(A) In the case of erroneous determinations as specified in paragraph (A)(2) of this rule, ODHS will work with providers who received payment from recipients to facilitate the timely reimbursement of full payment to those recipients by their provider. If the provider does not reimburse the recipient in a timely manner, the department will directly reimburse the recipient of the medicaid covered service as specified in paragraph (B) of this rule as expeditiously as possible, not to exceed ninety days following completion of all the requirements of this rule. In order for a recipient to obtain direct reimbursement, all of the following requirements must be met.
(1) (a) The service was a medicaid covered service, which is defined only for the purposes of this rule as a medically necessary service that is covered by the Ohio medicaid. Program and is delivered by a medical provider that qualifies for a medicaid provider agreement; and
(b) The service received by the medicaid recipient was not a nursing facility service.
(2) (a) The individual was incorrectly determined to be ineligible for medicaid and the date on which the individual received the medicaid service was within the period of coverage for which the individual should have been eligible for medicaid; or
(b) The individual was found to be eligible for medicaid but the determination of eligibility was incorrectly delayed and the date on which the individual received the medicaid service was within the period of coverage for which the individual should have been eligible for medicaid.
(3) The individual has requested a state hearing or judicial action to dispute the finding of ineligibility or incorrect delay in eligibility determination pursuant to paragraph (A)(2)(a) or (A)(2)(b) of this rule for the period of coverage which includes the date of service.
(4) For errors pursuant to paragraph (A)(2)(a) of this rule, there is a documented CDHS determination of a CDHS error, or a hearing, administrative appeal or judicial decision that the individual was incorrectly determined to be ineligible for medicaid for a period of coverage which includes the date of service. For delays pursuant to paragraph (A)(2)(b) of this rule, there is a determination in a hearing, administrative appeal or judicial decision that the individual was incorrectly delayed an eligibility determination for a period of coverage which includes the date of service.
(5) The individual requests reimbursement from ODHS for the medically necessary medicaid covered service within ninety days of receiving documentation specified in paragraph (A)(4) of this rule issued by a CDHS, ODHS or a court of law pertaining to the finding of an erroneous determination of eligibility or the finding of an incorrect delay in eligibility determination made pursuant to paragraph (A)(4) of this rule.
(6) Within ninety days of the individual's request for reimbursement as described in paragraph (A)(5) of this rule, the individual provides all of the following:
(a) Written verification of a bill from the provider which specifies the medicaid covered services provided;
(b) Written verification that he or she paid the provider; and
(c) Documentation requested by the department.
(7) The individual contacts the provider, requests reimbursement, and accepts full reimbursement if offered by the provider.
(8) The provider does not reimburse the individual within a reasonable period of time, not to exceed ninety days from the date the individual provides documentation pursuant to paragraph (A)(6) of this rule.
(B) ODHS will reimburse recipients who meet the conditions specified in paragraph (A) of this rule in the following manner:
(1) If the recipient obtained the service from a medicaid contracting provider, ODHS will reimburse the recipient's full documented payment.
(2) If the recipient obtained the service from a provider who does not contract with medicaid, ODHS will reimburse the lesser of the recipient's payment or an amount equal to the rate medicaid pays medicaid contracting providers for the same service.
(C) All the provisions set forth in the chapters of agency-level designation 5101:3 of the Administrative Code remain in effect, except that direct reimbursement by ODHS to individual recipients of medicaid covered services is permitted under the circumstances set forth in this rule. All notice and hearing provisions set forth in agency-level designation 5101:6 of the Administrative Code apply to determinations made under this rule, and hearing officers have authority to direct ODHS to make payments in accordance with this rule.
R.C. 119.032 review dates: 04/20/2004 and 04/20/2009
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 4/22/99