Ohio Admin. Code 5160-43-07 - Specialized recovery services program compliance: provider monitoring, oversight and investigations
(C) Structural
reviews.
(1) All service providers shall be
subject to structural reviews by ODM during each of the first three years after
a provider begins furnishing billable services. Thereafter, structural reviews
shall be conducted annually unless, at the discretion of ODM, biennial
structural reviews may be conducted with a provider when all of the following
apply;
(a) There were no findings against
the provider during the provider's most recent structural
review;
(b) The provider was not
substantiated to be the violator in an incident describedin rule
5160-43-06
of the Administrative Code; and
(c) The provider was not the subject
of more than one provider occurrence during the previous twelve
months.
(2) All program service providers
may be subject to an announced or unannounced structural review at any time as
determined by ODM.
(3) Structural reviews must be
conducted in person between the provider and ODM, unless prior-approved by ODM,
and in a manner consistent with paragraph (B) (3) of this rule.
(4) All structural reviews must use
an ODM-approved structural review tool.
(5) Structural reviews shall not
occur while the provider is furnishing services to an
individual.
(6) The structural review process
consists of the following activities:
(a) Except for unannounced
structural reviews, the provider shall be notified in advance of the review to
arrange a mutually acceptable time, date and location for the review. Advance
notification shall also include identification of the time period for which the
review is being conducted and a list of the types of documents required for the
review.
(b) The provider shall ensure the
availability of required documents and maintain the confidentiality of
information about the individual enrolled in the program.
(c) ODM shall examine any incident
reports or provider occurrences related to the provider. Documented findings of
non-compliance shall be addressed during the review.
(d) An evaluation of compliance with
the rules within this chapter of the Administrative Code shall be conducted by
ODM.
(e) A unit of service verification
shall be conducted by ODM to assure that all program services are authorized,
delivered and reimbursed in accordance with the individual's approved
person-centered care plan.
(f) An evaluation to determine
whether the provider has implemented all plans of correction that were approved
since the last review.
(g) At the conclusion of the review,
ODM shall conduct an exit conference with the provider to discuss preliminary
findings, any remediation and other required follow-up.
(7) ODM shall issue a written
findings report to the provider. The report shall summarize the overall outcome
of the structural review, specify the Administrative Code rules that are the
basis for which non-compliance has been determined, and outline the specific
findings of non-compliance that the provider must address in a plan of
correction, including any remediation.
(8) Plans of correction for
structural reviews must be submitted to ODM for all identified findings of
noncompliance, including any remediation, within forty-five calendar days after
the date on the written report.
(9) If ODM finds the provider's plan
of correction acceptable, it shall acknowledge, in writing, to the provider
that the plan addresses the findings outlined in the written report. If ODM
determines that it cannot approve the provider's plan of correction, ODM shall
inform the provider of this determination in writing, require the provider to
submit a new plan of correction and specify the required actions that must be
included in the plan of correction. The provider must submit the new plan of
correction within ten calendar days.
(10) If ODM determines through the
structural review process that an overpayment of a provider claim has occurred,
the provider shall make all payment adjustments in accordance with rule
5160-1-19 of the
Administrative Code and the provider's approved plan of
correction.
(11) ODM may take action against the
provider as specified in paragraph (B)(4)(b) of this rule for failure to comply
with the structural review requirements set forth in this rule.
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02, 5164.03
Prior Effective Dates: 08/01/2016
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