Current through all regulations passed and filed through September 16, 2024
(A) Notice of
overpayment.
An issuing state agency that identifies a medicaid overpayment
shall send a notification, by certified mail, return receipt requested, of the
overpayment amount to the medicaid provider. The issuing state agency shall
send a copy of the notification to ODJFS not later than five business days
after sending the notification to the provider. The notification of overpayment
shall contain a clear statement of all the following:
(1) The amount of the overpayment including
interest charges;
(2) A general
description of the grounds for the overpayment finding;
(3) A request that the provider voluntarily
repay the overpayment;
(4) The
address where payment should be made;
(5) The acceptable methods of payment;
(6) A statement that if voluntary
repayment is not made in full within thirty days of the provider's receipt of
notification that the issuing state agency will proceed with formal notice of
hearing rights in accordance with section
5111.914 of the Revised Code;
and
(7) A statement that as an
alternative to payment the provider may within thirty days of the date of
mailing of the notification submit to the issuing state agency a written
statement disputing the overpayment amount and requesting an opportunity to
negotiate a settlement of the overpayment.
(B) Negotiation of settlement.
The issuing state agency may in its sole discretion attempt to
negotiate a settlement in accordance with this rule. If the provider files a
written request to negotiate within thirty days of the date of mailing of the
notification in accordance with paragraph (A)(7) of this rule, and the issuing
state agency exercises its discretion to attempt to negotiate a settlement, the
issuing state agency shall notify the provider that the agency is rescinding
its notification of overpayment in order to negotiate a settlement of the
overpayment.
(1) The issuing state
agency must submit a negotiated settlement to ODJFS for review and approval or
rejection within thirty days after the provider's written statement filed in
accordance with paragraph (A)(7) of this rule. If the issuing state agency does
not submit a negotiated settlement to ODJFS within thirty days, the issuing
state agency shall issue a notice of opportunity for hearing in accordance with
section 5111.914 of the Revised Code and
rule 5101:6-51-04 of the
Administrative Code.
(2) If ODJFS
signs the agreement or issues written approval, the provider shall make
repayment under the terms of the settlement.
(3) If ODJFS rejects the settlement, the
issuing state agency shall issue a notice of opportunity for hearing in
accordance with section
5111.914 of the Revised Code and
rule 5101:6-51-04 of the
Administrative Code.
(4) If the
issuing state agency exercises its discretion to not attempt to negotiate a
settlement, the issuing state agency shall issue a notice of opportunity for
hearing in accordance with section
5111.914 of the Revised Code and
rule 5101:6-51-04 of the
Administrative Code.
(C) Terms of settlement.
A negotiated settlement shall comply with the following
standards:
(1) The settlement shall
expressly require repayment within forty-five days of the date of the later of
either full execution of the settlement or final written approval of the
settlement by ODJFS.
(2) The
negotiated settlement shall cover both the federal share and state share of the
amount the parties agree upon and interest charges.
(3) The negotiated settlement shall clearly
identify what disputed sums or facts are the subject of final resolution by the
settlement and shall identify the grounds upon which any amounts are
compromised.
(4) The negotiated
settlement may compromise the amount repaid only on the following grounds:
(a) The provider produces evidence showing
that specified sums identified are not an overpayment;
(b) A sum was identified as an overpayment
based upon an incorrect application of law or fact; or
(c) A sum was identified as an overpayment
based upon a clearly identified clerical error.
(5) The settlement may contain any other
terms the parties consider necessary for execution of the settlement but such
terms shall be invalid if they conflict with laws or rules governing the
medicaid program.
(6) A negotiated
settlement shall not be valid and enforceable unless ODJFS signs the agreement
or issues other written approval of the agreement.
(D) Nothing shall preclude settlement
negotiations on the same or different grounds after the issuance of a notice of
opportunity for hearing issued under authority of section
5111.914 of the Revised Code.
(E) Referral to the attorney
general for collection.
(1) If a settlement
is reached in accordance with this rule and the repayment is not received by
the forty-fifth day after full execution of the settlement
or final written approval of the settlement by
ODJFS, the issuing state agency shall refer the matter to the attorney
general's office for collection as required by section
131.02 of the Revised Code.
(2) If settlement is not reached
in accordance with section
5111.914 of the Revised Code,
repayment shall be due within forty-five days after the effective date of the
adjudication order that is issued pursuant to a hearing initiated under section
5111.914 of the Revised Code.
Except as provided in paragraph (E)(3) of this rule, if repayment is not received by
the forty-fifth day after the effective date of the adjudication order, the
issuing state agency shall refer the amount to the attorney general for
collection as required by section
131.02 of the Revised Code.
(3) If an appeal of the
adjudication order is timely filed and a stay is granted by the court within
forty-five days of the issuance of the adjudication order, the issuing state
agency shall not refer the matter to the attorney general's office for
collection until the expiration or lifting of the order granting the stay, or
until such other order of the court permits implementation of the adjudication
order.
(4) An issuing state agency
shall not certify a medicaid overpayment for collection by the attorney general
under section 131.02 of the Revised Code
without first following the procedures required by section
5111.914 of the Revised Code and
Chapter 5101:6-51 of the Administrative Code.
(5) The issuing state agency shall send a
report at least quarterly to ODJFS enumerating the status of recovery of any
amounts identified in notices issued under authority of this rule. The report
shall be in a form and manner specified by ODJFS.
