5101:3-1-17.4 Conversion to time-limited provider agreements and re-enrollment.

(A) Definitions:

(1) Open-ended provider agreement. This type of provider agreement has no specific termination date and continues to be in effect as long as agreeable by both parties.

(2) Time-limited provider agreement. This type of provider agreement is for a specific period of time and will expire on a designated date unless renewed in accordance with the Ohio department of job and family services (ODJFS) re-enrollment process. A time-limited provider agreement will be limited to no longer than seven years from the effective date.

(B) The use of time-limited provider agreements pursuant to this rule does not apply to provider agreements issued to the following, including any provider agreements issued to the following that are otherwise time-limited under the medicaid program:

(1) Nursing facilities, as defined in section 5111.20 of the Revised Code ;

(2) Intermediate care facilities for the mentally retarded, as defined in section 5111.20 of the Revised Code ;

(3) Managed care organizations under contract with the department pursuant to section 5111.17 of the Revised Code; and

(4) Hospitals.

(C) The following agreements shall be time-limited agreements or will be converted to time-limited agreements pursuant to section 5111.028 of the Revised Code,unless the provider is one of the provider types listed in paragraphs (B)(1) to (B)(4) of this rule:

(1) Any new provider agreement shall be time-limited in accordance with this rule .

(2) Any existing open-ended provider agreement held by a provider that was enrolled before January 1, 2008, shall be converted to a time-limited agreement on or before January 1, 2015, in accordance with this rule .

(a) ODJFS shall select the provider agreements to be converted and automatically phase in time-limited agreements in a manner and for a time determined by ODJFS.

(b) ODJFS shall notify the provider by sending a conversion notice by regular mail to the address on file that the provider has been automatically converted to a time-limited-agreement in accordance with this rule. Providers are not required to respond to the ODJFS conversion notice.

(c) Providers that have been selected and converted to time-limited agreements may not request that the proposed expiration be altered, either to an earlier or later date.

(3) ODJFS may convert any existing open-ended provider agreement to a time-limited provider agreement whenever the conversion is in the best interest of the medicaid consumers or the state of Ohio.

(4) The conversion from an open-ended to a time-limited provider agreement does not affect the amount or scope of medicaid reimbursement.

(5) The length of time-limited agreements is decided by ODJFS and is determined by provider type. The length of time-limited agreements may vary by provider type but will be consistent for all providers within like provider types. ODJFS may change the length of time-limited agreements by provider type and the length of these agreements may change or vary upon the discretion of ODJFS.

(6) ODJFS will notify the provider when its time-limited provider agreement is close to expiration and when the re-enrollment process is required, as described in paragraph (D) of this rule.

(D) Re-enrollment is the process that a provider with a time-limited agreement is required to follow to renew its provider agreement. The re-enrollment process does not apply to MCPs or open-ended agreements. The re-enrollment process is as follows: (1) ODJFS shall send a re-enrollment notice by regular mail ninety days prior to the expiration date of the provider's time-limited agreement to the provider's address on file notifying the provider that it is required to renew its agreement.

(2) The re-enrollment notice shall instruct the provider what is required to complete the re-enrollment process. Providers are expected to meet all conditions for participation as an eligible provider that are in effect in division 5101:3 of the Administrative Code at the time of re-enrollment.

(3) The provider shall submit all required information before the re-enrollment deadline date specified in the re-enrollment notice.

(4) A provider shall not initiate re-enrollment prior to the receipt of the re-enrollment notification sent by ODJFS as specified in paragraph (D) of this rule. This rule does not negate the requirement that a provider must disclose any changes to its provider agreement in accordance with rule 5101:3-1-17.3 of the Administrative Code. The reporting of changes in accordance with rule 5101:3-1-17.3 of the Administrative Code does not constitute the initiation of re-enrollment and remains the provider's responsibility.

(5) When a provider fails to re-enroll in the time and the manner required by ODJFS, as specified in this rule and in accordance with the re-enrollment notice referred to in paragraph (D)(2) of this rule, ODJFS may deny an application for re-enrollment or terminate a time-limited provider agreement. The denial or termination will take effect thirty days after ODJFS mails a written notice to the provider by regular mail to the address on file notifying the provider of the decision. ODJFS shall specify in the notice the date on which the provider is required to cease operating under a terminated provider agreement.

In lieu of denying an application for re-enrollment or terminating a time-limited agreement when a provider fails to re-enroll in the time and manner required and the agreement expires, ODJFS may deny claims submitted by the provider until the provider completes the re-enrollment process and the re-enrollment application is approved by ODJFS. Once the re-enrollment application is approved by ODJFS, ODJFS may allow the provider to re-submit any claims that were denied while its re-enrollment application pended ODJFS approval. ODJFS will not deny claims pursuant to this paragraph when a provider has re-enrolled in the time and the manner required by ODJFS.

(6) If a provider files an application for re-enrollment within the time and in the manner required, as specified in this rule, but the provider agreement expires before ODJFS acts on the application or before the effective date of the ODJFS decision on the application, the provider may continue operating under the terms of the expired agreement until the effective date of the ODJFS decision.

(7) If a provider files an application for re-enrollment in the time and manner required, as specified in this rule, but has not been able to obtain a renewal of its licensure, certification, accreditation, or registration due to a delay in processing by an official, board, commission, department, division, bureau or other agency of state or federal government:

(a) ODJFS shall not deny the application for re-enrollment or deny payment of services if the provider has included documentation with the re-enrollment application that the licensure, certification, accreditation, or registration has been delayed for processing by an official, board, commission, department, division, bureau or other agency of state or federal government; and

(b) When the decision is made by an official, board, commission, department, division, bureau or other agency of state or federal government to approve or reject an application for renewal of required licensure, certification, accreditation, or registration, the provider is obligated to notify ODJFS within thirty days of the date of approval or rejection in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(E) The effective date of a new provider agreement is the date on which the provider signs the application and meets all of the federal and state requirements for participation in the medicaid program. The effective date of a new provider agreement may be made retroactive for up to twelve months prior to the date of application. A retroactive period will be counted when assigning a time-limit to a new provider agreement to encompass dates on which the provider furnished covered services to a medicaid consumer for which the provider has not been reimbursed. Upon ODJFS approval of the application and the effective date of the agreement, ODJFS will accept claims submitted timely for the retroactive period. Exceptions to the twelve month retroactive period include:

(1) When required licensure, certification, accreditation, or registration is obtained by the provider within the twelve months prior to the application date, the effective date will be that date on which the required license, certification, accreditation, or registration was obtained.

(2) Claims submitted within the twelve month retroactive period will be denied for any service provided if the provider did not meet all ODJFS program requirements for participation on the date the service was provided.

(3) ODJFS may deny retroactive eligibility to a provider for failure to meet re-enrollment requirements as specified in this rule.

(F) Pursuant to section 5111.06 of the Revised Code, ODJFS is not required to issue a notice of hearing rights, in accordance with Chapter 119. of the Revised Code, when converting a provider agreement to a time-limited agreement or when terminating a time-limited provider agreement due to the provider's failure to file an application for re-enrollment.

(G) In processing an application for re-enrollment, ODJFS may conduct an on-site review at the provider's facility, place of business, or both, as ODJFS deems necessary to ensure program integrity.

Effective: 05/01/2010
R.C. 119.032 review dates: 02/09/2010 and 05/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.028
Rule Amplifies: 5111.01 , 5111.02 , 5111.028
Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79,
7/1/80, 7/7/80, 10/1/87, 1/1/95, 5/30/02, 8/11/05,
1/1/08