Ohio Administrative Code

(A) Definitions.(1) "Blood gas study" is the measurement of such characteristics of blood as the partial pressure of oxygen (PO2) or oxygen saturation. The term applies either to pulse oximetry or to an arterial blood gas (ABG) study.(2) "Group I" and "group II" criteria are sets…

(A) The default certificate of medical necessity (CMN) form is the ODM 01905, "Certificate of Medical Necessity: Compression Garments" (rev. 7/2024).(B) Payment may be made only for compression garments generating a pressure of at least eighteen millimeters of mercury (mm Hg).(C)…

(A) Definitions.(1) "Accessories" is a collective term that encompasses but is not necessarily limited to the following items:(a) Adapters;(b) Clips;(c) Additional connecting cable for lead wires;(d) Carrying pouches; and(e) Covers.(2) "Supplies" is a collective term that encompa…

(A) Definitions and explanations.(1) "Basic equipment package" is the following standard set of parts and accessories that come with a wheelchair at the time of purchase:(a) A sling or solid seat with back, a captain's chair, or a stadium-style seat;(b) Standard casters or wheels…

(A) Payment may be made directly to a provider for a pneumatic compressor or a related appliance or accessory only if the following conditions are satisfied:(1) The equipment is used to treat either lymphedema in the extremities or chronic venous insufficiency (CVI) with venous s…

(A) Definitions and explanations.(1) "Group 1," "group 2," and "group 3" are classes of pressure-reducing support surface.(a) Group 1 surfaces are generally non-powered pads or overlays that are designed to be placed on top of a hospital bed or standard mattress. They achieve the…

(A) Definition. "Apnea-hypopnea index (AHI)" is the mean number of episodes of apnea or hypopnea per hour recorded over a period of at least two hours without the use of a positive airway pressure device, reported by polysomnogram. Extrapolation or projection of the AHI is not pe…

(A) Coverage.(1) Payment for quantities of incontinence garments or incontinence supplies that exceed the indicated limit is subject to prior authorization (PA). The default certificate of medical necessity (CMN) form is the ODM 02912, "Certificate of Medical Necessity: Incontine…

(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…

(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 sampl…

(A) Coverage.(1) Separate payment may be made for a speech-generating device (SGD) furnished to a resident of a long-term care facility (LTCF).(2) The default certificate of medical necessity (CMN) form is the ODM 02924, "Certificate of Medical Necessity: Speech-Generating Device…

(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) 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…

(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 replace…

(A) Coverage.(1) Payment may be made for the purchase only of a noninvasive osteogenesis stimulator.(2) The default certificate of medical necessity (CMN) form is the ODM 07134, "Certificate of Medical Necessity: Osteogenesis Stimulators" (rev. 7/2024). The CMN includes an attest…

(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 o…

(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 …

(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) …

(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) 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 …

(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 ma…

(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)…

(A) Terminology.(1) The following abbreviations are used in this rule:(a) "AHI" stands for "apnea-hypopnea index."(b) "CAHI" stands for "central apnea-central hypopnea index."(c) "CompSA" stands for "complex sleep apnea."(d) "CSA" stands for "central sleep apnea."(e) "FEV1" stand…

(A) Definitions and explanations that apply to this chapter of the Administrative Code.(1) "Clinical consultation" is the formal evaluation by a physician or other qualified healthcare professional, performed on the written order of a treating practitioner, of test results that a…

(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, 2025).(B) Coverage.(1) The radiology procedures performed by a portable x-ray supplier have both a profession…

(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, 2025);(b) It takes the foll…

(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 d…

(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 …

(A) As a prerequisite to receiving private duty nursing (PDN) services, an individual must meet the requirements set forth in rule 5160-12-02 of the Administrative Code, as applicable, which require the individual to receive PDN authorization from the Ohio department of medicaid …

(A) A medicare certified home health agency (MCHHA) that meets the requirements of 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.(B) MCHHAs are required to:(1…

(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 accor…

(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 teleheal…

(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 h…

(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 minute…

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 516…

(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…

(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 (…

(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 …

(A) The following definitions apply to this rule:(1) "Dialysis center" means as defined in rule 5160-13-01 of the Administrative Code.(2) "Nursing facility" means as defined in rule 5160-3-02.3 of the Administrative Code.(3) "Nursing facility-based hemodialysis" means hemodialysi…

(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 (Octobe…

(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…

(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 acco…

(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 m…

(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.(B) Payment may be made only if all the conditions in this paragraph are met.(1) The necessity of the wheelcha…

(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 non-e…

(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.(B) Payment may be made only if all the requirements in this paragrap…

(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 …