Current through all regulations passed and filed through September 16, 2024
(A)
Appeals.
Pursuant to Chapter 5160-70 of the
Administrative Code, final settlements that are based upon final audits by the
department may be appealed by hospitals under Chapter 119. of the Revised Code.
Rule 5160-2-24 of the Administrative
Code describes final fiscal audits and final settlements performed by the
department. Rules
5160-1-27 and
5160-1-29 of the Administrative
Code describe the audits performed by the department which may be appealable
under Chapter 119. of the Revised Code. Since the scope and substance of these
two types of audits differ, in no instance will the conduct and implementation
of one type of audit preclude the conduct and implementation of the
other.
(B)
Utilization review reconsideration.
Pursuant to rule
5160-2-13 of the Administrative
Code, the department or a medical review entity under contract with the
department may make determinations regarding utilization review. These
determinations are subject to the reconsideration process described in rule
5160-70-02 of the Administrative
Code as follows:
(1)
A written request for a reconsideration should be
submitted to the department or the medical review entity, whichever made the
initial determination as indicated by the denial letter, within sixty calendar
days of the date of the determination. The department or the medical review
entity has thirty business days from receipt of the request for reconsideration
to issue a final and binding decision accepting, modifying, or rejecting its
previous determination. The request for reconsideration must include:
(a)
A copy of the
written determination;
(b)
A copy of the patient's medical record (if not already
submitted to the review entity); and
(c)
Copies of any and
all additional information that may support the provider's
position.
(2)
If the submitted request for a reconsideration is
incomplete, the department or the medical review entity will notify the
provider of missing documentation. The notice will give the provider two
business days to submit the missing documentation.
(3)
The department
will conduct an administrative review of the reconsideration decision if the
provider submits its request within thirty calendar days of that decision. The
department has thirty business days from receipt of the request for review to
issue a final and binding decision. A request for an administrative review must
include:
(a)
A
letter requesting a review of the reconsideration;
(b)
A statement as to
why the provider believes that the reconsideration decision was in error;
and
(c)
Any further documentation supporting the provider's
position.
(4)
The department may extend time frames described in
paragraphs (B)(1) and (B) (3) of this rule, where adherence to time frames
causes exceptional hardships to a large number of hospitals or where adherence
to time frames as described in paragraphs (B)(1) and (B)(3) of this rule causes
exceptional hardship to a hospital because potential determinations constitute
a large portion of that hospital's total medicaid business.
(C)
Reconsideration of hospital payments.
(1)
Except when the
department's determination is based on a finding made by medicare, the proper
application of rules 5160-2-65,
5160-2-75 and
5160-2-76 of the Administrative
Code and the proper calculation of amounts (including source data used to
calculate the amounts) determined in accordance with rules
5160-2-66 and
5160-2-67 of the Administrative
Code are subject to the reconsideration process described in rule
5160-70-02 of the Administrative
Code as follows:
(a)
Requests for reconsideration authorized by paragraph
(C)(1) of this rule should be submitted to the department in writing. If the
request for reconsideration involves a rate component or determination made at
the beginning of the rate year, the request should be submitted within ninety
calendar days of the beginning of the rate year. If the request involves an
adjustment or a determination made by the department after the beginning of the
rate year, the request should be submitted within thirty calendar days of the
date the adjustment or determination was implemented. The request should
include a statement as to why the provider believes that the rate component or
determination was incorrect as well as all documentation supporting the
provider's position.
(b)
The department has thirty business days from receipt of
the request for reconsideration to issue a final and binding
decision.
(2)
When a medicare audit finding was used by the
department in establishing a rate component and the finding is subsequently
overturned on appeal, the provider may request reconsideration of the affected
rate component. Such requests should be submitted to the department in writing
prior to final settlement as described in rule
5160-2-24 of the Administrative
Code and within thirty calendar days of the date the hospital receives
notification from medicare of the appeal decision. The request for
reconsideration of a medicare audit finding that has been overturned on appeal
should include all documentation that explain the appeal decision. The
department has thirty business days in which to notify the provider of its
final and binding decision regarding the medicare audit
finding.
(D)
State hearings for medicaid recipients whose claim for
hospital services is denied.
Any recipient whose claim for hospital
services is denied may request a state hearing in accordance with division
5101:6 of the Administrative Code. The determination of whether outlier
payments will be made or the amounts of outlier payments as described in rule
5160-2-65 of the Administrative
Code is not a denial of a claim for inpatient hospital services. Similarly, the
determination of amounts payable for inpatient hospital services involving
readmissions or transfers is not a denial of a claim for inpatient hospital
services.
(E)
The following items are not subject to the department's
reconsideration process:
(1)
The use of the diagnosis related groups (DRG)
classification system and the method of classification of discharges within
DRGs.
(2)
The assignment of DRGs and severity of illness
(SOI).
(3)
The assignment of relative weights to DRGs based on the
methodology set forth in rule
5160-2-65 of the Administrative
Code.
(4)
The establishment of peer groups as set forth in rule
5160-2-65 of the Administrative
Code.
(5)
The methodology used to determine prospective payment
rates as described in rule
5160-2-65 of the Administrative
Code.
(6)
The methodology used to identify cost thresholds for
services that may qualify for outlier payments as described in rule
5160-2-65 of the Administrative
Code.
(7)
The formulas used to determine rates of payment for
outliers, certain transfers and readmissions, and services subject to
pre-certification, as described, respectively, in rules
5160-2-65 and
5160-2-40 of the Administrative
Code.
(8)
The peer group average cost per discharge for all
hospitals except when the conditions detailed in rule
5160-2-65 of the Administrative
Code are met.
(9)
Statewide calculations of the direct and indirect
medical education threshold for allowable costs per intern and resident as
described in rule
5160-2-67 of the Administrative
Code.
(10)
The threshold for establishing which hospitals will be
recognized as providing a disproportionate share of indigent care as described
in rule 5160-2-09 of the Administrative
Code.
(11)
The use of the "Enhanced Ambulatory Patient Groups"
(EAPG) classification system and the method of classification of claim details
within EAPGs.
(12)
The assignment of EAPGs.
(13)
The assignment
of relative weights to EAPGs based on the methodology set forth in rule
5160-2-75 of the Administrative
Code.
(14)
The establishment of peer groups as set forth in rule
5160-2-75 of the Administrative
Code.
(15)
The methodology used to determine prospective payment
rates as described in rule
5160-2-75 of the Administrative
Code.
(16)
The peer group average cost per detail for all
hospitals except when the conditions detailed in rule
5160-2-75 of the Administrative
Code are met.
(17)
Technical denials, which are the result of failure to
submit medical records within thirty calendar days of the original request in
accordance with rules
5160-2-13 and
5160-1-17.2 of the
Administrative Code.
Replaces: 5160-2- 07.12
