reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-06.5 - Home and community based services (HCBS) waivers: assisted living

Current through all regulations passed and filed through July 1, 2024
(A) The Ohio
			 department of aging (ODA) is responsible for the daily administration of the
			 assisted living HCBS waiver. ODA will administer this waiver pursuant to an
			 interagency agreement with the Ohio department of medicaid (ODM), in accordance
			 with section 5162.35 of the Revised
			 Code.
(B) The assisted living HCBS
			 waiver is an alternative to nursing facility placement for persons age
			 twenty-one and over who require an intermediate level of care or a skilled
			 level of care as set forth in rule
			 5160-3-08 of the Administrative
			 Code and are enrolled in the waiver.
(1) The
			 assisted living HCBS waiver's services and program eligibility criteria are set
			 forth in Chapter 5160-33 of the Administrative Code.
(2) The maximum allowable reimbursement rates
			 for assisted living HCBS waiver program services are listed in appendix A to
			 this rule.
(3) Assisted living HCBS
			 reimbursement are provided in accordance with rule
			 5160-1-60 of the Administrative
			 Code.
(4) The billing maximum for
			 the community transition service listed in appendix A to this rule represents
			 the cumulative maximum for the items purchased or deposits made through the
			 community transition service as set forth in rule
			 173-39-02.17 of the
			 Administrative Code.
Click to
				view Appendix
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-08 - Coordination of benefits

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions.
(1)
									"Coordination of benefits" (COB) means the process of
			 determining which health plan or insurance policy will pay first or determining
			 the payment obligations of each health plan, medical insurance policy, or third
			 party resource when two or more health plans, insurance policies or third party
			 resources cover the same benefits for a medicaid covered
			 individual.
(2)
									"Coordination of benefits claim" (COB claim) means any
			 claim that meets either the definition of third party claim as described in
			 paragraph (A)(7) of this rule or the definition of medicare crossover claim as
			 described in rule
			 5160-1-05
			 of the Administrative Code.
(3)
									"Explanation of
			 benefits" (EOB) or "remittance advice" means the information sent to providers
			 or plan beneficiaries (covered individuals) by any other third party payer,
			 medicare, or medicaid to explain the adjudication of the claim.
(4)
									"Medicare
			 benefits" has the same meaning as in rule
			 5160-1-05
			 of the Administrative Code.
(5)
									"Third party"
			 (TP) has the same meaning as in section
			 5160.35 of the Revised
			 Code.
(6)
									"Third party benefit" means any health care service
			 available to individuals through any medical insurance policy or through some
			 other resource that covers medical benefits and the payment for those services
			 is either completely the obligation of the third party payer (TPP) or in part
			 the obligation of the individual, the third party payer, or medicaid (examples
			 of a third party benefit include private health or accidental insurance,
			 medicare, CHAMPUS or worker's compensation).
(7)
									"Third party
			 claim" means any claim submitted to the Ohio department of medicaid (ODM) for
			 reimbursement after all TPPs have met their payment obligations. In addition,
			 the following will be considered third party claims by ODM:
(a)
										Any claim
			 received by ODM that shows no prior payment by a TPP, but, ODM's records
			 indicate the medicaid covered individual has third party
			 benefits.
(b)
										Any claim received by ODM that shows no prior payment
			 by a TPP but the provider's records indicate the medicaid covered individual
			 has third party benefits.
(8)
									"Third party
			 liability" (TPL) means the payment obligations of the third party payer for
			 health care services rendered to eligible medicaid covered individuals when the
			 individual also has third party benefits as described in paragraph (A) (6) of
			 this rule.
(9)
									"Third party payer" (TPP) means an entity, other than
			 the medicaid or medicare programs, responsible for adjudicating and paying
			 claims for third party benefits rendered to an eligible medicaid covered
			 individual.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-09 - Co-payments

Current through all regulations passed and filed through July 1, 2024
This rule sets forth requirements regarding co-payments by
				
								individuals for medicaid-covered services.
(A) Certain medicaid services are subject to
			 
								individual co-payments. Information regarding these
			 services and co-payment amounts can be found in the following Administrative
			 Code rules:
(1) Co-payments for dental
			 services are described in rule 5160-5-01
			 of the Administrative Code.
(2)
			 Co-payments for vision services are described in rule
			 5160-6-01 of the Administrative Code.
(3) Co-payments for non-emergency emergency
			 department services are described in rule 5160-2- 21.1 of the Administrative
			 Code.
(4) Co-payments for pharmacy
			 services are described in rule 5160-9-09
			 of the Administrative Code.
(5)
			 Co-payment requirements for services provided through a medicaid managed care
			 plan are described in Chapter 5160-26-12 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-10 - Limitations on elective obstetric deliveries

Current through all regulations passed and filed through July 1, 2024
(A)
								 Payment for any
			 cesarean section, labor induction, or any delivery following labor induction is
			 subject to the following criteria:
(1)
									 Gestational age of the fetus must be determined to be
			 at least thirty-nine weeks;
or
(2)
									 If a delivery
			 occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions
			 must indicate medical necessity for the delivery.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-11 - Out-of-state coverage

Current through all regulations passed and filed through July 1, 2024
(A)
								Out-of-state
			 providers:
(1)
									Should be licensed, accredited, or certified by their
			 respective states to be considered eligible to receive reimbursement for
			 services provided to Ohio medicaid covered individuals.
(2)
									Should meet any
			 standards applicable to the provision of the service in the state in which the
			 service is being furnished, as well as those standards set forth in the Ohio
			 medicaid program and in the Administrative Code.
(3)
									Except as
			 provided in paragraph (A)(4) of this rule, need to enroll as Ohio medicaid
			 providers in order to obtain payment and follow appropriate billing procedures
			 in accordance with Chapter 5160-1 of the Administrative Code and Chapter 5160-3
			 of the Administrative Code for long term care nursing facility
			 services.
(4)
									Who are rendering services to medicaid covered
			 individuals enrolled in a managed care plan (MCP) are not required to enroll
			 with the Ohio department of medicaid (ODM) when:
(a)
										 The out-of-state
			 provider is not in the MCP's network and is providing services under a single
			 case agreement; or
(b)
										The out-of-state provider is a pharmacy that is
			 in-network with the MCP under a national contract.
(5)
									May have their
			 out-of-state provider's enrollment application denied by ODM based on the
			 denial, censure or revocation of their professional license by the applicable
			 licensing board of any other state, or if the applicable licensing board in
			 Ohio denies, censures or revokes a professional license even if another state's
			 licensing board approves the respective provider.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-13.1 - Medicaid recipient liability

Current through all regulations passed and filed through July 1, 2024
(A)
								In accordance
			 with
			 42 C.F.R.
			 447.15 (as in effect October 1, 2018), the
			 medicaid payment for a covered service constitutes payment-in-full. It shall
			 not be construed as a partial payment even when the payment amount is less than
			 the provider's charge.
(1)
									The provider shall not collect nor bill a medicaid
			 recipient for any difference between the medicaid payment and the provider's
			 charge, nor shall the provider ask a medicaid recipient to share in the cost
			 through a deductible, coinsurance, co-payment, missed appointment fee or other
			 similar charge, other than medicaid co-payments as defined in rule
			 5160-1-09 of the
			 Administrative Code and patient liability as described in Chapter 5160-3 and
			 rule
			 5160:1-6-07
			 of the Administrative Code.
(2)
									The provider
			 shall not charge a medicaid recipient a down payment, refundable or
			 otherwise.
(3)
									Should the individual become eligible for medicaid
			 after the date of service and the eligibility span includes the date of
			 service, the individual may not be financially
			 responsible.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-14 - Healthchek: early and periodic screening, diagnostic, and treatment (EPSDT) covered services

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions.
(1)
									"Healthchek" is Ohio's early and periodic screening,
			 diagnostic, and treatment (EPSDT) benefit for all medicaid recipients younger
			 than twenty-one years of age, described in
			 42
			 U.S.C. 1396d(r) (as in
			 effect 10/2017).
(2)
									"Bright futures guidelines" are the American academy of
			 pediatrics bright futures guidelines for preventive health care (rev. 2/2017),
			 available at http://www.aap.org.
(3)
									"Medical
			 necessity" and "medically necessary" have the same meaning as in rule
			 5160-1-01
			 of the Administrative Code.
(4)
									"Prior
			 authorization" is one of two processes:
(a)
										For members of a
			 medicaid managed care plan (MCP), it is the process established by the medicaid
			 MCP as required by rule 5160-26-05.1 of the Administrative
			 Code.
(b)
										For all other medicaid recipients, it is the process
			 outlined in rule
			 5160-1-31
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-16 - Preventive services

Current through all regulations passed and filed through July 1, 2024
(A)
								"Preventive
			 service" is a procedure, treatment, or other measure that is included in either
			 of two groups:
(1)
									Services addressed in any of the following
			 sources:
(a)
										"USPSTF A and B Recommendations" (January 2017), published
			 by the United States preventive services task force and available at
			 http://www.uspreventiveservicestaskforce.org;
(b)
										Immunization
			 schedules for January 2017 published by the centers for disease control and
			 prevention and available at
http://www.cdc.gov
;
(c)
										"Bright Futures: Guidelines for Health Supervision of
			 Infants, Children and Adolescents, 4th Edition" (2017), published by the
			 American academy of pediatrics and available at http://www.aap.org;
			 or
(d)
										"Recommendations for Preventive Services for Women"
			 (December 2016), published by the women's preventive services initiative and
			 available at
http://www.womenspreventivehealth.org
; or
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17 - Eligible providers

Current through all regulations passed and filed through July 1, 2024
This rule sets forth eligibility
				requirements for practitioners, group practices, or organizational providers
				enrolling with, and seeking reimbursement from, the Ohio medicaid
				program.
(A)
								Eligible provider means any practitioner, group
			 practice, or organization identified by the Ohio department of medicaid (ODM)
			 as a type of provider eligible to enroll in the medicaid program that:
(1)
									Meets the
			 applicable provider requirements and standards in agency 5160 of the
			 Administrative Code that address applicable service categories and provider
			 types covered under the Ohio medicaid program;
(2)
									Meets additional
			 requirements and standards set forth in this rule;
(3)
									Meets provider
			 screening requirements and, when applicable, pays the fee for enrollment as a
			 provider in the medicaid program in accordance with rule 5160-1-17.8 of the
			 Administrative Code; and
(4)
									Is approved for participation in the medicaid program
			 by ODM as evidenced by the issuance of both a signed "provider agreement" and
			 an Ohio medicaid provider number.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.3 - Provider disclosure requirements

Current through all regulations passed and filed through July 1, 2024
(A)
								
			 Definitions:
(1)
									 "Disclosing provider" means a medicaid provider,
			 managed care entity, or fiscal agent under contract with the department of
			 medicaid (ODM).
(2)
									 "Managing employee" means a general manager, business
			 manager, administrator, director, or other individual who exercises operational
			 or managerial control over, or who directly or indirectly conducts the
			 day-to-day operation of an institution, organization or agency.
(3)
									 "Agent" means
			 any person who has been delegated the authority to obligate or act on behalf of
			 a provider.
(4)
									 "Person with an ownership or control interest" means a
			 person or corporation that meets any of the following:
(a)
										 Has an ownership
			 interest totaling five per cent or more in the disclosing
			 provider;
(b)
										 Has an indirect ownership interest equal to five per
			 cent or more in the disclosing provider;
(c)
										 Has a
			 combination of direct and indirect ownership interest equal to five per cent or
			 more in the disclosing provider;
(d)
										 Owns an interest
			 of five per cent or more in any mortgage, deed of trust, note, or other
			 obligation secured by the disclosing entity if that interest equals at least
			 five per cent of the value of the property or assets of the disclosing
			 provider;
(e)
										 Is an officer or director of the disclosing provider
			 that is organized as a corporation or non-profit; or
(f)
										 Is a partner in
			 the disclosing provider that is organized as a partnership or limited liability
			 company.
(5)
									 "Significant business transaction" means any business
			 transaction or series of transactions that, during any one fiscal year, exceed
			 the lesser of twenty-five thousand dollars and five per cent of a provider's
			 total operating expenses.
(6)
									 "Indirect ownership interest" means an ownership
			 interest in an entity that has direct or indirect ownership in the disclosing
			 provider.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.3 - Provider disclosure requirements

Current through all regulations passed and filed through July 1, 2024
(A)
								For the purposes
			 of this rule, the following definitions apply:
(1)
									"Affiliation" has
			 the same meaning as in 42
			 C.F.R. 455.101 (as in effect on October 1,
			 2023).
(2)
									"Agent" has the same meaning as in
			 42 C.F.R.
			 455.101 (as in effect on October 1,
			 2023).
(3)
									"Disclosable event" has the same meaning as in
			 42 C.F.R.
			 455.101 (as in effect on October 1,
			 2023).
(4)
									"Disclosing provider" means a medicaid provider,
			 managed care entity, or fiscal agent under contract with the department of
			 medicaid (department) in accordance with
			 42 C.F.R.
			 455.101 (as in effect on October 1,
			 2023).
(5)
									"Indirect ownership interest" means an ownership
			 interest in an entity that has direct or indirect ownership in the disclosing
			 provider.
(6)
									"Managing employee" has the same meaning as in
			 42 C.F.R.
			 455.101 (as in effect on October 1,
			 2023).
(7)
									"Person with an ownership or control interest" means a
			 person or corporation that meets any of the following:
(a)
										Has an ownership
			 interest totaling five per cent or more in the disclosing
			 provider;
(b)
										Has an indirect ownership interest equal to five per
			 cent or more in the disclosing provider;
(c)
										Has a combination
			 of direct and indirect ownership interest equal to five per cent or more in the
			 disclosing provider;
(d)
										Owns an interest of five per cent or more in any
			 mortgage, deed of trust, note, or other obligation secured by the disclosing
			 entity if that interest equals at least five per cent of the value of the
			 property or assets of the disclosing provider;
(e)
										Is an officer or
			 director of the disclosing provider that is organized as a corporation or
			 non-profit; or
(f)
										Is a partner in the disclosing provider that is
			 organized as a partnership or limited liability company.
(8)
									"Significant business transaction" has the same meaning as
			 in 42 C.F.R.
			 455.101 (as in effect on October 1,
			 2023).
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.5 - Suspension of medicaid provider agreements

Current through all regulations passed and filed through July 1, 2024
(A)
								
			 Definitions:
(1)
									 "Credible allegation of fraud" means an accusation of
			 fraud as defined in section
			 5164.36 of the Revised
			 Code.
(2)
									 "Non-institutional provider" means any person or
			 entity with a medicaid provider agreement other than a hospital, long-term care
			 nursing facility, intermediate care facility for individuals with intellectual
			 disabilities or medicaid contracting managed care plans.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.6 - Termination and denial of provider agreement

Current through all regulations passed and filed through July 1, 2024
(A) For purposes of this rule, the following
			 definitions apply:
(1) "Ownership or control interest" means
			 having at least five per cent ownership, or interest,
			 either directly, indirectly, or in any combination.
(2) "Provider"
			 
									has
			 the same meaning as "eligible provider," as defined in rule
			 5160-1-17 of the Administrative Code.
(3) "Provider Agreement" means an agreement
			 as defined in rule 5160-1- 17.2 of the Administrative Code or any rule
			 contained in agency
									5160 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.7 - Application by a former participating medicaid provider to resume participation in the Ohio medicaid program [except for medicaid contracting managed care plans (MCPs)]

Current through all regulations passed and filed through July 1, 2024
(A) An individual or entity that at one time
			 was a participating provider in the Ohio medicaid program and whose provider
			 agreement was terminated either voluntarily or involuntarily in accordance with
			 rule 
								5160-1- 17.6 of the Administrative Code must complete
			 a new application for enrollment if that individual or entity wants to resume
			 participation in the Ohio medicaid program.
(B) In considering an application for
			 participation in the Ohio medicaid program by a former medicaid provider
			 described in paragraph (A) of this rule, and except as provided by paragraphs
			 (C) and (D) of this rule, the Ohio department of 
								medicaid (ODM) may grant
			 the application only if it is reasonably certain that the types of actions that
			 formed the basis for termination or exclusion have not recurred and will not
			 recur. In making this determination, ODM will
			 consider, in addition to any factors set forth in state law:
(1) The conduct of the former medicaid
			 provider from the date the provider's previous provider agreement was
			 terminated;
(2) Whether all fines,
			 and all debts due and owing, including overpayments, to any federal, state or
			 local government that relate to any of the state health care programs, have
			 been paid, or satisfactory arrangements have been made, that fulfill these
			 obligations; and
(3) Whether all
			 requirements for participation are met at the time of the application filed
			 pursuant to paragraph (A) of this rule, as evidenced by all appropriate and
			 required documentation submitted with the application by the former medicaid
			 provider.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.8 - Provider screening and application fee

Current through all regulations passed and filed through July 1, 2024
(A) In accordance with
			 42 C.F.R.
			 455.410 (as in effect
			 October
			 1, 2019) and rule
			 5160-1-17 of
			 the Administrative Code in order to become an eligible provider, a provider
			 must meet the screening requirements described in this rule and in section
			 5164.34 of the Revised Code and
			 pay an applicable application fee if required in the appendix to this rule.
			 Provider screening and application fees are required at the time of enrollment
			 and revalidation as defined in rule 5160-1-17.4 of the Administrative Code.
(1) Exemptions.
(a) If a provider is required to participate
			 in the medicare program as a condition of enrollment in medicaid or elects to
			 participate in the medicare program and has met the provider screening
			 requirements and paid an applicable application fee to the centers for medicare
			 and medicaid services (CMS) or its designee, the provider is exempt from the
			 application fee requirements set forth in this rule.
(b) If a provider has met the provider
			 screening requirements and paid an applicable application fee to another state
			 medicaid agency or its designee, the provider is exempt from the application
			 fee requirements set forth in this rule.
(c) A provider must provide documentation to
			 support it meets the criteria for an exemption described in paragraphs
			 (A)(1)(a) and (A)(1)(b) of this rule.
(d)
										When employed by
			 or independently contracted with an entity certified by the Ohio department of
			 mental health and addiction services, the following are exempt from the
			 provisions of paragraphs (E)(2) to (E)(4) of this rule when providing services
			 for the entity.
(i)
											Certified peer recovery supporters as defined in rule
			 5122-29-15.1 of the Administrative Code;
(ii)
											Practitioners
			 licensed or certified under Chapter 4757. of the Revised Code;
(iii)
											Practitioners
			 licensed or certified under Chapter 4758. of the Revised Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.9 - Ordering or referring providers

Current through all regulations passed and filed through July 1, 2024
(A)
								 Definitions for
			 purposes of this rule only:
(1)
									 A "participating provider" is an active provider who
			 bills the medicaid program for rendered services, or who is an active provider
			 who orders, prescribes, refers, or certifies but does not bill the medicaid
			 program.
(2)
									 An "ordering or referring only provider" is a provider
			 who orders, prescribes, refers, or certifies an item or service reported on a
			 claim, and is not a billing provider in the medicaid program. For example: a
			 provider orders items or services for the medicaid consumer, such as
			 prescription drugs, durable medical equipment, prosthetics, orthotics, and
			 supplies, clinical laboratory services, or imaging services, and may certify
			 home health services for a medicaid consumer.
(3)
									 "Physician" or
			 "supervising physician" means an individual authorized to practice medicine in
			 Ohio or another state.
(4)
									 "Other professional" means those providers, other than
			 physicians, who order, prescribe, refer, or certify an item or service reported
			 on a claim. Examples include but are not limited to: physician assistant,
			 clinical nurse specialist, nurse practitioner, clinical psychologist, certified
			 nurse midwife, clinical social worker, and interns, residents, and
			 fellows.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-17.12 - Qualified entity requirements and responsibilities for determining presumptive eligibility

Current through all regulations passed and filed through July 1, 2024
The Ohio department of medicaid (ODM)
				authorizes qualified entities (QEs) to determine presumptive eligibility (PE)
				based on self-attested information to grant immediate medicaid coverage to
				certain individuals seeking medicaid covered services. This rule sets forth
				eligibility requirements and responsibilities to maintain designation as a
				QE.
(A)
								For the purposes of this rule, "qualified entity" has the
			 same meaning as defined in rule
			 5160:1-1-01
			 of the Administrative Code.
(B)
								To become a QE,
			 the eligible entity must:
(1)
									Have an active provider agreement in accordance with
			 rule 5160-1-17.2 of the Administrative Code;
(2)
									Read the
			 presumptive eligibility training guide found on the ODM website,
www.medicaid.ohio.gov
; and
(3)
									Attest that it will meet the terms and conditions as a
			 QE by reading, signing, and sending ODM form 10252 "acknowledgment of terms and
			 conditions governing the presumptive eligibility determinations authority
			 granted by the Ohio department of medicaid to a qualified entity" (rev.
			 8/2019), found on the ODM website,
www.medicaid.ohio.gov
.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-18 - Telehealth

Current through all regulations passed and filed through July 1, 2024
(A) For the
			 purposes of this rule, the following definitions apply:
(1) "Patient site" is the physical location
			 of the patient at the time a health care service is provided through the use of
			 telehealth.
(2) "Practitioner site"
			 is the physical location of the treating practitioner at the time a health care
			 service is provided through the use of telehealth.
(3) "Telehealth" is the direct delivery of
			 health care services to a patient related to diagnosis, treatment, and
			 management of a condition.
(a) Telehealth is
			 the interaction with a patient via synchronous, interactive, real-time
			 electronic communication comprising both audio and video elements; or
(b) The following activities that are
			 asynchronous or do not have both audio and video elements:
(i) Telephone calls;
(ii) Remote patient monitoring; and
(iii) Communication with a patient through
			 secure electronic mail or a secure patient portal.
(c) For services rendered by behavioral
			 health providers as defined in rule
			 5160-27-01 of the Administrative
			 Code, telehealth is defined in rule
			 5122-29-31 of the Administrative
			 Code.
(d) Conversations or
			 electronic communication between practitioners regarding a patient without the
			 patient present is not considered telehealth unless the service would allow
			 billing for practitioner to practitioner communication in a non-telehealth
			 setting.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-19 - Submission of medicaid claims

Current through all regulations passed and filed through July 1, 2024
(A)
								Unless otherwise
			 directed by the Ohio department of medicaid (ODM), paper claims will not be
			 accepted. Except as otherwise provided in section
			 5164.46 of the Revised Code or a
			 state agency's interagency agreement, claims are to be submitted directly to
			 ODM through one of the following formats:
(1)
									Electronic data
			 interchange (EDI), in accordance with rule
			 5160-1-20 of the Administrative
			 Code.
(2)
									The ODM provider web portal; or
(3)
									Pharmacy
			 point-of-sale.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-25 - Interest on overpayments made to medicaid providers

Current through all regulations passed and filed through July 1, 2024
(A) Except for
			 medicaid contracting managed care plans (MCPs), and nursing facilities and
			 intermediate care facilities for individuals with
			 intellectual disabilities (ICF/IID)
								 rate recalculations performed in accordance
			 with sections
			 5165.41 and
			 5124.41
								
								 of the
			 Revised Code, any provider of services or
			 goods contracting with the Ohio department of medicaid
			 (ODM)
			 pursuant to Title XIX of the Social Security Act who, without intent, obtains
			 payment from the medicaid program in excess
			 of the amount to which the provider is entitled becomes liable for payment of
			 interest charged in accordance with this rule on the amount of the overpayment.
			 The interest rate charged is the average bank prime
			 rate in effect on the first day of the calendar quarter during which the
			 provider receives notice of the excess payment,
								as determined in accordance
			 with section
			 5164.60
								 of the Revised
			 Code. Interest payments shall
			 be calculated on the basis of simple interest.
(B) Interest payments shall be charged on a
			 daily basis for the period from the date the payment was made to the date upon
			 which repayment is received by the state.
(C) The "date payment was made" shall mean
			 the following:
(1) For any reasonable cost
			 basis, prospective payment basis, or other cost-related rate final settlement
			 issued by ODM, the "date payment was made" shall be ten days
			 from the date the final settlement is received by the provider as shown by the
			 U.S. postal service return receipt slip, with a notice of rights to appeal
			 pursuant to Chapter 119. of the Revised Code.
(2) For audits conducted in accordance with
			 rule 5160-1-27 of the Administrative Code, the "date
			 payment was made" shall be the latest date a warrant or electronic funds
			 transfer (EFT) was issued to pay an item included in the random
			 sample.
(3) For post-payment
			 reviews conducted in accordance with rule 5160-1-27
			 of the Administrative Code, the "date payment was made" shall be the latest
			 date a warrant or EFT was issued in payment of a claim that is included in the
			 review.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-27.1 - Hold and review process

Current through all regulations passed and filed through July 1, 2024
(A) "Hold and Review" is defined in
			 accordance with rule 5160-1-27 of the Administrative Code.
(1) Hold and review without prior
			 notification.
(a) The Ohio department
			 of medicaid (ODM) may place a medicaid provider's
			 claim(s) payment on hold and review, in whole or in part, without first
			 notifying the provider for the following reasons:
(i) In response to allegations of fraud or
			 other willful misrepresentation of claims submission; or
(ii) When a provider has been indicted for a
			 criminal offense.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-27.2 - Medicaid hold and review process for medicaid claims paid through state agencies other than the Ohio department of medicaid

Current through all regulations passed and filed through July 1, 2024
(A) "Medicaid administrative agency" means a
			 state agency other than the Ohio department of medicaid
			 that:
(1) Administers a component of the
			 medicaid program under the terms of a contract with ODM under
			 section 
										5162.35
									 of the Revised
			 Code; and
(2) Pays claims for
			 medicaid services or reimburses local entities for claims paid for medicaid
			 services.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-29 - Medicaid fraud, waste, and abuse

All regulations passed and filed
  through January 1, 2024
(A) For purposes of this rule, the following
  definitions apply:
(1)
									"Abuse" has the same meaning as in
  42 C.F.R.
  455.2 (as in effect on October 1,
  2023).
(2)
									"Fraud" has the same meaning as in
  42 C.F.R.
  455.2 (as in effect on October 1,
  2023).
(3)
									"Waste" means any preventable act such as inappropriate
  utilization of services or misuse of resources that results in unnecessary
  expenditures to the medicaid program.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-31 - Prior authorization

Current through all regulations passed and filed through July 1, 2024
(A)
								Reimbursement for
			 certain items or services covered under the medicaid program is dependent on
			 obtaining prior authorization from the Ohio department of medicaid (ODM), its
			 designee, or a medicaid managed care entity (MCE). Prior authorization requests
			 have to be approved by ODM, its designee, or MCE before the services are
			 rendered or the items are delivered unless the services or items meet the
			 provisions stated in section 5160.34 of the Revised Code or paragraph (D) of
			 this rule.
(B)
								Except as authorized under section 5160.34 of the
			 Revised Code, prior authorization requests submitted via paper cannot be
			 processed. All other prior authorization requests should be submitted pursuant
			 to the instructions located at
www.medicaid.ohio.gov
.
(C)
								For services or items requiring prior authorization,
			 only those approved in the prior authorization determination will be eligible
			 for reimbursement.
(D)
								The following exceptions to prior authorization
			 apply:
(1)
									In
			 situations where the provider considers a delay in providing services or an
			 item requiring prior authorization to be detrimental to the health of the
			 medicaid recipient, the services or item may be rendered or delivered and
			 approval for reimbursement sought after the fact.
(2)
									In cases of
			 emergency, for prescribed drugs requiring prior authorization, the prescribed
			 drug may be rendered without prior authorization in accordance with rule
			 5160-9-03 of the Administrative Code.
(3)
									In the discretion
			 of and as instructed by ODM, a retroactive prior authorization may be
			 sought.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-32 - Medicaid: safeguarding and releasing information

Current through all regulations passed and filed through July 1, 2024
(A)
								"Safeguarded
			 information" includes but is not limited to the following types of
			 information:
(1)
									Names and addresses; and
(2)
									Social security
			 numbers; and
(3)
									Medical services provided; and
(4)
									Social and
			 economic conditions or circumstances; and
(5)
									Agency evaluation
			 of personal information; and
(6)
									Medical data,
			 including diagnosis and past history of disease or disability;
			 and
(7)
									Any information received in connection with the
			 identification of third party coverage; and
(8)
									Any information
			 received for verifying income eligibility and amount of medical assistance
			 payments. Income information received from the social security administration
			 (SSA) or the internal revenue service (IRS) must be safeguarded according to
			 the requirements of the agency that furnished the data.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-32.1 - Standard authorization form

Current through all regulations passed and filed through July 1, 2024
(A)
								In accordance
			 with section 3798.10 of the Revised Code, a
			 standardized authorization form that meets all requirements specified in
			 45
			 C.F.R. 164.508 and, where applicable, 42
			 C.F.R Part 2 as in effect on October 1, 2018, for the use and disclosure of
			 protected health information is found in appendix A to this
			 rule.
(B)
								If the standardized authorization form is properly
			 executed, and adequately identifies the individual identified in section I of
			 the form found in appendix A to this rule, by either an individual or the
			 individual's personal representative, it shall be accepted by any person or
			 governmental entity in this state as valid authorization for the use or
			 disclosure of the individual's protected health information to the persons or
			 governmental entities specified in the form. Please use the instructions found
			 in appendix B to this rule to assist with completing the standard authorization
			 form.
(C)
								A person or governmental entity is not precluded from
			 accepting as valid authorization for the use or disclosure of protected health
			 information a form other than the form prescribed in paragraph (A) of this rule
			 if the other form meets all requirements specified in
			 45
			 C.F.R. 164.508 and, if applicable, 42 C.F.R
			 Part 2 as in effect on October 1, 2018.
(D)
								Nothing in this
			 rule shall require obtaining authorization or use of the form found in appendix
			 A to this rule when use or disclosure of the information is required or
			 permitted without such authorization by 45 C.F.R. Chapter A, Subchapter C and,
			 if applicable, 42 C.F.R. Part 2 as in effect on October 1,
			 2018.
(E)
								The standard authorization form must be accepted
			 state-wide thirty days post effective date.
Appendix A
Appendix B
Click to
				view Appendix
Click to
				view Appendix
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-33 - Medicaid: authorized representatives

Current through all regulations passed and filed through July 1, 2024
(A)
								Designation of an
			 authorized representative.
(1)
									An individual may designate any person or organization
			 to serve as that individual's authorized representative. Any person serving as
			 an authorized representative must be at least eighteen years or
			 older.
(2)
									Authority for a person or organization to act on behalf
			 of the individual accorded under state law, including but not limited to, a
			 court order establishing legal guardianship, must be treated as a written
			 designation by the individual of authorized representation.
(3)
									The designation
			 of an authorized representative must be in writing, and must identify what
			 duties the individual is authorizing the representative to
			 perform.
(4)
									If the designated authorized representative is
			 unwilling or unable to accept the responsibility of being an authorized
			 representative, the authorized representative must inform the administrative
			 agency and the individual of the refusal or withdrawal.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-39 - Verification of home care service provision to home care dependent adults

Current through all regulations passed and filed through July 1, 2024
(A) Home care
			 service providers, as defined in this paragraph, must have a system as follows.
(1) Definitions.
(a) "Home care dependent adult" means a
			 consumer who:
(i) Resides in a private home or
			 other non-institutional, unlicensed living arrangement without a parent or
			 guardian present;
(ii) Requires,
			 due to health and safety needs, regularly scheduled home care services to
			 remain in the home or other living arrangement; and,
(iii) Is sixty years of age or older, or is
			 at least twenty-one years of age but less than sixty years of age, and has a
			 physical disability or mental impairment.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-42 - Provider credentialing

Current through all regulations passed and filed through July 1, 2024
In accordance with the federal
				credentialing standards found in
				42 CFR
				422.204, "provider selection and
				credentialing" (as in effect on October 1, 2021), this rule details the
				credentialing and recredentialing process for medicaid providers.
(A)
								For purposes of
			 this rule, the following definitions apply.
(1)
									"Council for
			 affordable quality healthcare (CAQH)" is a non-profit organization which
			 created a process allowing ODM to use a single, uniform application for
			 credentialing. This end-to-end process simplifies data collection, primary
			 source verification, and sanctions monitoring, to support ODM's credentialing
			 needs.
(2)
									"Credentialing" means an evaluation of the
			 qualifications of health care providers that seek contracts or participation
			 agreements with ODM.
(3)
									"Credentialing committee" means the group of
			 individuals appointed by ODM for provider and facility review, as well as
			 reconsidering providers and facilities initially denied by credentialing as
			 described in paragraph (K) of this rule.
(4)
									"Delegate" means
			 a hospital group or physician hospital organization formed by a hospital and
			 group of physicians granted the authority by ODM to credential its health care
			 providers who require credentialing.
(5)
									"Delegation"
			 means the act of ODM granting another health care entity the authority to
			 credential its health care providers who require credentialing.
(6)
									"Designee" means
			 a third party with whom ODM has contracted to complete certain credentialing
			 related administrative tasks and information gathering tasks required to
			 fulfill credentialing and re-credentialing for those providers whose
			 credentialing is not completed through the process of delegation;
			 and
(7)
									"Eligible provider" has the same meaning as a person or
			 entity who is an eligible provider as defined in rule
			 5160-1-17 of
			 the Administrative Code who is enrolled with ODM.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-42.1 - Delegated credentialing

Current through all regulations passed and filed through July 1, 2024
(A)
								The Ohio
			 department of medicaid (ODM) authorizes eligible provider delegates to perform
			 credentialing activities on behalf of individual providers in accordance with
			 rule 5160-1-42 of the Administrative
			 Code.
(B)
								"Delegate" and "Delegation" have the same meaning as in
			 rule 5160-1-42 of the Administrative
			 Code.
(C)
								Entities seeking delegation will be expected to meet
			 the following criteria to become an authorized delegate and to maintain
			 delegate status:
(1)
									Be an eligible provider as defined in rule
			 5160-1-17 of the Administrative
			 Code:
(2)
									Participate with home-state agency that administers
			 titles XIX (medicaid), XXI (children's health insurance program - CHIP), or
			 XVIII (medicare) of the Social Security Act;
(3)
									Be based in Ohio
			 or a contiguous state;
(4)
									Have at least fifty Ohio medicaid enrolled and active
			 affiliated individual providers;
(5)
									Submit to the
			 credentialing department a request in writing; and
(6)
									Complete a
			 pre-delegation audit conducted by ODM to include review of the following
			 information maintained by the delegate:
(a)
										Credentialing
			 policies and procedures;
(b)
										Sample of practitioner credentialing
			 files;
(c)
										Credentialing meeting minutes; and
(d)
										Ongoing sanctions
			 monitoring.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-60 - Medicaid payment

Current through all regulations passed and
  filed through July 1, 2024
(A) The medicaid payment for a covered
  procedure, service, or supply constitutes payment in full and may not be
  construed as a partial payment when the payment amount is less than the
  provider's submitted charge. A provider may not collect from a medicaid
  recipient nor bill a medicaid recipient for any difference between the medicaid
  payment and the provider's submitted charge, nor may a provider ask a medicaid
  recipient to share in the cost through a deductible, coinsurance, copayment, or
  other similar charge other than medicaid copayments as defined in rule
  5160-1-09 of the Administrative
  Code. Nothing in agency 5160 of the Administrative Code, however, precludes a
  provider from requesting payment, collecting, or waiving the collection of
  medicare copayments from a medicaid recipient for medicare part D services.
  Medicaid recipient liability provisions set forth in rule
  5160-1-13.1 of the
  Administrative Code do not apply to medicare part D services.
(B) Providers are expected to submit their
  usual and customary charge (the amount charged to the general public) on all
  claims. The medicaid payment amount for a covered service, procedure, or supply
  is the lesser of the submitted charge or the established medicaid maximum.
  Medicaid maximum payment amounts for many existing services, procedures, and
  supplies, particularly services rendered by practitioners of the healing arts,
  are set forth in the appendix to this rule. The initial maximum payment amount
  for a covered procedure, service, or supply represented by a new procedure code
  that takes effect at the beginning of a calendar year is established in
  accordance with paragraph (J) of this rule. Specific payment amounts or payment
  formulas set forth in other rules in agency 5160 of the Administrative Code
  supersede corresponding entries in the appendix to this rule.
(C) Pursuant to rule
  5160-1-08 of the Administrative
  Code, providers are expected to take reasonable measures to determine any
  third-party resource available to a medicaid recipient and to file a claim with
  that third party when required to do so under rule
  5160-1-08 of the Administrative
  Code. When there is a third-party payer, medicaid payment for a covered
  procedure, service, or supply is the lesser of two amounts:
(1) The provider's submitted charge;
  or
(2) The medicaid maximum payment
  amount less the sum of all third-party payments and any applicable medicaid
  copayment (unless the difference is zero or less, in which case medicaid will
  make no further payment).