Current through all regulations passed and filed through September 16, 2024
(B)
Except as
provided in paragraph (C) of this rule and section
5164.58 of the Revised Code, the
department shall do the following by issuing an order pursuant to an
adjudication conducted in accordance with Chapter 119. of the Revised
Code:
(1)
Pursuant to section 5164.38 of the Revised Code,
refuse to enter into a provider agreement with a provider;
(2)
Pursuant to
section 5164.38 of the Revised Code,
refuse to revalidate a medicaid provider's provider agreement;
(3)
Pursuant to
section 5164.38 of the Revised Code,
suspend or terminate an existing medicaid provider's provider
agreement;
(4)
Pursuant to section
5164.38 of the Revised Code,
take any action based upon a final fiscal audit;
(5)
Pursuant to
section 5165.46 of the Revised
Code:
(a)
Take
any audit disallowance that the department makes as the result of a nursing
facility cost report audit under section
5165.109 of the Revised
Code;
(b)
Make any adverse finding that results from an
exception review of resident assessment data conducted for a nursing facility
under section 5165.193 of the Revised Code
after the effective date of the nursing facility's medicaid payment rate for
direct care costs that is based on the resident assessment
data;
(c)
Recover any medicaid payment deemed an overpayment
based upon the final cost report filed by an exiting nursing facility operator
under section 5165.523 of the Revised
Code;
(d)
Impose any penalty under section
5165.42 of the Revised Code or
section 5165.523 of the Revised
Code.
(6)
Pursuant to section
5165.525 of the Revised Code,
issue a final debt summary report;
(7)
Pursuant to
division (A) of section
5165.77 of the Revised Code,
terminate a nursing facility's participation in the medical assistance program,
appoint a temporary manager of a nursing facility, or deny payment to a nursing
facility for all medicaid eligible residents admitted after the effective date
of the order.
(C)
The Chapter 119. administrative procedures, including
hearing rights, are not applicable to department actions that include, but are
not limited to, the following:
(1)
Pursuant to section
5164.38 of the Revised Code, the
termination of the provider agreement because the terms of the provider
agreement require the medicaid provider to hold a license, permit, or
certificate or maintain a certification issued by an official, board,
commission, department, division, bureau, or other agency of state or federal
government other than the department of medicaid, and the license, permit,
certificate, or certification has been denied, revoked, not renewed, suspended,
or otherwise limited;
(2)
Pursuant to section
5164.38 of the Revised Code, the
termination of the provider agreement because the terms of the provider
agreement require the medicaid provider to hold a license, permit, or
certificate or maintain certification issued by an official, board, commission,
department, division, bureau, or other agency of state or federal government
other than the department of medicaid, and the provider has not obtained the
license, permit, certificate, or certification;
(3)
Pursuant to
section 5164.38 of the Revised Code, the
denial of the medicaid provider's application for a provider agreement or the
provider's provider agreement is terminated or not revalidated, because of or
pursuant to any of the following:
(a)
The termination, refusal to renew, or denial of a
license, permit, certificate, or certification by an official, board,
commission, department, division, bureau, or other agency of this state other
than the department of medicaid, notwithstanding the fact that the provider may
hold a license, permit, certificate, or certification from an official, board,
commission, department, division, bureau, or other agency of another
state;
(b)
Division (E)(3)(b) of section
5164.38 of the Revised Code and
division (D) of section
5164.35 of the Revised Code,
when a judgment has been entered in either a criminal or civil action against a
medicaid provider or its owner, officer, authorized agent, associate, manager,
or employee in an action brought pursuant to section
109.85 of the Revised Code,
except if the provider or owner can demonstrate to the department that the
provider or owner did not directly or indirectly sanction the action of its
authorized agent, associate, manager, or employee which resulted in the entry
of judgment;
(c)
Division (E)(3)(b) of section
5164.38 of the Revised Code and
division (E) of section
5164.35 of the Revised Code,
when the attorney general on behalf of the state has commenced proceedings in
any court of competent jurisdiction and settled or compromised any such case
brought under section
5164.35 of the Revised
Code;
(d)
The provider's termination, suspension, or exclusion
from the medicare program or from another state's medicaid program and, in
either case, the termination, suspension, or exclusion is binding on the
provider's participation in the Ohio medicaid program;
(e)
The provider has
pleaded guilty to or been convicted of a criminal activity materially related
to the medicare or medicaid programs;
(f)
The conviction
of the provider or its owner, officer, authorized agent, associate, manager, or
employee of one of the offenses that caused the provider's provider agreement
to be suspended pursuant to section
5164.36 of the Revised Code;
and
(g)
The failure of the provider to provide the department
the national provider identifier assigned to the provider by the national
provider system pursuant to
45 C.F.R
162.408 (October 1, 2014). In this case, the
department may take its action by sending a notice explaining the action to the
provider. The notice shall be sent to the provider's last known address on
record with the department. The notice may be sent by ordinary
mail.
(4)
Pursuant to section
5164.38 of the Revised Code, the
denial of the provider's application for a provider agreement, or the
provider's provider agreement is terminated or suspended, as a result of action
by the United States department of health and human services and that action is
binding on the provider's medicaid participation;
(5)
Pursuant to
section 5164.38 of the Revised Code,
referencing sections 5164.36 and
5164.37 of the Revised Code, the
suspension of the provider's provider agreement and payments pending indictment
of the provider;
(6)
Pursuant to section
5164.38 of the Revised Code, the
denial of the application for a provider agreement because the application was
not complete. In this case, the department may take its action by sending a
notice explaining the action to the applicant. The notice shall be sent to the
applicant's last known address on record with the department. The notice may be
sent by ordinary mail;
(7)
Pursuant to section
5164.38 of the Revised Code, the
conversion of the provider's provider agreement under section
5164.32 of the Revised Code from
a provider agreement that is not time-limited to a provider agreement that is
time-limited. In this case, the department may take its action by sending a
notice explaining the action to the provider. The notice shall be sent to the
provider's last known address on record with the department. The notice may be
sent by ordinary mail;
(8)
Unless the provider is a nursing facility or ICF/IID,
the non-revalidation of the provider's provider agreement pursuant to division
(B)(1) of section 5164.32 of the Revised
Code;
(9)
The suspension, termination, or non-revalidation of
the provider's provider agreement because of either of the following:
(a)
Any reason
authorized or required by one or more of the following:
42
C.F.R. 455.106,
455.23,
455.416,
455.434,
or
455.450
(October 1, 2014);
(b)
The provider has not billed or otherwise submitted a
medicaid claim for two years or longer. In this case, the department may take
its action by sending a notice explaining the action to the provider. The
notice shall be sent to the provider's address on record with the department.
The notice may be sent by ordinary mail.
(10)
Acts of the
director, agency employees or contractors of ODM that are ministerial in
nature;
(11)
Actions of ODM that are subject to public hearings
under an administrative review procedure other than the review provided by
Chapter 119. of the Revised Code;
(12)
Rate
calculations and interim settlements;
(13)
Claims payment
denial determinations and claims adjustments for reasons including, but not
limited to, duplicate payments and payment for services not
rendered;
(14)
Notices of operational deficiency, and reviews and
audits that are not subject to the Chapter 119. administrative
procedure;
(15)
Proceedings, authorized by section
5101.31 of the Revised Code and
rules in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, provided to
applicants for, or recipients of, benefits administered by the department, its
designees, or contractors;
(16)
Personnel
action appeals of employees of ODM or of a county department of job and family
services;
(17)
Disputes involving the issuance, denial, or
termination of a contract, a grant, or an interagency agreement issued by ODM
or a protest filed with regard to a request for proposals or a request for
application issued by ODM;
(18)
Administrative
actions taken by ODM that involve program administration and funding affecting
county departments of job and family services.
(D)
Except as
otherwise set forth in the Ohio Administrative Code, actions taken that meet
the exceptions of paragraph (C) of this rule and other administrative actions
regarding medicaid providers that are not subject to hearings under Chapter
119. of the Revised Code and those individuals or providers who do not have
medicaid provider agreements and are proposed for exclusion from participation
may be reconsidered by the director, assistant director, or the deputy director
over the area where the contestation arose. The director, assistant director,
or the deputy director may designate who conducts the reconsideration, provided
that the designee was not involved in the original decision or contestation. If
the department takes an action that is subject to reconsideration, the
department may set deadlines by which the person affected by the action shall
submit his or her written request for reconsideration and the documentation
supporting the request. The deadline shall be no fewer than thirty days from
the date appearing on the letter sent to the person. When the department sets a
deadline for requesting reconsideration, reconsideration requests and
supporting documentation received after the deadline may be considered at the
department's discretion. ODM shall not reconsider its reconsideration
decisions.
(1)
See Chapter 5160-2 of the Administrative Code for additional provisions
specific to hospital services.
(2)
See Chapter
5160-3 of the Administrative Code for additional provisions specific to nursing
facilities.
(3)
See Chapter 5160-26 of the Administrative Code for
additional provisions specific to managed care plans (MCPs).
(E)
When
the department takes an action under paragraph (B)(2) or (B)(3) of this rule
and the provider requests an adjudication hearing pursuant to Chapter 119. of
the Revised Code, the department may withhold payments to the provider if each
of the following conditions is met:
(1)
The department complies with the provisions of section
119.07 of the Revised
Code;
(2)
The department does not request a hearing continuance;
and
(3)
The department issues an adjudication order within
thirty days after the hearing is completed.
(F)
When the
department takes an action under paragraph (B)(4) of this rule and the provider
requests an adjudication hearing pursuant to Chapter 119. of the Revised Code,
the department may withhold payment to the provider if each of the following
conditions is met:
(1)
The department complies with the provisions of section
119.07 of the Revised
Code;
(2)
The department does not request a hearing
continuance;
(3)
The department issues an adjudication order within
thirty days after the hearing is completed; and
(4)
The department
withholds only an amount that does not exceed the amounts determined in the
final fiscal audit.
