Ohio Admin. Code 4123-6-02.51 - Provider access to the HPP - Denial of provider, entity or MCO enrollment or certification based on criminal conviction or civil action
(A) The
administrator may refuse to enroll, certify
or recertify, or may terminate enrollment,
or decertify from participation in the HPP, any
provider, entity or MCO that:
(1) Is owned, directly or indirectly, by an
individual or entity that has a felony conviction in any jurisdiction, a
conviction under a federal controlled substance act, a misdemeanor conviction
for an act involving dishonesty, fraud, or misrepresentation, a conviction for
a misdemeanor committed in the course of practice, or a felony or misdemeanor conviction involving
dishonesty, fraud, or misrepresentation related to any compensation or benefits
payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code, or court supervised intervention or treatment in lieu of
conviction pursuant to section 2951.041 of the Revised Code or the equivalent
law of another state.
(2)
Has one or more owners, shareholders, members, partners, managing employees,
officers or directors, who have a conviction or
court supervised intervention or treatment in lieu of conviction as
described in paragraph (A)(1) of this rule; and including any
provider, entity or MCO that is no longer
so described because of a transfer of ownership or interest to an immediate
family member or a member of the person's household in anticipation of or
following a conviction or court supervised
intervention or treatment in lieu of conviction as described in
paragraph (A)(1) of this rule.
(3)
Is owned directly, or indirectly, by an individual or entity who has engaged in
specific conduct which demonstrates financial irresponsibility. Such conduct
shall include, but not be limited to:
(a)
Specific examples of insolvency of businesses owned or controlled by the
individual or entity;
(b) Specific
examples of failures to pay debts or judgments;
(c) Specific examples of activity which has
defrauded any person, entity or organization, regardless of whether such
activity has resulted in criminal prosecution;
(d) Any finding of fraud in a civil or
administrative proceeding related to any compensation or benefits payable under
Chapter 4121., 4123., 4127., or 4131. of the Revised Code or the equivalent
laws of another state.
(B)
The administrator
may refuse to enroll, certify or recertify, or may terminate enrollment or
decertify from participation in the HPP, any provider or entity that:
(1)
Is owned,
directly or indirectly, by an individual or entity that has been convicted of
or pleaded guilty to a criminal offense as set forth in the appendix to rule
4123-6-02.2 of the Administrative Code. The provider or entity is ineligible
for enrollment, certification, or recertification for the same period of
ineligibility provided in the appendix to rule 4123-6-02.2 of the
Administrative Code for the criminal offense.
(2)
Has one or more
owners, shareholders, members, partners, managing employees, officers or
directors who have a conviction or plea of guilty to a criminal offense as set
forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The
provider or entity is ineligible for enrollment, certification, or
recertification for the same period of ineligibility provided in the appendix
to rule 4123-6-02.2 of the Administrative Code for the criminal
offense.
(3)
It is owned directly, or indirectly, by an individual
or entity who has engaged in specific conduct which demonstrates financial
irresponsibility as described in paragraph (A)(3) of this rule.
(1) The person, health
care provider, managed care organization, or its owner, or an officer,
authorized agent, associate, manager, or employee of a person, provider, or
organization is convicted of or pleads guilty to a violation of sections
2913.48
or
2923.31
to
2923.36
of the Revised Code or any other criminal offense related to the delivery of or
billing for health care benefits.
(2) There exists an entry of judgment against
the person, health care provider, managed care organization, or its owner, or
an officer, authorized agent, associate, manager, or employee of a person,
provider, or organization and proof of the specific intent of the person,
health care provider, managed care organization, or owner to defraud, in a
civil action brought pursuant to section
4121.444
of the Revised Code.
(3) There
exists an entry of judgment against the person, health care provider, managed
care organization, or its owner, or an officer, authorized agent, associate,
manager, or employee of a person, provider, or organization in a civil action
brought pursuant to sections
2923.31
to
2923.36
of the Revised Code.
(1) Directly provide services to any other
bureau provider or have an ownership interest, as an individual or through any
other entity or entities, of five percent or more in a provider of services
that furnishes services to any other bureau provider;
(2) Arrange for, render, or order services
for claimants during the period that the agreement of the person, health care
provider, managed care organization, or its owner is terminated as described in
division (C)(1) of section
4121.444
of the Revised Code;
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.444, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.444
Prior Effective Dates: 04/01/2007, 09/01/2013, 11/13/2015
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) The administrator may refuse to enroll, certify or recertify, or may terminate enrollment, or decertify from participation in the HPP , any provider , entity or MCO that:
(1) Is owned, directly or indirectly, by an individual or entity that has a felony conviction in any jurisdiction, a conviction under a federal controlled substance act, a misdemeanor conviction for an act involving dishonesty, fraud, or misrepresentation, a conviction for a misdemeanor committed in the course of practice, or a felony or misdemeanor conviction involving dishonesty, fraud, or misrepresentation related to any compensation or benefits payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code, or court supervised intervention or treatment in lieu of conviction pursuant to section 2951.041 of the Revised Code or the equivalent law of another state.
(2) Has one or more owners, shareholders, members, partners, managing employees, officers or directors, who have a conviction or court supervised intervention or treatment in lieu of conviction as described in paragraph (A)(1) of this rule; and including any provider , entity or MCO that is no longer so described because of a transfer of ownership or interest to an immediate family member or a member of the person's household in anticipation of or following a conviction or court supervised intervention or treatment in lieu of conviction as described in paragraph (A)(1) of this rule.
(3) Is owned directly, or indirectly, by an individual or entity who has engaged in specific conduct which demonstrates financial irresponsibility. Such conduct shall include, but not be limited to:
(a) Specific examples of insolvency of businesses owned or controlled by the individual or entity;
(b) Specific examples of failures to pay debts or judgments;
(c) Specific examples of activity which has defrauded any person, entity or organization, regardless of whether such activity has resulted in criminal prosecution;
(d) Any finding of fraud in a civil or administrative proceeding related to any compensation or benefits payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code or the equivalent laws of another state.
(B) The administrator may refuse to enroll, certify or recertify, or may terminate enrollment or decertify from participation in the HPP , any provider or entity that:
(1) Is owned, directly or indirectly, by an individual or entity that has been convicted of or pleaded guilty to a criminal offense as set forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The provider or entity is ineligible for enrollment, certification , or recertification for the same period of ineligibility provided in the appendix to rule 4123-6-02.2 of the Administrative Code for the criminal offense.
(2) Has one or more owners, shareholders, members, partners, managing employees, officers or directors who have a conviction or plea of guilty to a criminal offense as set forth in the appendix to rule 4123-6-02.2 of the Administrative Code. The provider or entity is ineligible for enrollment, certification , or recertification for the same period of ineligibility provided in the appendix to rule 4123-6-02.2 of the Administrative Code for the criminal offense.
(3) It is owned directly, or indirectly, by an individual or entity who has engaged in specific conduct which demonstrates financial irresponsibility as described in paragraph (A)(3) of this rule.
(1) The person, health care provider , managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization is convicted of or pleads guilty to a violation of sections 2913.48 or 2923.31 to 2923.36 of the Revised Code or any other criminal offense related to the delivery of or billing for health care benefits.
(2) There exists an entry of judgment against the person, health care provider , managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization and proof of the specific intent of the person, health care provider, managed care organization, or owner to defraud, in a civil action brought pursuant to section 4121.444 of the Revised Code.
(3) There exists an entry of judgment against the person, health care provider , managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization in a civil action brought pursuant to sections 2923.31 to 2923.36 of the Revised Code.
(1) Directly provide services to any other bureau provider or have an ownership interest, as an individual or through any other entity or entities, of five percent or more in a provider of services that furnishes services to any other bureau provider ;
(2) Arrange for, render, or order services for claimants during the period that the agreement of the person, health care provider , managed care organization, or its owner is terminated as described in division (C)(1) of section 4121.444 of the Revised Code;
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.444, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.444
Prior Effective Dates: 04/01/2007, 09/01/2013, 11/13/2015