(A) "Hold and Review" is defined in
accordance with rule
5101:3-1-27
5160-1-27 of the Administrative Code.
(1) Hold and review without prior
notification.
(a) The Ohio department
of job and family services (ODJFS)
of medicaid (ODM) may place a medicaid provider's
claim(s) payment on hold and review, in whole or in part, without first
notifying the provider for the following reasons:
(i) In response to allegations of fraud or
other willful misrepresentation of claims submission; or
(ii) When a provider has been indicted for a
criminal offense.
(b)
ODJFS
ODM
shall notify the provider in writing within ten business days that the
provider's claims have been, and will continue to be, subject to hold and
review.
The notice shall describe the documentation
needed to review the claims placed on hold and review along with the items
stated in paragraphs (E)(1) to (E)(6) of this rule.
(2) Hold and review with prior
notification.
(a)
ODJFS
ODM may place a
medicaid provider's claim(s) payment on hold and review, in whole or in part,
with prior notice to the provider under the following circumstances:
(i) When the information is used to
complement or follow up a provider certification or other quality review
process;
(ii) Upon request from the
office of the attorney general, the office of inspector general or the auditor
of state;
(iii) A medicaid
provider's agreement has been proposed for termination for reasons other than
those stated in paragraph (A) of this rule; or
(iv) For reasons otherwise necessary to
assure the basic integrity of claims submission and payment.
(b)
ODJFS
ODM will notify
the provider in writing within ten business days before the effective start
date of the hold and review.
(B) Review of the medicaid provider's claims
and documentation for the hold and review process is subject to the provisions
of rule
5101:3-1-27
5160-1-27 of the Administrative Code.
(C) The hold and review may be applied
without regard to date of service. Claims subject to
the hold and review process include any claims for payment received by ODJFS
after the effective date of the hold and review even if such claims are for
dates of service that occurred prior to the effective date of the hold and
review
(D) Failure by
ODJFS
ODM to
notify a provider of a hold and review shall not impede the agency from taking
actions under this rule.
(E) The
notice from
ODJFS
ODM shall:
(1) State
the general reasons for the withholding of the medicaid provider's claims
payments, but need not disclose any specific information concerning an ongoing
investigation involving alleged fraud and/or willful
misrepresentation;
(2) State the
effective date
ODJFS
ODM implements the hold and review process;
(3) State the types of services and claims,
in whole or in part, that will be subject to the hold and review processAny claims received by ODJFS on or after the date of written
notification may be subject to hold and review even if such claims are for
dates of service that occurred prior to the effective date of the hold and
review;
(4)
State
Identify
the documentation required to be submitted to
ODJFS
ODM by the
provider:
(a) Except for medicaid providers
required to submit medical claims to ODJFS electronically, all claims from
providers placed on hold and review must be submitted in non-electronic (paper)
format.
(b) Providers who must submit
medical claims electronically must submit paper documentation supporting each
claim submitted electronically. These claims will not be processed until both
the claim and the supporting documentation are reviewed by
ODJFS.
(5) Inform
the provider of the right to submit evidence for consideration to
ODJFS
ODM;
(6)
State the contact at
ODJFS
ODM for questions regarding the hold and review
process.
(F)
Except for medicaid providers required to submit
medical claims to ODM electronically, all claims from providers placed on hold
and review must be submitted in non-electronic (paper) format.
(G)
Providers who
must submit medical claims electronically must submit paper documentation
supporting each claim submitted electronically. These claims will not be
processed until both the claim and the supporting documentation are reviewed by
ODM.
(F)
(H)
ODJFS
ODM may, if appropriate, send copies of the notice to
local, state and federal entities that are involved in the review or that need
to be aware of the review in order to assure the integrity of claims submission
and payment.
(G)
(I)
ODM has one hundred twenty
days from the date each claim for payment is received to review the claim and
make a determination whether or not to do one of the following:
No later than one hundred twenty days from the date
ODJFS holds a claim for review, ODJFS shall forward the claim for adjudication
if it is determined that the documentation supports the validity of the claim,
or for denial processing if the documentation submitted does not support that
paying the claim would be in compliance with law or if the provider fails to
submit the requested supporting documentation to ODJFS. If the review results
in ODJFS concluding that the provider has a pattern of submitting claims that
are not in compliance with law, ODJFS may issue a "Notice of Operation
Deficiency" to the provider and continue to hold and review the provider's
claims until the operational deficiency is eliminated.
(1)
Forward the claim
for adjudication;
(2)
Forward the claim for denial; or
(3)
Issue a "Notice
of Operation Deficiency."
(H)
(J)
Medicaid providers are not entitled to a hearing
under Chapter 119. or section 5111.06 of the Revised Code for any action taken
by ODJFS under this rule
The hold and review
process is not subject to Chapter 119. of the Revised Code or any other
appeal.
.
Notes
Ohio Admin. Code
5160-1-27.1
Effective:
9/3/2015
Five Year Review (FYR) Dates:
04/29/2015 and
09/03/2020
Promulgated
Under: 119.03
Statutory
Authority: 5164.02,
5166.02,
5162.10
Rule
Amplifies: 5164.02,
5166.02,
5162.10
Prior
Effective Dates: 09/01/2007