Revalidating medicare enrollment

"System" includes both records that are manually stored and records that are stored using electronic data processing equipment.

(16) "Upgrade" means a substantial redesign of an existing computer system for the purpose of providing a substantial amount of new application functionality, or application modifications that would involve substantial administrative or fiscal resources to implement, but would not include maintenance, minor updates and patches, or modifications that entail a limited addition of functionality due to changes in business or legal requirements.

Medical necessity is a fundamental concept underlying the medicaid program.(A) Medical necessity for individuals covered by early and periodic screening, diagnosis and treatment (EPSDT) is defined as procedures, items, or services that prevent, diagnose, evaluate, correct, ameliorate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability.

(B) Medical necessity for individuals not covered by EPSDT is defined as procedures, items, or services that prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without which the person can be expected to suffer prolonged, increased or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort.

(7) "Information owner" means the individual appointed in accordance with division (A) of section 1347.05 of the Revised Code to be directly responsible for a system.

(8) "Interconnection of Systems" Refers to a linking of systems that belong to more than one agency, or to an agency, and other organization , which linking of systems results in a system that permits each agency or organization involved in the linking to have unrestricted access to the systems of the other agencies and organizations. (10) "Personal information" has the same meaning as defined in division (E) of section 1347.01 of the Revised Code.

(2) "Acquisition of a new computer system" means the purchase of a "computer system," as defined in this rule, that is not a computer system currently in place nor one for which the acquisition process has been initiated as of April 7, 2009.

(3) "Confidential personal information" (CPI) has the meaning as defined by division (A)(1) of section 1347.15 of the Revised Code.

(7) The service is rendered by an eligible provider or panel provider for managed care plan participating provider.

(B) A medical service is not reimbursable if:(1) The service is charged to medicaid at a rate greater than the provider's usual and customary charge to other patients.(a) Inpatient hospital services billed by hospitals reimbursed on a prospective payment basis, as defined in Chapter 5101:3-2 of the Administrative Code, will not pay, in the aggregate, more than the provider's customary and prevailing charges for comparable services.

(b) Chapter 5101:3-3 of the Administrative Code defines these provisions as they apply to providers of long-term care services.

(E) The definition and conditions of medical necessity articulated in this rule apply throughout the entire medicaid program.

More specific criteria regarding the conditions of medical necessity for particular categories of service may be set forth within ODM coverage policies or rules.

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(2) The service is free to the public, except when medicaid reimbursement for such services is prescribed by federal law.

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