Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-35 - Medicaid School Program › Section 5160-35-01 - Definitions

Current through all regulations passed and filed through July 1, 2024
(A) For the
			 purposes of Chapter 5160-35 of the Administrative Code, the following terms are
			 defined as:
(1) At the direction of:
			 communication of a plan of care to a licensed practical nurse by a licensed
			 physician or registered nurse who is acting within the scope of his or her
			 practice under Ohio law for the provision of nursing services by the licensed
			 practical nurse.
(2) Clinical
			 setting: for the purpose of counseling and social work roles, a location in the
			 school, or a location for which the medicaid school program provider has
			 contracted for the delivery of services, where the child's confidentiality can
			 be maintained when a service is being rendered.
(3) Community school: a public school,
			 independent of any school district, established in accordance with Chapter
			 3314. of the Revised Code that is part of the state's program of
			 education.
(4) Common procedural
			 terminology (CPT): also known as current procedural
			 terminology, is a list of descriptive terms and identifying codes, as published by the American medical association
			 (AMA) for reporting medical services and procedures performed.
(5) Direct service costs: costs associated
			 with salaries, benefits, and contract compensation for individuals and entities
			 delivering services to an eligible child, services as defined in rule
			 5160-35-05
			 of the Administrative Code and as defined in paragraph (B)(2) of rule
			 5160-35-06
			 of the Administrative Code.
(6)
			 Eligible child: a student for whom medicaid reimbursement may be sought through
			 the medicaid school program who is enrolled in an entity defined in paragraph
			 (B)(1) of rule
			 5160-35-02
			 of the Administrative Code, who is between the age of three to twenty-one, and
			 has an individualized education program in which is indicated services that are
			 allowable under medicaid.
(7)
			 Healthcare common procedure coding system (HCPCS): is a uniform method for
			 health care providers and medical suppliers to report professional services,
			 procedures and supplies.
(8) The
			 individualized education program (IEP) is as defined in section
			 3323.011 of the Revised
			 Code.
(9) Licensed practitioner of
			 the healing arts: for purposes of these rules, includes the
			  qualified practitioners
			 delineated in rule
			 5160-35-05
			 of the Administrative Code .
(10) Local
			 education agency: 
									school districts of the state as defined in sections
			 3311.01 to
			 
									
										3311.05
									 of the Revised
			 Code.
(11) Medicaid authorized
			 prescriber: a physician (M.D. or D.O.), podiatrist, dentist, or advanced
			 practice nurse working within his or her scope of practice as defined by state
			 law.
(12)
									Medicaid school program authorized referrer: is a licensed
			 practitioner of the healing arts who refers for services under the medicaid
			 school component of the medicaid program as set forth in section
			 5162.366 of the Revised
			 Code.
(13) Medical home: a physician, physician group
			 practice, or an advanced practice nurse with a current medicaid provider
			 agreement, or a provider with a contract with an Ohio medicaid managed care
			 plan. This provider serves as an ongoing source of primary and preventive care
			 and provides assistance with care coordination for the patient.
(14)
			 Medically necessary: skilled services recommended by a qualified licensed
			 practitioner in accordance with rules
			 5160-35-05
			 and
			 5160-35-06
			 of the Administrative Code who is acting within the scope of his or her
			 licensure that meet the requirements in rule
			 5160-1-01
			 of the Administrative Code and meet general principles regarding reimbursement
			 for medicaid covered services found in rule
			 5160-1-02
			 of the Administrative Code. For the purpose of the
			 medicaid school program, it is recognized that medically necessary services are
			 those education related identified in the individualized education program
			 (IEP) that meet medicaid reimbursement requirements.
(15)
			 Medicaid school program (MSP): is as set forth in Chapter 5160-35 of the
			 Administrative Code.
(16) MSP provider:
			 educational entity that meets the qualifications
			 delineated in rule
			 5160-35-02
			 of the Administrative Code.
(17) Other costs:
			 costs for service-related activities for which there is no CPT or HCPCS code
			 and for which claiming is not possible by the MSP provider due to medicaid rule
			 restrictions; administrative claiming, equipment, supplies, indirect costs, and
			 billing fees.
(18) Skilled services: services of such complexity and
			 sophistication that the service can be safely and effectively performed only by
			 or under the supervision of a licensed practitioner of the healing arts
			 practicing within the scope of their licensure. Skilled services do not include
			 services provided by persons not licensed in accordance with the Ohio Revised
			 Code.
(19) State school: school under the control and
			 supervision of the state board of education established for students who are
			 deaf or blind as defined by section
			 3325.01 of the Revised
			 Code.
(20) Supervision: is as defined in rules
			 4753-7-02,
			 4755-27-01,
			 4755-27-02, 4755-27-04, and 4755-7-04 of the
			 Administrative Code.
(21)
									Telehealth: is the direct delivery of health care
			 services to a patient via secure, synchronous, interactive, real-time
			 electronic communication comprised of both audio and video elements in
			 accordance with rule
			 5160-1-18 of the
			 Administrative Code. Practitioners must act within their scope of practice and
			 in accordance with their licensure agreements.