# Ohio Admin. Code 5160-1-01: Rule 5160-1-01. Medicaid medical necessity: definitions and principles

> Ohio · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_01

## Section

- **Citation:** Ohio Admin. Code 5160-1-01
- **Heading:** Rule 5160-1-01. Medicaid medical necessity: definitions and principles
- **Jurisdiction:** Ohio
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Ohio Administrative Code / Agency 5160 / Chapter 5160-1 / Rule 5160-1-01

## Text

119.03 (A) Medical necessity for individuals covered by early and periodic screening, diagnosis and treatment (EPSDT) is criteria of coverage for 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 criteria of coverage for 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. (C) Conditions of medical necessity for a procedure, item, or service are met if all the following apply: (1) It meets generally accepted standards of medical practice; (2) It is clinically appropriate in its type, frequency, extent, duration, and delivery setting; (3) It is appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome; (4) It is the lowest cost alternative that effectively addresses and treats the medical problem; (5) It provides unique, essential, and appropriate information if it is used for diagnostic purposes; and (6) It is not provided primarily for the economic benefit of the provider nor for the sole convenience of the provider or anyone else other than the recipient. (D) The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment
f the provider nor for the sole convenience of the provider or anyone else other than the recipient. (D) The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment. (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 the Ohio department of medicaid (ODM) coverage policies or rules. Last updated July 18, 2025 at 1:31 PM Supplemental Information Authorized By: 5164.02 Amplifies: 5164.02 2/24/2027 7/1/2006

## Nearby sections

- [Ohio Admin. Code 5160-1-01 Rule 5160-1-01. Medicaid medical necessity: definitions and principles](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_01.md)
- [Ohio Admin. Code 5160-1-02 Rule 5160-1-02. General reimbursement principles](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_02.md)
- [Ohio Admin. Code 5160-1-04 Rule 5160-1-04. Employee access to confidential personal information](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_04.md)
- [Ohio Admin. Code 5160-1-05 Rule 5160-1-05. Medicaid coordination of benefits with the medicare program (Title XVIII)](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05.md)
- [Ohio Admin. Code 5160-1-05.1 Rule 5160-1-05.1. Payment for "Medicare Part C" cost sharing](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05_1.md)
- [Ohio Admin. Code 5160-1-05.3 Rule 5160-1-05.3. Payment for "Medicare Part B" cost sharing](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_05_3.md)
- [Ohio Admin. Code 5160-1-06.1 Rule 5160-1-06.1. Home and community-based service waivers: PASSPORT](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_06_1.md)
- [Ohio Admin. Code 5160-1-06.5 Rule 5160-1-06.5. Home and community based services (HCBS)](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_06_5.md)
- [Ohio Admin. Code 5160-1-08 Rule 5160-1-08. Coordination of benefits](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_08.md)
- [Ohio Admin. Code 5160-1-09 Rule 5160-1-09. Co-payments](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_09.md)
- [Ohio Admin. Code 5160-1-10 Rule 5160-1-10. Limitations on elective obstetric deliveries](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_10.md)
- [Ohio Admin. Code 5160-1-11 Rule 5160-1-11. Out-of-state coverage](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_11.md)
- [Ohio Admin. Code 5160-1-13.1 Rule 5160-1-13.1. Medicaid recipient liability](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_13_1.md)
- [Ohio Admin. Code 5160-1-14 Rule 5160-1-14. Healthchek: early and periodic screening, diagnostic, and treatment (EPSDT) covered services](https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_14.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_OH_ADC_5160_1_01. Check the current official text before relying on it. Not legal advice.