reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-22 - DMEPOS: ventilators

Current through all regulations passed and filed through July 1, 2024
(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 to a resident of a longterm care facility
			 (LTCF).
(2) Payment may be made for
			 a ventilator on a rental basis only. The default certificate of medical
			 necessity (CMN) form is the ODM 01902, "Certificate of Medical Necessity:
			 Ventilators" (rev. 
									7/2021).
(3) For the rental of a primary ventilator,
			 
									a CMN includes the following information:
(a) Diagnosis;
(b) Specification of the condition or
			 conditions for which ventilatory support is needed;
(c) An estimated length of need;
(d) The continuity of ventilatory support
			 
										needed (
			 constant, during the day, at night, for sleep only);
(e) The ventilator type, mode, and settings
			 or parameters;
(f) A list of other
			 respiratory equipment in use; and
(g) If applicable, documentation showing that
			 the individual is being weaned.
(4) For the rental of a secondary or back-up
			 ventilator, the CMN 
									includes appropriate attestation to at least one
			 of the following statements:
(a) The
			 individual cannot maintain spontaneous respiration for at least four
			 hours;
(b) Because of regular
			 activities outside the home 
										such as school
										or outpatient
			 therapy), the individual needs a second ventilator with a suitable power
			 source; or
(c) The average
			 emergency medical team response time to the individual's address is estimated
			 to be more than two hours.
(5)
									A multi-function
			 ventilator is an all-in-one device that also has the capability to perform the
			 functions of other respiratory equipment such as an oxygen concentrator, a
			 nebulizer, a suction device, or a cough-assist device. A device that may serve
			 either as a ventilator or as a positive airway pressure device but not as both
			 simultaneously is not a multi-function ventilator.
(a)
										Payment may be
			 made for a multi-function ventilator only if at least one additional function
			 ("ventilator plus one") is used.
(b)
										For each
			 additional function, whether included when the unit is first dispensed or
			 activated later, the appropriate CMN applies. A prescription is sufficient when
			 no CMN is specified for a particular function.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-23 - DMEPOS: pulse oximeters

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1)
									
									Payment may be made only for a pulse oximeter that
			 meets the following criteria:
(a) It is
			 correctly calibrated, preset, and sealed such that its settings cannot be
			 adjusted by the average user; and
(b) It is capable either of converting data
			 (e.g., number of sampling hours, oxygen saturation level, aggregated results)
			 directly to electronic or printed form or of recording and storing data for
			 later conversion.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-25 - DMEPOS: lactation pumps

Current through all regulations passed and filed through July 1, 2024
(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 individual,
			 which reduces the risk of contamination. It generally features adjustable
			 suction pressure and adjustable pumping speed. It is intended only for
			 temporary, short-term use.
(2)
									The prescriber of
			 a lactation pump may be involved in the care of the individual woman, of the
			 infant, or of both.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-26 - DMEPOS: nutrition products

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1) Enteral and parenteral nutrition.
(a) The default certificate of medical
			 necessity (CMN) form is the ODM 01907, "Certificate of Medical Necessity:
			 Enteral and Parenteral Nutrition" (rev. 
										7/2024). The
			 CMN 
										includes the following information:
(i) Attestation to one of the following
			 statements:
(a) The individual is able to
			 ingest food but cannot derive sufficient energy and nutrients from ordinary
			 food, even if the food is prepared in a liquefied, puréed, or blended
			 form;
(b) The individual is unable
			 to ingest food safely but can digest it; or
(c) The individual is unable to digest food
			 in the alimentary canal and must obtain nutrition parenterally.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-27 - DMEPOS: continuous passive motion (CPM) devices

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1)
									No particular
			 form or format is specified for the certification of medical
			 necessity.
(2) Payment may be made
			 for the rental of a continuous passive motion (CPM) device to be used in a
			 personal residence, beginning within forty-eight hours after total knee
			 replacement surgery or the surgical revision of a total knee replacement, for a
			 period not to exceed twenty-one days. 
									On the prescription for the device,
									
			 the first date and last date of use are
			 indicated.
(3) Separate payment
			 may be made for the purchase of one complete set of accessories (e.g., pads,
			 straps, hook-and-loop closures) if the individual does not already have such
			 accessories as a result of previous use of a CPM device.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-29 - DMEPOS: insulin pumps

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Sensor-augmented insulin pump system" is
			 an insulin infusion pump equipped with a continuous glucose monitoring (CGM)
			 sensor. The pump uses the glucose readings taken by the CGM sensor to modify
			 the amount of insulin infused.
(2)
			 "Insulin pump," for purposes of this rule, is a collective term encompassing a
			 portable external insulin infusion pump and a sensor-augmented insulin pump
			 system.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-30 - DMEPOS: ambulation aids

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Ambulation aid" is a collective term for
			 a cane, crutch, or walker.
(2)
			 "Ambulatory limitation" is an impediment to walking that has either of two
			 effects:
(a) It prevents an individual from
			 completing activities of daily living within a reasonable time (or at all);
			 or
(b) It places an individual at a
			 demonstrably higher risk of injury, exacerbation of illness, or death when
			 activities of daily living are performed.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-31 - DMEPOS: footwear and foot orthoses

Current through all regulations passed and filed through July 1, 2024
(A) Orthopedic shoes.
(1)
									No particular
			 form or format is specified for the certification of medical
			 necessity.
(2) Payment may be made
			 for an orthopedic shoe only if at least one of the following conditions is met:
(a) The shoe is an integral part of an
			 orthotic device (brace);
(b) The
			 shoe has been molded specifically for the 
										individual;
(c) The shoe is one of a mismated
			 pair;
(d) The shoe is used to treat
			 talipes equino varus (club foot);
(e) For an individual younger than
			 eight years of age, the shoe is used independently of an orthotic device for
			 one of the following purposes:
(i) Treatment
			 of metatarsus adductus, femoral torsion, tibial torsion, vertical talus,
			 fracture of a major bone, or osteochondrosis; or
(ii) Post-surgical control;
(f) For 
										an
			 individual eight years of age or older, the shoe is used for treatment of
			 moderate or severe peripheral neuropathy or peripheral arterial disease;
			 or
(g) A modification or addition
			 to the shoe is medically necessary and has been prescribed by a physician, an
			 advanced practice registered nurse, or a physician assistant.
(3) Greater frequency
			 of shoe replacement may be allowed for 
									individuals younger than eight years of age. Payment
			 for shoe replacement beyond an established frequency for
			 
									individuals younger than twenty-one years of age
			 
									is subject
			 to prior authorization (PA).
(4) No payment is made
			 for an orthopedic shoe that is to be worn over a prosthesis.
(5)
			 Payment for a foot orthosis includes the acquisition (by casting or other
			 means) of the model on which the orthosis is constructed.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-32 - DMEPOS: ostomy supplies and urological supplies

Current through all regulations passed and filed through July 1, 2024
(A)
								No particular
			 form or format is specified for the certification of medical necessity.
(B)
								Stoma maintenance supplies. If more than one type
			 of supply serve the same function, then payment may be made only for the
			 dispensing of one type at a time (e.g., skin barrier applied as a liquid, in a
			 spray, or with a wipe or swab; drainage management with a stoma cap, a stoma
			 plug, or gauze pads).
(C) Urination aids.
(1) Indwelling catheters.
(a) Frequency limits imposed on catheter
			 replacement may be exceeded without prior authorization (PA) for
			 
										reasons
			 including but not limited to  the following 
										examples:
(i) Accidental removal of a
			 catheter;
(ii) Malfunction of a
			 catheter;
(iii) Obstruction of a
			 catheter by encrustation, mucus plug, or blood clot; or
(iv) A history of recurrent obstruction or
			 infection, as a precaution against which the prescriber has specified more
			 frequent changing of the catheter.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-34 - DMEPOS: wound dressings and related supplies

Current through all regulations passed and filed through July 1, 2024
(A) Coverage.
(1)
									No particular
			 form or format is specified for the certification of medical
			 necessity.
(2) Payment may be made
			 for wound dressings and related supplies as long as medical necessity
			 exists.
(3) Payment may be made
			 for dressings placed over a percutaneous catheter or tube as long as the
			 catheter or tube remains in place and after removal until the insertion point
			 heals.
(4) Clinical
			 indications, contraindications, and application guidelines for certain types of
			 wound dressing are summarized in the appendix to this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-35 - DMEPOS: cranial remolding devices

Current through all regulations passed and filed through July 1, 2024
(A)
								No particular
			 form or format is specified for the certification of medical
			 necessity.
(B)
								
								Payment may be
			 made only for a cranial remolding device 
								that
			 meets the standards established by the United States food and drug
			 administration for a class II medical device.
(C) Payment may be made
			 for the purchase of a cranial remolding device to treat any of the following
			 conditions if the associated criteria are met.
(1) Positional (non-synostotic)
			 plagiocephaly:
(a) The individual is at least
			 three months old but not older than eighteen months;
(b) Any of the following asymmetries is
			 present:
(i) A right/left discrepancy in the
			 skull base of at least six millimeters, measured subnasally to the
			 tragus;
(ii) A right/left
			 discrepancy in the cranial vault of at least ten millimeters, measured from the
			 frontozygomaticus point to the euryon; or
(iii) A right/left discrepancy in the
			 orbitotragial distances of at least four millimeters; and
(c) The asymmetry has not substantially
			 improved after two months of conservative cranial repositioning therapy or
			 physical therapy.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-36 - DMEPOS: continuous glucose monitors

Current through all regulations passed and filed through July 1, 2024
(A)
								Definition.
			 "Continuous glucose monitor (CGM)" is a device that can constantly measure
			 glucose levels in interstitial body fluid. The sensor, transmitter, and
			 receiver may be separate parts or may be combined. The receiver may have the
			 capacity to record data.
(B)
								Coverage.
(1)
									This rule does not apply to either of the following
			 items:
(a)
										An
			 insulin infusion pump into which a continuous glucose monitoring sensor is
			 integrated, coverage and payment policies for which are addressed in rule
			 5160-10-29
			 of the Administrative Code; or
(b)
										A disposable
			 tubeless subcutaneous insulin administration device, which is covered as a
			 pharmacy benefit in accordance with Chapter 5160-9 of the Administrative
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-11 - Independent Laboratory and X-Ray Services › Section 5160-11-21 - Portable x-ray supplier services

Current through all regulations passed and filed through July 1, 2024
(A)
								Providers. An
			 entity may enroll in medicaid as a portable x-ray supplier only if it complies
			 with the conditions set forth in 42 C.F.R. part 486 subpart C (October 1,
			 2020).
(B)
								Coverage.
(1)
									The radiology procedures performed by a portable x-ray
			 supplier have both a professional component and a technical component.
(a)
										In general, a
			 portable x-ray supplier performs the technical component of a
			 procedure.
(b)
										A portable x-ray supplier may receive payment for the
			 technical component alone if it performs only the technical component and the
			 professional component is performed by a physician or other qualified
			 healthcare professional not associated with the portable x-ray supplier by
			 ownership, employment, or contract (e.g., interpretation of an x-ray is
			 performed by an individual's treating practitioner).
(c)
										A portable x-ray
			 supplier may receive payment for a global procedure if it performs both the
			 professional and the technical components and the professional component is
			 performed by a physician or other qualified healthcare professional who owns,
			 is employed by, or is under contract with the portable x-ray
			 supplier.
(d)
										A portable x-ray supplier cannot receive payment for
			 the professional component alone.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-11 - Independent Laboratory and X-Ray Services › Section 5160-11-31 - Independent diagnostic testing facility (IDTF) services

Current through all regulations passed and filed through July 1, 2024
(A)
								Providers.
(1)
									An entity may enroll in medicaid as an independent
			 diagnostic testing facility (IDTF) only if it meets the following
			 criteria:
(a)
										It
			 meets all standards set forth in and provide services in accordance with
			 42 C.F.R.
			 410.33 (October 1, 2020);
(b)
										It takes the
			 following measures to establish accountability:
(i)
											It ensures that
			 each supervising practitioner attests in writing, at the time of the initial
			 application and at each renewal of the Ohio medicaid provider agreement, that
			 one of two statements is true:
(a)
												The practitioner owns the facility, in whole or in
			 part, and employs the operating personnel; or
(b)
												The practitioner
			 works for the facility either as an employee (full-time or part-time) or under
			 contract and has responsibilities that include checking the procedure and
			 quality control manuals; observing the performance of operators or technicians;
			 verifying that the equipment and personnel meet applicable conditions for
			 federal, state, and local licensure and registration; and ensuring that safe
			 operating procedures and quality control procedures are used;
(ii)
											It
			 maintains and updates procedure and quality control manuals;
			 and
(iii)
											It keeps all records of quality control must be kept
			 for the period of time specified in rule 5160-1-17.2 of the Administrative
			 Code; and
(c)
										It performs only procedures that are not subject to the
			 "Clinical Laboratory Improvement Amendments of 1988" (CLIA, Pub. L. No.
			 100-578,
			 42 U.S.C.
			 263a as in effect on January 1,
			 2021).
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-01 - Home health services: provision requirements, coverage and service specification

Current through all regulations passed and filed through July 1, 2024
(A) "Home health services" includes home
			 health nursing, home health aide services and skilled therapies.
(B) Home health services are reimbursable
			 only if a qualifying treating physician, advance
			 practice nurse or physician assistant certifying the need for home health
			 services documents that he or she had a face-to-face encounter with the
			 individual within ninety days prior to the start of care date, or within thirty
			 days following the start of care date. To be a qualifying treating physician,
			 the physician will be a doctor of medicine or osteopathy legally
			 authorized to practice medicine and surgery as authorized under Chapter 4731.
			 of the Revised Code. Advanced practice registered nurses in accordance with
			 rule
			 5160-4-04
			 of the Administrative Code  or a physician assistant in
			 accordance with rule
			 5160-4-03 of
			 the Administrative Code  have the authority to conduct the
			 face-to-face encounter .
			 The face-to-face encounter with the individual will occur
			 independent of any provision of home health services to the individual.
			 The face-to-face encounter may be completed using
			 telehealth. The face-to-face encounter will be
			 documented as follows:
(1) For home health
			 services unrelated to an inpatient hospital stay, the face-to-face encounter
			 will be
			 documented by the qualifying treating physician,
			 advance practice nurse or physician assistant using:
(a) The ODM 07137 "Certificate of Medical
			 Necessity for Home Health Services and Private Duty Nursing Services" (rev.
			 2/2016) or
(b) The individual's
			 plan of care if all of the data elements specified for home health services
			 unrelated to an inpatient hospital stay on the ODM 07137 are included and the
			 plan of care contains the signature,  credentials
			 and the date of the  signature
			 of the qualifying treating physician, advance practice
			 nurse or physician assistant.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-02 - Private duty nursing services: provision requirements, coverage and service specification

Current through all regulations passed and filed through July 1, 2024
(A) "Private duty nursing (PDN)" is a
			 continuous nursing service that requires the skills of and is performed by
			 either a registered nurse (RN) or a licensed practical nurse (LPN) at the
			 direction of a registered nurse. A service is not considered a PDN service
			 merely because it was performed by a licensed nurse. A covered PDN visit must
			 meet the definition in paragraph (A) of rule
			 5160-12-04
			 of the Administrative Code and be more than four hours in length but less than
			 or equal to twelve hours in length per nurse, on the same date or during a
			 twenty-four hour time period, unless:
(1) An
			 unforseen event causes a medically necessary scheduled visit to end at four or
			 less hours, or extend beyond twelve hours, up to and including, but no more
			 than sixteen hours; or
(2) Less
			 than a two hour lapse between visits has occurred and the length of the PDN
			 service requires an agency to provide a change in staff; or
(3) Less than a two hour lapse between visits
			 has occurred and the PDN service is provided by more than one non-agency
			 provider.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-03.1 - Non-agency nurses and otherwise-accredited agencies: qualifications and requirements

Current through all regulations passed and filed through July 1, 2024
(A)
								 "Non-agency
			 nurses" and "otherwise-accredited agencies" who meet the qualifications and
			 requirements of this rule can provide private duty nursing (PDN) in accordance
			 with rule
			 5160-12-02
			 of the Administrative Code.
(B) A "non-agency
			 nurse" that meets the requirements in accordance with this rule is eligible to
			 participate in the Ohio medicaid program upon execution of a provider agreement
			 in accordance with rule 5160-1- 17.2 of the Administrative Code. A non-agency
			 nurse is required to:
(1)
									Be a
			 registered nurse or licensed practical nurse at the direction of a registered
			 nurse practicing within the scope of his or her nursing license pursuant to
			 Chapter 4723. of the Revised Code as an independent provider.
(2)
									
									Comply with the requirements of
			 a medicare
			 certified home health agency in accordance to rule
			 5160-12-03 of the Administrative Code except for
			 paragraphs (A), (B)(1) and (B)(6) of rule 5160-12-03 of the Administrative Code.
(3)
									
									Not be the
			 parent, step-parent, foster parent or legal guardian of an individual who is
			 under eighteen years of age, or the individual's spouse.
(4)
									
									Meet all conditions of
			 participation in paragraphs (C) and (D) of rule 5160-45-10 of the Administrative Code.
(5)
									 Comply with all
			 federal, state and local laws and regulations as applicable.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-04 - Home health and private duty nursing: visit policy

Current through all regulations passed and filed through July 1, 2024
(A) Reimbursement of home health or private
			 duty nursing (PDN) services in accordance with this chapter are on a per visit
			 basis. A "visit" is the duration of time that a covered home health service or
			 private duty nursing (PDN) service is provided during an in-person
			 or telehealth encounter to one or more
			 individuals receiving medicaid at the same residence on the same date during
			 the same time period.
(1) A visit begins with
			 the provision of a covered service and ends when the in-person
			 or telehealth encounter ends.
(2) A visit must have a lapse of time of two
			 or more hours between any previous or subsequent visit for the provision of the
			 same covered service unless the length of a private duty nursing visit requires
			 an agency to provide a change in staff.
(3) A visit must have a lapse of two or more
			 hours between the provision of home health nursing and PDN service.
(4) A visit must be verified using an
			 ODM-approved electronic visit verification (EVV) system in accordance with rule
			 5160-1-40
			 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-05 - Reimbursement: home health services

Current through all regulations passed and filed through July 1, 2024
(A) Definitions of terms used for billing
			 home health services rates set forth in appendix A to this rule are:
(1) "Base rate," as used in this rule and
			 appendix A to this rule, means the amount reimbursed by Ohio medicaid:
(a) For the initial thirty-five to sixty
			 minutes of home health aide service delivered;
(b) For the initial thirty-five to sixty
			 minutes of home health nursing service delivered; or
(c) Up to the first four units of initial
			 home health skilled therapy service delivered.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-06 - Reimbursement: private duty nursing services

Current through all regulations passed and filed through July 1, 2024
(A) Definitions of terms used for billing
			 private duty nursing services (PDN) rates set forth in appendix A to this rule
			 are:
(1) "Base rate," as used in this rule and
			 appendix A to this rule, means the amount reimbursed by Ohio medicaid for the
			 initial thirty-five to sixty minutes of service delivered.
(2) "Unit rate," as used in this rule and
			 appendix A to this rule, means the amount reimbursed by Ohio medicaid for each
			 fifteen minute units of service delivered when the initial visit is:
(a) Greater than sixty minutes in length;
			 or
(b) Less than or equal to
			 thirty-four minutes in length.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-07 - Reimbursement: exceptions

Current through all regulations passed and filed through July 1, 2024
Home health, RN assessment, RN
				consultation, and private duty nursing (PDN) service providers may be
				reimbursed when any of the exceptions set forth in this rule
				apply through no fault of the provider:
(A) Requirements of paragraphs (D)(2) of rule
			 
								5160-12-01 and (E)(2) of rule
			 5160-12-02 of the Administrative Code
			 
								are not
			  met 
								due to any of the following:
(1)
			 Services are not identified on the all services plan when the
			 
									individual is enrolled 
									on an
			 Ohio
			 department of medicaid (ODM)-administered waiver, and the provider has
			 documented attempts to work with the case manager and the case manager's
			 supervisors to identify the services on the all services plan. Documentation
			 shall include written proof of the provider's attempts to obtain the all
			 services plan that identifies the services. This exception does not extend to
			 instances in which the provider disagrees with the amounts of service
			 identified on the all services plan.
(2) Services are not documented on the
			 
									service plan or individual
			 service plan when the 
									individual is enrolled 
									on an
			 Ohio department of aging (ODA) or
			 department
			 of developmental disabilities (DODD)-administered waiver, and the
			 provider has documented attempts to work with the case manager and the case
			 manager's supervisors to identify the services on the
			 
									service plan. Documentation shall include written
			 proof of the provider's attempts to obtain the 
									service plan
			 that identifies the services. This exception does not extend to instances in
			 which the provider disagrees with the amounts of service identified on the
			 service plan.
(3) The provider verified and documented
			 before providing services that either:
(a) The
			 
										individual was not enrolled 
										on a home and
			 community-based services (HCBS) waiver at the initiation of services and every
			 six months thereafter,
										
										and the case manager cannot produce documentation
			 that the provider was notified that the individual had become enrolled
			 
										on an HCBS
			 waiver;
			 or
(b) The
			 
										individual was not enrolled 
										on
										a
										HCBS
			 waiver and subsequently, at any point during the delivery of services, the provider became
			 aware of the 
										individual's enrollment and the provider notified
			 the case manager and requested that the services be identified on the plan. And
			 the case manager cannot produce documentation that the provider was notified
			 that the individual had become enrolled
			 
										on
										
										a HCBS
			 waiver.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-12 - Ohio Home Care Program › Section 5160-12-08 - Registered nurse assessment and registered nurse consultation services

Current through all regulations passed and filed through July 1, 2024
(A) For the purpose
			 of this rule:
(1) A "plan of care" is the
			 medical treatment plan that is established, approved, and signed by a treating
			 physician, advance practice nurse or physician's assistant in accordance with
			 the Coronavirus Aid, Relief, and Economic Security (CARES) Act, S.3548 (2020),
			 prior to a provider requesting reimbursement for a service. The plan of care
			 has the same meaning as set forth in rule
			 5160-51-01
			 of the Administrative Code and is not the same as an all services plan,
			 individual service plan, or helping Ohioans move expanding choice (HOME choice)
			 service plan.
(2) A "registered
			 nurse (RN) assessment" is the medicaid service performed by an RN pursuant to
			 paragraphs (B) and (D) of this rule. It may include a recommendation subject to
			 orders written by the treating physician, but not a determination of the amount
			 or duration of nursing services. The RN assessment may be completed using
			 telehealth.
(3) An "RN
			 consultation" is a face-to-face or telephone contact between a directing RN and
			 a licensed practical nurse (LPN) pursuant to paragraphs (C) and (D) of this
			 rule, when an individual experiences a significant change that necessitates a
			 change in the existing interventions the LPN must perform during a nursing
			 service visit, and that will result in a change in the individual's plan of
			 care. RN consultation does not replace routine direction and supervision
			 provided by an RN to an LPN where evidence of significant change does not exist
			 and/ or does not necessitate a change in the LPN's intervention or the
			 individual's plan of care.
(4) A
			 "significant change" is a change experienced by an individual that warrants an
			 RN assessment. Significant changes may include, but are not limited to, a
			 change in health status, caregiver status, location/residence, referral to or
			 active involvement on the part of a protective service agency, and/or
			 institutionalization.
(5) A
			 "nursing service visit" is the duration of time that a nurse provides covered
			 medicaid services, face to face, to an individual at the individual's residence
			 on the same date during the same time period.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-13 - Ambulatory Health Care Clinic Services › Section 5160-13-01 - Clinic services

Current through all regulations passed and filed through July 1, 2024
(A)
								Unless otherwise
			 noted, any limitations or requirements specified in the Revised Code or in
			 agency 5160 of the Administrative Code apply to services addressed in this
			 rule.
(B)
								This rule does not apply to federally qualified health
			 centers (FQHCs) nor to rural health clinics (RHCs), policies for which are set
			 forth in Chapter 5160-28 of the Administrative Code.
(C)
								Definition.
			 "Clinic" is an entity that meets all of the following criteria:
(1)
									It renders
			 healthcare services on an outpatient basis under the direction of a physician
			 or dentist.
(2)
									It operates from a fixed location, a specifically
			 designed mobile unit, or both.
(3)
									It is
			 freestanding administratively, organizationally, and financially independent of
			 an institution such as a hospital or long-term care facility. It may be
			 physically located in a hospital or long-term care facility so long as it
			 remains independent.
(4)
									It does not provide overnight
			 accommodations.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-13 - Ambulatory Health Care Clinic Services › Section 5160-13-02 - Dialysis services rendered by a dialysis center

Current through all regulations passed and filed through July 1, 2024
(A) Coverage and limitations.
(1) Payment may be made for dialysis
			 performed for the treatment of kidney dysfunction resulting from conditions
			 such as end-stage renal disease (ESRD) or acute kidney injury (AKI).
(2) If an individual is eligible for both
			 medicare and medicaid, then coverage by medicaid as the primary payer continues
			 only until medicare coverage begins.
(3) Payment may be made for hemodialysis (HD)
			 or for any of three types of peritoneal dialysis: intermittent peritoneal
			 dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), or continuous
			 cycling peritoneal dialysis (CCPD).
(4)
									CAPD or CCPD is
			 peritoneal dialysis normally performed in a setting other than a dialysis
			 center.
(5) Dialysis self-care
			 training is instruction of the individual or a caregiver on how to perform
			 self-dialysis with little or no professional assistance. It is customarily
			 provided in conjunction with a session of dialysis treatment.
(6)
			 The following frequency limits apply:
(a) HD
			  - one session per day, three
			 sessions per week;
(b)
										IPD, CAPD, or CCPD
			  - one session per day, seven sessions per
			 week;
(c) HD self-care training - a
			 total of twenty-five sessions to be conducted within a period not to exceed
			 ninety-one days;
(d) IPD self-care
			 training - a total of twelve sessions to be conducted within a period not to
			 exceed twenty-eight days; and
(e)
			 CAPD or CCPD self-care training - a total of fifteen sessions.
(7) Frequency limits
			 may be exceeded only if the medical necessity of the additional service is
			 documented in the medical record by the practitioner who is primarily
			 responsible for the dialysis services.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-01 - Transportation: definitions

Current through all regulations passed and filed through July 1, 2024
(A)
								Provisions in this chapter do not
			 necessarily apply to transportation furnished in accordance with other chapters
			 of agency 5160 of the Administrative Code.
(B) The following definitions apply to this
			 chapter:
(1)
									Terms that have
			 the same meaning as in
			 42
			 C.F.R. 414.605 (October 1, 2020) include the
			 following items:
(a)
										"Advanced life support, level 1
			 (ALS1)";
(b)
										"Advanced life support, level 2
			 (ALS2)";
(c)
										"Basic life support (BLS)";
(d)
										"EMT-basic,"
			 "EMT-intermediate, and "EMT-paramedic" (collectively, "advanced life support
			 (ALS) personnel");
(e)
										"Fixed wing air ambulance";
(f)
										"Rotary wing air
			 ambulance"; and
(g)
										"Specialty care transport (SCT)."
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-10 - Transportation: non-emergency services through a CDJFS

Current through all regulations passed and filed through July 1, 2024
(A)
								Pursuant to
			 42 C.F.R.
			 431.53, the Ohio department of medicaid (ODM)
			 is obligated to ensure necessary transportation for medicaid-eligible
			 individuals to and from providers of covered healthcare services. ODM fulfills
			 this obligation in large measure through three-way subgrant agreements with the
			 Ohio department of job and family services (ODJFS) and with each county
			 department of job and family services (CDJFS). This rule sets forth the
			 responsibilities and expectations placed by ODM on each CDJFS in the
			 administration of this medicaid-funded non-emergency transportation assistance
			 benefit. In signing a subgrant agreement, a CDJFS agrees to be bound by this
			 rule and by any other applicable provision of the Administrative
			 Code.
(B)
								For each individual to whom non-emergency
			 transportation assistance is provided, a CDJFS is expected to select the type
			 of assistance that is most cost-effective, is suitable to the individual's
			 needs and circumstances, and enables timely access. If one type of assistance
			 proves infeasible, a CDJFS may select another type.
(1)
									A CDJFS may
			 decline to provide medicaid-funded non-emergency transportation assistance to a
			 medicaid-eligible individual under this rule if either of the following
			 criteria is met:
(a)
										The associated healthcare service is not part of the
			 individual's medicaid benefit package; or
(b)
										The requested
			 non-emergency transportation assistance is not necessary for any of the
			 following reasons:
(i)
											A medicaid managed care organization (MCO) is obligated
			 to furnish transportation to the individual under its provider agreement with
			 ODM;
(ii)
											The individual is a resident of a long-term care
			 facility (nursing facility, skilled nursing facility, or intermediate care
			 facility for individuals with intellectual disabilities), for whom
			 transportation is provided in accordance with Chapter 5160-3 or Chapter
			 5123:2-7 of the Administrative Code;
(iii)
											A medicaid
			 hospice provider is obligated to provide or arrange transportation that is
			 necessary for the individual to receive care related to a terminal
			 illness;
(iv)
											Suitable transportation is available free of charge to
			 the general public; or
(v)
											Failure to provide the requested assistance will have
			 no effect on the individual's ability to obtain the healthcare
			 service.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-14 - Transportation: non-emergency services through a CDJFS: program integrity provisions

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Private transportation vendor (PTV)" is
			 an entity that meets the following criteria:
(a) It seeks to establish or to maintain a
			 contract with a county department of job and family services (CDJFS) to supply
			 transportation service to medicaid recipients in accordance with rule
			 5160-15-10 of the Administrative Code; and
(b) It is not a government agency, transit
			 authority, public transportation system, or other quasi-governmental
			 organization.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-21 - Transportation: services from an eligible provider: conditions of provider participation

Current through all regulations passed and filed through July 1, 2024
(A)
								Definition.
			 "Eligible provider" has the same meaning as in rule
			 5160-1-17 of
			 the Administrative Code.
(B)
								 Transportation-specific criteria. For each entity
			 enrolled as an eligible provider of transportation services, the following
			 conditions are met:
(1)
									The entity, each crew member, and each attendant comply
			 with all applicable local, state, and federal laws, regulations, and rules,
			 including all applicable provisions developed in accordance with Chapter 4765.
			 or Chapter 4766. of the Revised Code;
(2)
									Each vehicle
			 meets all applicable permit provisions developed in accordance with Chapter
			 4766. of the Revised Code; and
(3)
									If the entity
			 provides ground ambulance services, it is also enrolled in medicare as an
			 ambulance service provider or supplier.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-22 - Transportation: services from an eligible provider: wheelchair van services

Current through all regulations passed and filed through July 1, 2024
(A) Payment may be
			 made for the following wheelchair van services:
(1) Transport by wheelchair van;
(2) Mileage, wheelchair van; and
(3) Attendant services, wheelchair
			 van.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-23 - Transportation: services from an eligible provider: ground ambulance services

Current through all regulations passed and filed through July 1, 2024
(A) Payment may be
			 made for the following ground ambulance services:
(1) Basic life support, provided in a
			 non-emergency (BLS non-emergency);
(2) Basic life support, provided in an
			 emergency (BLS emergency);
(3)
			 Advanced life support, level 1, provided in a non-emergency (ALS1
			 nonemergency);
(4) Advanced life
			 support, level 1, provided in an emergency (ALS1 emergency);
(5) Advanced life support, level 2
			 (ALS2);
(6) Specialty care
			 transport (SCT);
(7) Mileage,
			 ground ambulance; and
(8) Attendant
			 services, ground ambulance.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-24 - Transportation: services from an eligible provider: air ambulance services

Current through all regulations passed and filed through July 1, 2024
(A) Payment may be
			 made for the following air ambulance services:
(1) Ambulance transport,
			 fixed
			 wing;
(2) Ambulance transport,
			 rotary
			 wing;
(3) Mileage,
			 fixed
			 wing ambulance; and
(4) Mileage,
			 rotary
			 wing ambulance.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-25 - Transportation: services from an eligible provider: points of transport

Current through all regulations passed and filed through July 1, 2024
(A) For purposes of
			 this chapter, medicaid recognizes the following twelve points of transport,
			 which represent the origin or destination of a discrete one-way trip:
(1) Ten points of transport recognized by the
			 centers for medicare and medicaid services (CMS):
(a) A diagnostic or therapeutic site other
			 than a practitioner's office or a hospital, such as an alcohol and drug
			 rehabilitation center, an ambulatory surgery center, an independent diagnostic
			 testing facility, or a medical equipment supplier;
(b) A residential, domiciliary, or custodial
			 facility that is not a skilled nursing facility ;
(c) A dialysis facility located in a
			 hospital;
(d) A hospital;
(e) A site of transfer between modes of
			 transport, such as an airstrip or a helipad;
(f) A dialysis facility not located in a
			 hospital;
(g) A skilled nursing
			 facility;
(h) A practitioner's
			 office, which includes but is not limited to the office of an individual health
			 professional,
										
										the office of a
			 group of health professionals,
										 or a clinic;
(i) A residence other than a residential,
			 domiciliary, or custodial facility; and
(j) The scene of an accident or an acute
			 event;
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-26 - Transportation: services from an eligible provider: service limitations and allowances

Current through all regulations passed and filed through July 1, 2024
(A) No payment can be made for the following
			 services and associated costs:
(1)
			 Transportation services for an individual who is not medicaid-eligible at the
			 time of transport;
(2)
			 Transportation of a medicaid-eligible individual for a purpose other than the
			 receipt of medicaid-coverable services;
(3) Transportation of a medicaid-eligible
			 individual to or from a service provided outside the limits of the individual's
			 medicaid benefit package;
(4)
			 Transports during which there is no medicaid-eligible individual in the
			 vehicle;
(5) Services that are
			 available to the general public without charge;
(6) Excessive mileage resulting from the use
			 of unnecessarily indirect routes;
(7) The service of hospital staff members as
			 attendants during transportation to or from a hospital (which is treated as an
			 inpatient or outpatient hospital service);
(8) Transportation of any person other than
			 the medicaid-eligible individual and an attendant who accompanies the
			 medicaid-eligible individual; and
(9) Duplicate attendant services provided by
			 the same individual simultaneously to more than one passenger.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-15 - Medical Transportation Services › Section 5160-15-27 - Transportation: services from an eligible provider: documentation

Current through all regulations passed and filed through July 1, 2024
(A) Certification
			 is 
								needed to confirm the necessity of wheelchair van
			 services and most non-emergency ambulance services. No certification is
			 
								needed
			 for transportation services furnished by an eligible provider that are
			 automatically deemed to be necessary in accordance with rule
			 5160-15-22,
			 5160-15-23,
			 or
			 5160-15-24
			 of the Administrative Code. A 
								medicaid managed care organization
			 (MCO) is not 
								obliged to use the practitioner certification
			 process described in paragraph (B) of this rule to certify the necessity of a
			 transportation service furnished to a medicaid-eligible individual enrolled in
			 the 
								MCO.
(B)
			 For transportation services that 
								need certification but are not furnished to a
			 medicaid-eligible individual enrolled in an 
								MCO, a
			 practitioner certification form is used.
(1)
			 The nature of the practitioner certification form depends on the type of
			 transportation service.
(a) For wheelchair van
			 services, an ODM 03452, "Certification of Necessity for Transportation by
			 Wheelchair Van" (07/2015), 
										is used.
(b) For non-emergency ground ambulance
			 services, documents required by the primary payer of the claim are acceptable;
			 if medicaid is the primary payer, then an ODM 01960, "Certification of
			 Necessity for NonEmergency Transportation by Ground Ambulance" (07/2015),
			 is
			 used.
(c) For air ambulance
			 services, any document that includes the information specified in paragraph
			 (B)(1)(b) of rule
			 5160-15-24
			 of the Administrative Code is acceptable.