shall be used as the basis for establishing the medicaid program's dispensing fees for terminal distributors in accordance with section 5164.753 of the Revised Code. The survey shall be completed and its resu...

...In December of every even-numbered year, the medicaid director shall establish dispensing fees, effective the following July, for terminal distributors of dangerous drugs that are providers of drugs under the medicaid program. In establishing dispensing fees, the director shall take into consideration the results of the survey conducted under section 5164.752 of the Revised Code. The director may establish dispensing...