(1) "Affected party" means a person whose interests are subject to an adjudication by ODJFS, including providers and licensees.
(2) "Appellant" means an affected party who has requested an adjudication hearing pursuant to Chapter 119. of the Revised Code.
(3) "Contract" means any agreement through which ODJFS purchases goods or services from a vendor.
(4) "Department" means the Ohio department of job and family services.
(5) "Depository agent" means the office of legal services of ODJFS and its official mailing address for the purpose of receiving correspondence or filings for any hearing held under authority of Chapter 5101:6-50 of the Administrative Code.
(6) "Director" means the director of ODJFS or the director's designee.
(7) "Final fiscal audit" means a medicaid report of examination or a medicaid final settlement or a medicaid hospital final settlement, including a final settlement in which Title V monies are offset against medicaid monies proposed for adjudication by ODJFS.
(8) "Grant" means an award of funds by ODJFS to a public agency or private nonprofit corporations that does not include the purchase or lease of services, materials, or supplies for ODJFS.
(10) "Last known address" means the most recent mailing address reported to ODJFS by the person in compliance with requirements to provide the person's address.
(11) "License" means any license, permit, certificate, commission, or charter issued by ODJFS. License does not include any arrangement whereby a person, institution, or entity furnishes medicaid services under a provider agreement with ODJFS.
(12) "Licensee" means any person, institution, or entity, governmental or non-governmental, that furnishes services under a license issued by ODJFS pursuant to statute.
(13) "ODJFS" means the Ohio department of job and family services.
(14) "Order" means any final adjudication of facts, issues, or amounts in controversy in any hearing conducted under the authority of Chapter 5101:6-50 of the Administrative Code before ODJFS and any final disposition or directive of the director regarding the rights, duties, privileges, benefits, legal relationships, jurisdictional status, or standing of any affected party or appellant.
(15) "Person" means an individual, a firm, a corporation, an association, an institution, a partnership, or an entity.
(16) "Provider" means any person, governmental or non-governmental, that furnishes medicaid services under a provider agreement with ODJFS.
(17) "Provider agreement" means a contract between ODJFS and a person who provides medical services and supplies pursuant to rules contained in division 5101:3 of the Administrative Code.
(B) Application of procedures contained in Chapter 5101:6-50 of the Administrative Code
Chapter 5101:6-50 of the Administrative Code prescribes the procedures to be followed in all hearings held before ODJFS pursuant to sections 119.06 to 119.13, 5103.03, 5103.12, 5104.04, and 5164.38 of the Revised Code. The provisions of Chapter 5101:6-50 of the Administrative Code are to be interpreted and construed to achieve their general purpose of providing orderly and fair procedures for conducting hearings before ODJFS. Section 1.14 of the Revised Code controls the computing of time deadlines referenced in Chapter 5101:6-50 of the Administrative Code.
(C) Actions that do not provide hearing rights under this chapter
Unless otherwise noted, Chapter 5101:6-50 of the Administrative Code does not apply to circumstances that include, but are not limited to, the following:
(1) Acts of the director or other officers of ODJFS that are ministerial in nature.
(2) Actions of ODJFS that are subject to hearings under an administrative review procedure other than the review provided by Chapter 119. of the Revised Code.
(3) Denial, termination, suspension, conversion, or non-renewal of a provider agreement exempted from the hearing procedures of Chapter 119. of the Revised Code by division (D) of section 5164.38 of the Revised Code, or by paragraph (A) of rule 5160-1-57 of the Administrative Code.
(4) Rate calculations, interim settlements, overpayments, duplicate payments, payments for services not rendered, denied claims, and claim adjustments that may be reconsidered by the appropriate ODJFS staff upon written request by the affected provider to the deputy director of the office of ODJFS where the contestation arose as set forth in paragraph (B) of rule 5160-1-57 of the Administrative Code or as set forth in rule 5160-2- 07.12 or 5160-2-40 of the Administrative Code.
(5) Reviews, notices of operational deficiency, requests for records, and audits that do not result in an adjudication order as provided in rule 5160-1-27 of the Administrative Code.
(6) Actions involving in-home aides pursuant to Chapter 5104. of the Revised Code.
(7) Hearings, authorized by section 5101.35 of the Revised Code and rules in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, provided to applicants for, or recipients of, benefits under Ohio works first; prevention, retention or contingency program; temporary assistance for needy families; food assistance; medicaid; social services; adoptions; disability financial assistance; residential state supplement payments; Titles IV-A, IV-B, IV-D, IV-E, XIX, XX, or XXI of the Social Security Act (as in effect on 2/28/14), 49 Stat. 620 or other assistance programs; who are aggrieved because of the actions of ODJFS, other state agencies, or of a county department of job and family services, child support enforcement agency, public children services agency, or other county agencies.
(8) Except as provided in paragraph (D) of this rule, disputes involving a Title XX social services contract entered into between ODJFS or a county department of job and family services, public children services agency, or child support enforcement agency and a contractor of services.
(9) Personnel action appeals of employees of ODJFS or of a county department of job and family services, public children services agency, or child support enforcement agency.
(10) Disputes involving the issuance, denial, or termination of a contract, a grant, or an interagency agreement issued by ODJFS or a protest filed with regard to a request for proposals issued by ODJFS.
(11) Administrative actions taken by ODJFS that involve program administration and funding affecting county departments of job and family services, public children services agencies, or child support enforcement agencies.
(13) Actions and disputes involving the use or access to funds administered under the Workforce Investment Act of 1998, 112 Stat. 936, 239 U.S.C.A. 2801, the Wagner-Peyser Act, 48 Stat. 113 (1933), 29 U.S.C.A. 49, and Chapters 4141. and 6301. of the Revised Code, or any other funds for which the United States department of labor is responsible for direct or indirect oversight.
(D) Actions that provide hearing rights under this chapter
Except as provided in paragraph (C) of this rule, those actions of ODJFS that afford the right to a hearing pursuant to ODJFS authority provided in Chapter 119. of the Revised Code include the proposal of the director to do the following:
(1) Enter into or refuse to enter into a provider agreement with a provider, or suspend, terminate, renew, or refuse to renew an existing provider agreement, under circumstances where ODJFS is required by section 5164.38 of the Revised Code to issue an adjudication order in accordance with Chapter 119. of the Revised Code.
(2) Take any action based upon a final fiscal audit.
(3) Refuse to issue a license, whether it is a renewal or a new license, unless a hearing was held before the refusal to issue such license.
(4) Suspend or revoke a license.
(5) Require a person to obtain a license when the person claims that the law does not impose such a requirement, except when ODJFS pursues injunctive relief through division (H) of section 5104.04 of the Revised Code.
(E) See rule 5160-1-57 of the Administrative Code for additional provisions specific to hearing rights of providers from proposed actions of ODJFS to deny, terminate, or not renew a provider agreement.
(F) See Chapter 5101:6-51 of the Administrative Code for additional provisions specific to hearing rights of providers from actions taken pursuant to section 5164.58 of the Revised Code by state agencies under contract with ODJFS.
R.C. 119.032 review dates: 11/18/2013 and 02/01/2019
Promulgated Under: 119.03
Statutory Authority: 5101.02, 5164.02
Rule Amplifies: 119.06, 119.07, 119.09, 5101.24, 5103.03, 5103.12, 5104.03, 5104.04, 5164.02 , 5164.38
Prior Effective Dates: 1/1/83, 1/10/87, 10/1/87, 12/1/87 (Emer), 2/16/88, 2/1/99, 4/1/04, 10/1/08