Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-43 - Specialized Recovery Services Program
Section 5160-43-07 - Specialized recovery services program compliance: provider monitoring, oversight and investigations
Universal Citation: OH Admin Code 5160-43-07
Current through all regulations passed and filed through September 16, 2024
(A) The Ohio department of medicaid (ODM) is responsible for the ongoing monitoring and oversight of all providers of specialized recovery services (hereafter referred to as providers) and contractors to ensure compliance with program requirements.
(B) Monitoring and oversight of specialized recovery services program providers and recovery management contractors:
(1) ODM and/or its designee (hereafter
referred to as ODM) shall conduct ongoing monitoring and oversight of providers
and contractors, to verify each provider is:
(a) Complying with the terms and conditions
of its medicaid provider agreement or contract, the program and all applicable
federal, state and local regulations;
(b) Ensuring the health and welfare of
individuals to whom they provide services; and
(c) Ensuring the provision of quality
services as part of the program.
(2) Monitoring and oversight may include, but
is not limited to:
(a) Interviews with
individuals enrolled in the program and/or their authorized representative or
legal guardian, providers and contractor staff;
(b) Visits to the provider's place of
business or another agreed upon location for the purpose of examining or
collecting records, reviewing documentation, and conducting structural reviews;
and
(c) Reviews of electronic
and/or hard copy records and billing documentation.
(3) Providers and contractors shall fully
cooperate with all requests made by ODM, as part of the monitoring and
oversight process. This includes, but is not limited to:
(a) Upon request, arranging for or furnishing
an adequate workspace for ODM to conduct visits. This workspace must be in a
secure location which protects sensitive information from being disclosed
contrary to relevant confidentiality and information disclosure laws;
(b) Making all requested information
available at the time of review, and in accordance with the terms of compliance
with contracts, as applicable;
(c)
Providing reports
as requested by ODM to monitor performance; and
(d)
Ensuring the availability of supervisors and/or other staff who may possess
relevant information to answer questions.
(4) At the conclusion of a provider
monitoring and oversight review:
(a) ODM shall
notify the provider or contractor in writing of its findings.
(b) ODM may:
(i) Request the provider or contractor submit
to ODM a plan of correction within the prescribed time frame. The plan of
correction shall set forth the action(s) that must be taken by the provider or
contractor to correct each finding, and establish a target date by which the
corrective action must be completed. If ODM does not approve the submitted plan
of correction, ODM may request a new plan of correction or take other
appropriate action;
(ii) Provide
technical assistance to the provider or contractor;
(iii) Refer the provider or contractor to
other regulatory and oversight entities for further investigation;
(iv) Issue the provider or contractor a
notice of operational deficiency based upon the review and findings;
(v) Propose suspension or termination of the
provider's medicaid provider agreement pursuant to section
5164.38 of the Revised Code and
rules 5160-1-17.5 and
5160-1-17.6 of the
Administrative Code, as applicable; or
(vi) Terminate the contractor's contract
pursuant to its terms.
(C) Investigation of provider occurrences.
(1) Upon discovery, ODM
or its designee shall investigate provider occurrences including requesting any
documentation required for the investigation.
(2) If ODM substantiates the provider
occurrence, it shall notify the provider in a manner that confirms provider
receipt. The notification shall specify:
(a)
The provider's action or inaction that constituted the provider
occurrence;
(b) The Administrative
Code rule(s) that support the finding(s) of noncompliance; and
(c) Actions the provider must take to correct
the finding(s) of non-compliance, including any remediation or required payment
adjustments.
(3) Plans
of correction for provider occurrences must be submitted to ODM for all
identified findings of non-compliance, including any remediation, within
forty-five calendar days after the date on the written report.
(4) If ODM finds the provider's plan of
correction acceptable, it shall acknowledge, in writing, to the provider that
the plan addresses the findings outlined in the written report. If ODM
determines that it cannot approve the provider's plan of correction, it shall
inform the provider of this determination in writing, require the provider to
submit a new plan of correction and specify the required actions that must be
included in the plan of correction. The provider must submit the new plan of
correction within ten calendar days.
(5) If ODM determines through the
investigation of a provider occurrence that an overpayment of a provider claim
has occurred, the provider shall make all payment adjustments in accordance
with rule
5160-1-19 of the Administrative
Code and the provider's approved plan of correction.
(6) ODM may take action against the provider
as specified in paragraph (B)(4)(b) of this rule for failure to comply with the
investigation of provider occurrences requirements set forth in this
rule.
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.
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