Current through all regulations passed and filed through September 16, 2024
(A) "Hold and Review" is defined in
accordance with rule 5160-1-27 of the Administrative Code.
(1) Hold and review without prior
notification.
(a) The Ohio department
of medicaid (ODM) may place a medicaid provider's
claim(s) payment on hold and review, in whole or in part, without first
notifying the provider for the following reasons:
(i) In response to allegations of fraud or
other willful misrepresentation of claims submission; or
(ii) When a provider has been indicted for a
criminal offense.
(b)
ODM
shall notify the provider in writing within ten business days that the
provider's claims have been, and will continue to be, subject to hold and
review.
(2) Hold and review with prior
notification.
(a)
ODM may place a
medicaid provider's claim(s) payment on hold and review, in whole or in part,
with prior notice to the provider under the following circumstances:
(i) When the information is used to
complement or follow up a provider certification or other quality review
process;
(ii) Upon request from the
office of the attorney general, the office of inspector general or the auditor
of state;
(iii) A medicaid
provider's agreement has been proposed for termination for reasons other than
those stated in paragraph (A) of this rule; or
(iv) For reasons otherwise necessary to
assure the basic integrity of claims submission and payment.
(b)
ODM will notify
the provider in writing within ten business days before the effective start
date of the hold and review.
(B) Review of the medicaid provider's claims
and documentation for the hold and review process is subject to the provisions
of rule 5160-1-27 of the Administrative Code.
(C) The hold and review may be applied
without regard to date of service.
(D) Failure by
ODM to
notify a provider of a hold and review shall not impede the agency from taking
actions under this rule.
(E) The
notice from ODM shall:
(1) State
the general reasons for the withholding of the medicaid provider's claims
payments, but need not disclose any specific information concerning an ongoing
investigation involving alleged fraud and/or willful
misrepresentation;
(2) State the
effective date ODM implements the hold and review process;
(3) State the types of services and claims,
in whole or in part, that will be subject to the hold and review process;
(4)
Identify
the documentation required to be submitted to ODM by the
provider:
(5) Inform
the provider of the right to submit evidence for consideration to
ODM;
(6)
State the contact at ODM for questions regarding the hold and review
process.
(F)
Except for medicaid providers required to submit
medical claims to ODM electronically, all claims from providers placed on hold
and review must be submitted in non-electronic (paper) format.
(G)
Providers who
must submit medical claims electronically must submit paper documentation
supporting each claim submitted electronically. These claims will not be
processed until both the claim and the supporting documentation are reviewed by
ODM.
(H)
ODM may, if appropriate, send copies of the notice to
local, state and federal entities that are involved in the review or that need
to be aware of the review in order to assure the integrity of claims submission
and payment.
(I)
ODM has one hundred twenty
days from the date each claim for payment is received to review the claim and
make a determination whether or not to do one of the following:
.
(1)
Forward the claim
for adjudication;
(2)
Forward the claim for denial; or
(3)
Issue a "Notice
of Operation Deficiency."
(J)
The hold and review
process is not subject to Chapter 119. of the Revised Code or any other
appeal.
