Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-1 - General Provisions
Section 5160-1-17.8 - Provider screening and application fee
Universal Citation: OH Admin Code 5160-1-17.8
Current through all regulations passed and filed through September 16, 2024
(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 an applicable application fee if required in the appendix to this rule. Provider screening and application fees are required at the time of enrollment and revalidation as defined in rule 5160-1-17.4 of the Administrative Code.
(1) Exemptions.
(a) If a provider is required to participate
in the medicare program as a condition of enrollment in medicaid or elects to
participate in the medicare program and has met the provider screening
requirements and paid an applicable application fee to the centers for medicare
and medicaid services (CMS) or its designee, the provider is exempt from the
application fee requirements set forth in this rule.
(b) If a provider has met the provider
screening requirements and paid an applicable application fee to another state
medicaid agency or its designee, the provider is exempt from the application
fee requirements set forth in this rule.
(c) A provider must provide documentation to
support it meets the criteria for an exemption described in paragraphs
(A)(1)(a) and (A)(1)(b) of this rule.
(d)
When employed by
or independently contracted with an entity certified by the Ohio department of
mental health and addiction services, the following are exempt from the
provisions of paragraphs (E)(2) to (E)(4) of this rule when providing services
for the entity.
(i)
Certified peer recovery supporters as defined in rule
5122-29-15.1 of the
Administrative Code;
(ii)
Practitioners licensed or certified under Chapter 4757.
of the Revised Code;
(iii)
Practitioners licensed or certified under Chapter 4758.
of the Revised Code.
(2) The appendix to this rule sets forth:
(a) The screening risk level assigned to each
provider type in accordance with paragraph (B) of this rule; and
(b) The provider types that must pay an
application fee in accordance with paragraph (G) of this rule.
(B) The appropriate screening based on screening risk level must be given to all service locations of an enrolled provider. Providers must disclose all service locations at time of enrollment and notify the department of changes or additional service locations within thirty days of the change in order to be reimbursed for services delivered at that location.
(C) In accordance with 42 C.F.R. 455.452 (as in effect October 1, 2019), the Ohio department of medicaid (ODM) reserves the right to conduct additional screenings and background checks as determined necessary by ODM or its designee.
(D) Screening requirements differ by risk level. If more than one risk level could apply to a provider, the highest level of screening is required.
(1) Limited.
(a) Providers are subject to verification
that they meet any applicable medicaid requirements as stated in agency 5160 of
the Administrative Code for their provider type; and
(b) Providers are subject to license
verifications, including state licensure verification in states other than
Ohio; and
(c) Providers are subject
to database checks on a pre- and post-enrollment basis to ensure that providers
continue to meet the enrollment criteria for their provider type.
(i) Database checks must confirm the identity
and exclusion status of providers and any person with a five per cent or
greater ownership or control interest; or any person who is an agent or an
individual (including a general manager, business manager, administrator,
director, or consultant) who directly or indirectly manages, advises, or
supervises any element of the practices, finances, or operations of the
provider entity.
(ii) Databases to
be checked include, but are not limited to, the social security
administration's death master file, the national plan and provider enumeration
systems (NPPES), the list of excluded individuals/entities maintained by the
office of the inspector general, health and human services, the medicare
exclusion database (MED), or the system for awards management (SAM), the list
of providers terminated by another state's medicaid program, the nurse aid
registry maintained by the Ohio department of health and the abuser registry
maintained by the Ohio department of developmental disabilities.
(iii)
A provider is
disqualified from receiving a medicaid provider agreement during the time the
provider is on one or more of the following registries or databases:
(a)
The social
security administration's death master file;
(b)
The list of
excluded individuals or entities maintained by the office of the inspector
general, health and human services;
(c)
The medicare
exclusion database (MED;
(d)
The list of providers terminated by another state's
medicaid program;
(e)
The abuser registry maintained by the Ohio department
of developmental disabilities;
(f)
The system for
awards management (SAM) list of individuals or entities with an
exclusion;
(g)
The nurse aid registry abuse listing maintained by the
Ohio department of health.
(2) Moderate.
(a) Providers are subject to the requirements
in paragraph (D)(1) of this rule; and
(b) Providers are subject to on-site visits.
(i) Pre- and post-enrollment site visits by
ODM or its designee will verify that information provided to ODM or its
designee is accurate and to determine compliance with medicaid enrollment
requirements.
(ii) Once enrolled,
providers must allow CMS or its agents or contractors, or ODM or its agents or
contractors to conduct unannounced on-site inspections of any and all provider
locations.
(3) High.
(a) Providers are subject to the requirements
in paragraphs (D)(1) and (D) (2) (b) of this rule; and
(b) Each person with a five per cent or
greater ownership or control interest with the provider is subject to a
criminal background check and is required to submit to a fingerprint-based
background check within thirty days of submission of the application in a form
and manner determined by ODM, or its designee.
(E) The following sets forth the exclusionary offenses and exclusion time periods from participation in the medicaid program:
(1) Tier I. Permanent exclusion.
(a) Individuals who have been convicted of or
pleaded guilty to, an offense in any of the following sections of the Revised
Code are permanently excluded from participation in the medicaid program:
(i)
2903.01 (aggravated
murder);
(ii)
2903.02(murder);
(iii)
2903.03 (voluntary
manslaughter);
(iv)
2903.11 (felonious
assault);
(v)
2903.15 (permitting child
abuse);
(vi)
2903.16 (failing to provide for
a functionally-impaired person);
(vii)
2903.34 (patient abuse or
neglect);
(viii)
2903.341 (patient
endangerment);
(ix) 2905.01
(kidnapping);
(x) 2905.02
(abduction);
(xi)
2905.32 (human
trafficking);
(xii)
2905.33 (unlawful conduct with
respect to documents);
(xiii)
2907.02(rape);
(xiv)
2907.03 (sexual
battery);
(xv)
2907.04 (unlawful sexual conduct
with a minor, formerly corruption of a minor);
(xvi)
2907.05 (gross sexual
imposition);
(xvii)
2907.06 (sexual
imposition);
(xviii) 2907.07
(importuning);
(xix) 2907.08
(voyeurism);
(xx)
2907.12 (felonious sexual
penetration, as that offense existed prior to September 3, 1996);
(xxi)
2907.31 (disseminating matter
harmful to juveniles);
(xxii)
2907.32 (pandering
obscenity);
(xxiii)
2907.321 (pandering obscenity
involving a minor);
(xxiv)
2907.322 (pandering
sexually-oriented matter involving a minor);
(xxv)
2907.323 (illegal use of a minor
in nudity-oriented material or performance);
(xxvi)
2909.22 (soliciting or providing
support for act of terrorism);
(xxvii)
2909.23 (making terroristic
threats);
(xxviii) 2909.24
(terrorism);
(xxix)
2913.40 (medicaid
fraud);
(xxx) If related to another
offense under paragraph (E)(1)(a) of this rule,
2923.01(conspiracy),
2923.02(attempt),
or 2923.03(complicity);
or
(b) A conviction
related to fraud, theft, embezzlement, breach of fiduciary responsibility, or
other financial misconduct involving a federal or state-funded program,
excluding the disqualifying offenses set forth in section
2913.46 of the Revised Code
(illegal use of supplemental nutrition assistance program (SNAP) or women,
infants, and children (WIC) program benefits) and paragraph (E)(2)(a)(xiii) of
this rule; or
(c) A violation of an
existing or former municipal ordinance or law of this state, any other state,
or the United States that is substantially equivalent to any of the offenses or
violations described in paragraph (E)(1)(a) or (E)(1) (b) of this
rule.
(2) Tier II.
Ten-year exclusionary period.
(a) Individuals
who have been convicted of or pleaded guilty to, an offense in any of the
following sections of the Revised Code are excluded from participation in the
medicaid program for a period of ten years from the date the individual was
fully discharged from all imprisonment, probation or parole:
(i)
2903.04 (involuntary
manslaughter);
(ii)
2903.041 (reckless
homicide);
(iii)
2905.04 (child stealing, as that
offense existed prior to July 1, 1996);
(iv)
2905.05 (child
enticement);
(v)
2905.11(extortion);
(vi)
2907.21 (compelling
prostitution);
(vii)
2907.22 (promoting
prostitution);
(viii)
2907.23 (enticement or
solicitation to patronize a prostitute; procurement of a prostitute for
another);
(ix)
2909.02 (aggravated
arson);
(x)
2909.03(arson);
(xi)
2911.01 (aggravated
robbery);
(xii)
2911.11 (aggravated
burglary);
(xiii)
2913.46 (illegal use of SNAP or
WIC program benefits);
(xiv)
2913.48 (worker's compensation
fraud);
(xv)
2913.49 (identity
fraud);
(xvi)
2917.02 (aggravated
riot);
(xvii)
2923.12 (carrying concealed
weapons);
(xviii)
2923.122 (illegal conveyance or
possession of deadly weapon or dangerous ordnance in a school safety zone,
illegal possession of an object indistinguishable from a firearm in a school
safety zone);
(xix)
2923.123 (illegal conveyance,
possession, or control of deadly weapon or ordnance into courthouse);
(xx)
2923.13 (having weapons while
under a disability);
(xxi)
2923.161 (improperly discharging
a firearm at or into a habitation or school);
(xxii)
2923.162 (discharge of firearm
on or near prohibited premises);
(xxiii)
2923.21 (improperly furnishing
firearms to minor);
(xxiv)
2923.32 (engaging in a pattern
of corrupt activity);
(xxv)
2923.42 (participating in a
criminal gang);
(xxvi)
2925.02 (corrupting another with
drugs);
(xxvii)
2925.03 (trafficking in
drugs);
(xxviii)
2925.04 (illegal manufacture of
drugs or cultivation of marijuana);
(xxix)
2925.041 (illegal assembly or
possession of chemicals for the manufacture of drugs);
(xxx)
3716.11 (placing harmful or
hazardous objects in food or confection); or
(xxxi) If related to an offense under
paragraph (E)(2)(a) of this rule,
2923.01(conspiracy),
2923.02(attempt),
or 2923.03(complicity);
or
(b) A violation of an
existing or former municipal ordinance or law of this state, any other state or
the United States that is substantially equivalent to any of the offenses or
violations described under paragraph (E)(2)(a) of this rule.
(c) If the individual has been convicted of
multiple disqualifying offenses, including an offense listed in paragraph
(E)(2)(a) or (E)(2)(b) of this rule, and another offense or offenses listed in
paragraph (E)(2)(a), (E)(3)(a), (E)(3)(b), (E)(4)(a), or (E)(4)(b) of this
rule, the individual is subject to a fifteen-year exclusionary period beginning
on the date the individual was fully discharged from all imprisonment,
probation or parole for the most recent offense.
(3) Tier III. Seven-year exclusionary period.
(a) Individuals who have been convicted of or
pleaded guilty to, an offense in any of the following sections of the Revised
Code are excluded from participation in the medicaid program for a period of
seven years from the date the individual was fully discharged from all
imprisonment, probation or parole:
(i)
959.13 (cruelty to
animals);
(ii)
959.131 (prohibitions concerning
companion animals);
(iii)
2903.12 (aggravated
assault);
(iv)
2903.21 (aggravated
menacing);
(v)
2903.211 (menacing by
stalking);
(vi) 2905.12
(coercion);
(vii)
2909.04 (disrupting public
services);
(viii)
2911.02(robbery);
(ix)
2911.12(burglary);
(x)
2913.47 (insurance
fraud);
(xi)
2917.01 (inciting to
violence);
(xii) 2917.03
(riot);
(xiii)
2917.31 (inducing
panic);
(xiv)
2919.22 (endangering
children):
(xv)
2919.25 (domestic
violence);
(xvi) 2921.03
(intimidation);
(xvii) 2921.11
(perjury);
(xviii)
2921.13 (falsification,
falsification in a theft offense, falsification to purchase a firearm, or
falsification to obtain a concealed handgun license);
(xix)
2921.34(escape);
(xx)
2921.35 (aiding escape or
resistance to lawful authority);
(xxi)
2921.36 (illegal conveyance of
weapons, drugs or other prohibited items onto the grounds of a detention
facility or institution);
(xxii)
2925.05 (funding drug
trafficking);
(xxiii)
2925.06 (illegal administration
or distribution of anabolic steroids);
(xxiv)
2925.24 (tampering with
drugs);
(xxv)
2927.12 (ethnic intimidation);
or
(xxvi) If related to an offense
under paragraph (E)(3)(a) of this rule,
2923.01(conspiracy),
2923.02(attempt),
or 2923.03(complicity);
or
(b) A violation of an
existing or former municipal ordinance or law of this state, any other state or
the United States that is substantially equivalent to any of the offenses or
violations described under paragraph (E)(3)(a) of this rule.
(c) If an individual has been convicted of
multiple disqualifying offenses, including an offense listed in paragraph
(E)(3)(a) or (E)(3)(b) of this rule, and another offense or offenses listed in
paragraph (E)(3)(a), (E)(3) (b), (E)(4)(a), or (E)(4)(b) of this rule, the
individual is subject to a ten-year exclusionary period beginning on the date
the individual was fully discharged from all imprisonment, probation or parole
for the most recent offense.
(4) Tier IV. Five-year exclusionary period.
(a) Individuals who have been convicted of or
pleaded guilty to, an offense in any of the following sections of the Revised
Code are excluded from participation in the medicaid program for a period of
five years from the date the individual was fully discharged from all
imprisonment, probation or parole:
(i) 2903.13
(assault);
(ii) 2903.22
(menacing);
(iii)
2907.09 (public
indecency);
(iv) 2907.24
(soliciting);
(v) 2907.25
(prostitution);
(vi)
2907.33 (deception to obtain
matter harmful to juveniles);
(vii)
2911.13 (breaking and
entering);
(viii) 2913.02
(theft);
(ix)
2913.03 (unauthorized use of a
vehicle);
(x)
2913.04 (unauthorized use of
computer, cable or telecommunication property);
(xi)
2913.05 (telecommunication
fraud);
(xii)
2913.11 (passing bad
checks);
(xiii)
2913.21 (misuse of credit
cards);
(xiv)
2913.31 (forgery - forging
identification cards or selling or distributing forged identification
cards);
(xv)
2913.32 (criminal
simulation);
(xvi)
2913.41 (defrauding a rental
agency or hostelry);
(xvii)
2913.42 (tampering with
records);
(xviii)
2913.43 (securing writings by
deception);
(xix)
2913.44 (personating an
officer);
(xx)
2913.441 (unlawful display of
law enforcement emblem);
(xxi)
2913.45 (defrauding
creditors);
(xxii)
2913.51 (receiving stolen
property);
(xxiii)
2919.12 (unlawful
abortion);
(xxiv)
2919.121 (unlawful abortion upon
minor);
(xxv)
2919.123 (unlawful distribution
of an abortion-inducing drug);
(xxvi)
2919.23 (interference with
custody);
(xxvii)
2919.24 (contributing to the
unruliness or delinquency of a child);
(xxviii)
2921.12 (tampering with
evidence);
(xxix)
2921.21 (compounding a
crime);
(xxx)
2921.24 (disclosure of
confidential information);
(xxxi)
2921.32 (obstructing
justice);
(xxxii)
2921.321 (assaulting or
harassing a police dog, horse, or service animal);
(xxxiii)
2921.51 (impersonation of peace
officer);
(xxxiv)
2925.09 (illegal administration,
dispensing, distribution, manufacture, possession, selling, or using of any
dangerous veterinary drug);
(xxxv)
2925.11 (drug possession, other
than a minor drug possession offense);
(xxxvi)
2925.13 (permitting drug
abuse);
(xxxvii)
2925.22 (deception to obtain a
dangerous drug);
(xxxviii)
2925.23 (illegal processing of
drug documents);
(xxxix)
2925.36 (illegal dispensing of
drug samples);
(xl)
2925.55 (unlawful purchase of
pseudoephedrine product);
(xli)
2925.56 (unlawful sale of
pseudoephedrine product);
(xlii) If
related to an offense under paragraph (E)(4)(a) of this rule,
2923.01(conspiracy),
2923.02(attempt),
or 2923.03(complicity);
or
(b) A violation of an
existing or former municipal ordinance or law of this state, any other state or
the United States that is substantially equivalent to any of the offenses or
violations described under paragraph (E)(4)(a) of this rule.
(c) If an individual has been convicted of
multiple disqualifying offenses listed in paragraph (E)(4)(a) or (E)(4)(b) of
this rule, the individual is subject to a seven-year exclusionary period
beginning on the date the individual was fully discharged from all
imprisonment, probation or parole for the most recent offense.
(5) Tier V. No exclusionary
period.
(a) Individuals who have been
convicted of or pleaded guilty to, an offense in any of the following sections
of the Revised Code are not subject to an exclusionary period and may
participate in the medicaid program:
(i)
2919.21
(non-support/contributing to non-support of dependents);
(ii)
2925.11 (drug possession that is
a minor drug possession offense); or
(iii)
2925.14 (drug paraphernalia);
or
(iv)
2925.141 (illegal use or
possession of marijuana drug paraphernalia); or
(b) A violation of an existing or former
municipal ordinance or law of this state, any other state or the United States
that is substantially equivalent to any of the offenses or violations described
under paragraph (E)(5)(a) of this rule.
(F) Pardons and certificates. A conviction of, or a plea of guilty to, an exclusionary offense as set forth in paragraph (E) of this rule shall not prevent a provider from enrollment if any of the following circumstances apply:
(1) The
provider has been granted an unconditional pardon for the offense pursuant to
Chapter 2967. of the Revised Code;
(2) The provider has been granted an
unconditional pardon for the offense pursuant to an existing or former law of
the state of Ohio, any other state, or the United States, if the law is
substantially equivalent to Chapter 2967. of the Revised Code;
(3) The provider has been granted a
conditional pardon for the offense pursuant to Chapter 2967. of the Revised
Code, and the condition(s) under which the pardon was granted have been
satisfied;
(4) The provider's
conviction or guilty plea has been set aside pursuant to law; or
(5) A certificate of qualification for
employment has been issued by an Ohio court of common pleas pursuant to section
2953.25 of the Revised Code, or
an equivalent certification has been issued by an out of state or federal
jurisdiction.
(6)
Provider applications that include a certificate of
qualification for employment or an equivalent certification associated with a
permanent exclusion offense as stated in paragraph (E)(1) of this rule, will be
reviewed by ODM and a decision will be rendered by ODM on a case-by-case basis
as to whether a provider agreement will be approved or not in accordance with
section 2953.25 of the Revised
Code.
(G) Application fee.
(1) Provider types identified as subject to
an application fee in the appendix to this rule must submit the fee in a form
and manner determined by ODM at the time of application for enrollment or
revalidation as a medicaid provider. If proof of fee payment is not submitted
with the provider's application, the application will be rejected as
incomplete.
(2) Individual
physicians and non-physician practitioners are exempt from paying an
application fee in accordance with
42 C.F.R.
455.460, (October 1, 2019).
(3) ODM may waive an application fee if:
(a) ODM determines that imposing the fee
would have an adverse impact on beneficiary access to services; and
(b) ODM has requested and CMS has approved a
waiver of the fee.
(4)
If ODM receives approval from CMS to waive a medicaid application fee,
providers are still subject to the screening requirements set forth in this
rule.
(5) The application fee is
equal to the amount established by CMS and includes an annual adjustment for
inflation in accordance with
42
U.S.C. 1395cc(j)(2)(C) (i)
(January 1, 2020).
(6) The application fee will not be refunded
if:
(a) Enrollment is denied as a result of
failure to meet the provider screening requirements described in this
rule;
(b) If enrollment is denied
based on the results of the provider screening.; or
(c) If ODM or its designee identifies other
circumstances under which refunding the application fee is not
warranted.
(H) If enrollment is denied as a result of failure to meet the provider screening requirements or failure to pay any associated application fee, the provider may request a hearing pursuant to Chapter 119. of the Revised Code.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
