Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-71 - Hearings for recovery of overpayments
Section 5160-71-01 - Chapter 119. hearings conducted under authority of section 5111.914 of the Revised Code: definitions and scope of applicability
Universal Citation: OH Admin Code 5160-71-01
Current through all regulations passed and filed through September 16, 2024
(A) The following definitions apply to Chapter 5101:6-51 of the Administrative Code.
(1) "Affected party" means a person whose
interests are subject to an adjudication by the Ohio department of job and
family services (ODJFS) under authority of section
5111.914 of the Revised Code.
(2) "Appellant" means an affected
party who has requested an adjudication hearing pursuant to Chapter 119. of the
Revised Code.
(3) "Department"
means ODJFS.
(4) "Depository
agent" means the official mailing address of the office of legal
and acquisition services of ODJFS for the purpose
of receiving correspondence or filings for any hearing held under authority of
section 5111.914 of the Revised Code.
(5) "Director" means the director
of ODJFS or the director's designee.
(6) "Hearing" means a hearing held by an
issuing state agency under authority of section
5111.914 of the Revised Code and
that is in compliance with sections
119.06 to
119.13 of the Revised Code.
(7) "Issuing state agency" means a
state agency that has entered into a contract with ODJFS under section
5111.91 of the Revised Code and
that has issued a notice of overpayment under authority of section
5111.914 of the Revised Code.
This shall not include a political subdivision directly or by contract.
(8) "ODJFS" means the Ohio
department of job and family services.
(9) "Order" means an adjudication issued by
ODJFS of the facts and/or sums in controversy in any hearing conducted by an
issuing state agency under the authority of section
5111.914 of the Revised Code
that is a final disposition of the director as regard to the rights, duties,
privileges, benefits, legal relationships, jurisdictional status, or standing
of any appellant of a proceeding initiated under authority of section
5111.914 of the Revised Code.
(10) "Person" means a person,
firm, corporation, association, or partnership.
(11) "Provider" means any person, institution
or entity, governmental or non-governmental, that furnishes medicaid services
under a provider agreement with ODJFS pursuant to Title XIX of the Social
Security Act, 79 Stat. 286 (1965),
42 U.S.C.
1396
, as amended.
(12) "Provider agreement" means a contract
between ODJFS and a provider of medical services and supplies pursuant to rules
contained in Chapter 5101:3-1 of the Administrative Code.
(13) "Repayment due date" means the date that
payment is due to the state based upon notification of an identified
overpayment. The repayment due date shall be established as follows:
(a) If a settlement is reached in accordance
with section 5111.914 of the Revised Code,
the repayment shall be due no later than the forty-fifth day after full
execution of the settlement. A settlement is fully executed only after all
parties to the settlement have signed the settlement and ODJFS has issued
written approval of the settlement either by signing the settlement or by
separate written approval.
(b) If
settlement is not reached in accordance with section
5111.914 of the Revised Code,
the repayment shall be due within forty-five days after the effective date of
the adjudication order.
(B) Scope of applicability.
(1) Chapter 5101:6-51 of the Administrative
Code prescribes the procedures to be followed in all hearings held before an
issuing state agency pursuant to section
5111.914 of the Revised Code.
The procedures set forth in Chapter 5101:6-51 of the Administrative Code shall
be followed in all instances of notices of overpayments issued by the issuing
state agency except as follows. The issuing state agency is not required to
follow the procedures set forth in Chapter 5101:6-51 of the Administrative Code
in cases where a provider requests one or more claims adjustments if all of the
following conditions are met:
(a) The
provider's request is not a request to negotiate, or to dispute a notice of
overpayment, and
(b) The
adjustments can be completed in full within forty-five days of the provider's
request.
(2) An issuing
state agency's proposed findings shall be limited to findings of overpayments
for medicaid services where the alleged overpayments were made under the
component of the medicaid program that the issuing state agency administers.
(3) Proposed findings issued under
authority of section 5111.914 of the Revised Code are
not a "final fiscal audit" as defined in rule
5101:6-50-01 of the
Administrative Code.
(4) The right
to a hearing pursuant to authority provided in section
5111.914 of the Revised Code is
limited to an issuing state agency's proposal to recover a medicaid
overpayment.
(5) The provisions of
Chapter 5101:6-51 of the Administrative Code are to be interpreted and
construed to achieve their general purpose of providing orderly and fair
procedures for conducting hearings before a state agency.
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