Current through all regulations passed and filed through September 16, 2024
(A) As specified in
Chapter
5160-1 of the Administrative Code, all medicaid
providers are required to keep such records as are necessary to establish
that conditions of payment for medicaid covered services
have been met, and to fully disclose the basis for the
type, frequency, extent, duration, and delivery setting
of services provided to medicaid recipients, and to document significant business
transactions. Medicaid providers are required to provide such records and
documentation to the Ohio department of medicaid (ODM) or its
designee, the secretary of the federal department of health and human
services, or the state medicaid fraud control unit upon request.
(B) For purposes of this rule, the following
definitions apply:
(1) "Audit" means a
postpayment examination, made in
consideration of generally accepted auditing
standards, of a medicaid provider's records and documentation to determine
program compliance, the extent and validity of services paid for under the
medicaid program and to identify any inappropriate payments. The department
shall have the authority to use statistical methods to conduct audits and to
determine the amount of overpayment. An audit may result in a final
adjudication order by the department.
(2) "Hold and Review" means a process of
prepayment review of a medicaid provider's claims, including client records,
medical records, or other supporting documentation, for determination of
appropriate claims payment or reimbursement.
(a) Hold and review administered by
ODM will
be done in accordance with rule 5160-1- 27.1 of the Administrative
Code.
(b) Hold and review
administered by state agencies other than ODM will be done
in accordance with rule 5160-1- 27.2 of the Administrative Code.
(3) "Review" means a
post-payment examination of a medicaid provider's paid
claims to determine program compliance, validity of payments and identification
of recovery of overpayments under the medicaid program. Review also means
special
projects or
analysis to
determine quality of care, compliance with accepted standards of care,
and general program compliance
. A review may result in an
educational letter, a request for a corrective
action plan subject to department approval, and/or recovery of inappropriate paid claims due to non-program
compliance.
(4) "Notice of operational deficiency" means
a written notice issued by the department that identifies provider conduct,
treatment or practices that are determined by the department not to be in the
best interests of the consumer or the medicaid program and/or are noncompliant
with the regulations governing the medicaid program and that must be corrected.
The notice states the nature of the deficiency, the time period that the
provider has to correct the deficiency and the person within the department the
provider is to contact to verify that the deficiency has been
corrected.
(C) Records,
documentation and information must be available regarding any services for
which payment has been or will be claimed to determine that payment has been or
will be made in accordance with applicable federal and state requirements. For
the purposes of this rule, an invoice constitutes a business transaction but
does not constitute a record which is documentation of a medical
service.
(D) Various methods of
audit and review will be utilized in all cases of suspected
fraud, waste and abuse, in accordance with rule
5160-1-29 of the Administrative Code. If
fraud, waste and abuse are apparent, the
department will take action to gain compliance and recoup inappropriate
payments.
(E) The provider must
maintain all records as stipulated in this rule and rule
5160-1- 17.2 or Chapter 5160-3 of the
Administrative Code, as applicable.
(F) All records, documentation and/or
information requested in accordance with paragraph (B) of this rule shall be
submitted to the department or its
designee, in an appropriate manner as determined by the department. Records
subject to audit and review must be produced at no cost to the department.
(1) Records subject to audit and review must
be made available for examination in the time period described in rule
5160-1- 17.2 of the Administrative Code, or as
determined by the department or its
designee. Failure to supply requested records, documentation and/or information
as indicated in this rule will result in no payment for outstanding
services.
(2) In all situations, the department has the authority to conduct an
on-site visit with the provider at the provider's location for the examination
or collection of records, and/or for compliance verification. Upon such
occasions, as deemed necessary by the department or its designee, a member of the provider's staff is to
be assigned to assist in collecting the information. Upon request from the
department, the provider will photocopy or make the applicable records
available for photocopying.
(3)
Services billed to and reimbursed by the department, which are not validated in
the recipients' records, are
subject to recoupment through the audit and review process described in this
rule.
