Ohio Administrative Code

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 …

(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 gestat…

(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 se…

(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 no…

(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 January 1,2025).(2) "Bright futures guidelines" are t…

(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 …

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 …

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 r…

Provisions of provider agreements for long term care nursing facilities are defined in Chapter 5160-3 of the Administrative Code. Provisions for provider agreements for medicaid contracting managed care plans are defined in Chapter 5160-26 of the Administrative Code.A valid provi…

(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" h…

(A) Revalidation is the process that a provider is required to follow to renew and revalidate its provider agreement. Provider agreements must be revalidated no later than five years from the effective date of the original or the last revalidated provider agreement, whichever is …

(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,…

(A) Definitions, for purposes of this rule the definitions below apply:(1) "Credible allegation of fraud" as defined in section 5164.36 of the Revised Code.(2) "Non-institutional provider" as defined in rule 5160-1-17.5 of the Administrative Code.(B) The Ohio department of medica…

(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…

(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 fo…

(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…

(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 "order…

(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 practitione…

(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 …

(A) For purposes of this rule, the following definitions apply:(1) "Covered entity" has the same meaning as in 45 C.F.R. 160.103 (as in effect on October 1, 2021).(2) "Electronic data interchange (EDI) transactions" are transactions developed by standards development organization…

(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 p…

(A) As specified in Chapter 5160-1 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, frequency, e…

(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…

(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…

(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 s…

(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 …

(A) "Safeguarded information" includes but is not limited to the following types of information about individual medicaid applicants, enrollees, or former recipients:(1) Names and addresses; (2) Social security numbers; (3) Medical services provided; (4) Social and economic condi…

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, 2025, for the use and disclosure of protected health information…

(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 pe…

(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 p…

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 foll…

(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 516…

(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 med…

(A) For purposes of this rule:(1) "Applicant for reimbursement" is: (a) An individual who has been determined eligible for a retroactive eligibility period in accordance with rule 5160:1-2-01 of the Administrative Code, and who is seeking reimbursement for medical expenses for wh…

(A) The term "by-report" identifies a covered procedure, service, or supply for which no single maximum payment amount has been established and for which payment is not determined by prior authorization. Claims for by-report procedures, services, and supplies are reviewed manuall…

(A) The following services are entirely excluded from coverage:(1) A service that is experimental in nature and is not performed in accordance with standards of medical practice;(2) A service that is related to forensic studies;(3) An autopsy service;(4) A service for the treatme…

Provisions concerning episode based payments are set forth in rule 5160-19-04 of the Administrative Code. Authorized By: 5162.05, 5164.02, 5167.02 Amplifies: 5164.02, 5164.03 Five Year Review Date: 4/29/2021 Prior Effective Dates: 12/31/2015 (Emer.), 4/29/2016

Provisions concerning patient centered medical homes (PCMH) and eligible providers are set forth in rule 5160-19-01 of the Administrative Code. The PCMH rules implement the Ohio department of medicaid's comprehensive primary care (CPC) program and CPC for kids programs. Authorize…

Provisions concerning patient centered medical homes (PCMH) and payments are set forth in rule 5160-19-02 of the Administrative Code. The PCMH rules implement the Ohio department of medicaid's comprehensive primary care (CPC) program and CPC for kids programs. Authorized By: 5164…

(A) For the purpose of this rule, the following definitions apply.(1) "Attributed individual" is the Ohio medicaid covered individual for whom a qualified behavioral health entity eligible under this rule has accountability for providing behavioral health care coordination.(2) "A…

(A) Definitions.(1) "Practitioner," for purposes of this rule, is a collective term for the following professionals:(a) Doctor of medicine or osteopathy;(b) Advanced practice registered nurse;(c) Dentist;(d) Optometrist;(e) Podiatrist; or(f) Chiropractor.(2) "Regular practitioner…

The department of medicaid (ODM) will make relief payments available to Ohio medicaid hospitals defined in paragraph (A) of this rule, as authorized under Section 270.15 of Amended Substitute House Bill 45 of the 134th General Assembly:(A) ODM will make available a one-time lump …

(A) The Ohio department of medicaid (ODM) will deposit a portion of the intergovernmental transfers (IGT) that are paid under any state directed payment (SDP) program as authorized under 42 CFR 438.6(c) effective as of July 9, 2024. (B) On or after the effective date of this rule…

(A) Scope.(1) This rule sets forth general coverage and payment policies for durable medical equipment (DME), prostheses, orthotic devices, medical supplies, and supplier services dispensed or rendered by an enrolled DMEPOS provider.(2) Additional conditions specific to a particu…

(A) Definitions.(1) "Major repair" is a repair for which the combined medicaid allowed amounts for materials and labor exceed one hundred twenty dollars for an orthotic or prosthetic device or one hundred dollars for any other item.(2) "Minor repair" is a repair for which the com…

(A) Prescribing provider. Only a physician experienced in the management of patients at risk for sudden cardiac death (SCD), such as a cardiologist, electrophysiologist, or cardiac surgeon, may prescribe a wearable cardioverter-defibrillator (WCD).(B) Coverage.(1) Separate paymen…

(A) Definitions and explanations.(1) "Assistance," for purposes of this rule, is help with bathing-related tasks that individuals cannot accomplish by themselves, such as getting into and out of a bathing chair, moving in and out of the bathing area, or fastening and unfastening …