Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-1 - General Provisions
Section 5160-1-17.5 - Suspension of medicaid provider agreements

(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, intermediate care facility for individuals with intellectual disabilities or medicaid contracting managed care plans.

(1) Upon determining there is a credible allegation of fraud for which an investigation is pending against a provider under the medicaid program, unless good cause to not suspend is found pursuant to 42 CFR 455.23(e) or (f), effective Feb. 2, 2011; or

(2) Upon receiving notice and copy of an indictment that charges a non-institutional provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense as specified in division (E) of section 5164.37 of the Revised Code.

(1) If a provider is suspended pursuant to this rule, then any other provider agreements where the provider is an owner, officer, authorized agent, manager, or employee may also be suspended.

(2) A provider, its owner or owners, officer, authorized agent, associate, manager, or employee shall not own or provide services to any other medical provider or risk contractor or arrange for, render, or order services for medicaid recipients during the period of suspension.

(3) During the period of suspension, the provider owner or owners, officer, authorized agent, associate, manager, or employee shall not receive reimbursement in the form of direct payments from ODM or indirect payments of medicaid funds.

(4) The suspension shall continue until either of the following:

(5) If ODM commences a process to terminate the suspended provider agreement, the suspension shall continue in effect until the termination process is concluded.

(1) A provider, owner, or owners subject to a suspension may request a reconsideration in accordance with section 5164.36 or 5164.37 of the Revised Code . A request for reconsideration is not subject to Chapter 119. of the Revised Code.

(2) The reconsideration shall be conducted by the ODM director or the director's designee in the office where the contestation arose provided that the designee was not involved in the original decision. Decisions made by the director or the director's designee are not appealable or subject to further reconsideration.

Replaces: 5160-1- 17.5