The purpose of this rule is to authorize the process for prior authorization of waiver services when an individual funding level exceeds the funding range determined by the Ohio developmental disabilities profile (ODDP) for individuals enrolled in the individual options waiver.
(B) Standards and procedures.
(1) The prior authorization process shall be followed in accordance with rule 5123:2-9-07 of the Administrative Code.
(2) The Ohio department of developmental disabilities (DODD) shall inform the office of medical assistance (OMA) of all approvals and denials. OMA may review all approvals and denials and may take corrective action in accordance with 42 C.F.R. 431.246 .
(3) DODD and the county board shall maintain all records related to the review of prior authorizations for a period of six years following receipt of the request.
(C) Provider payment standards.
Provider payment standards for the individual options waiver are established in rule 5101:3-41-18 and Chapter 5123:2-9 of the Administrative Code.
(D) Monitoring, compliance, and sanctions.
(1) DODD shall submit to OMA, on a quarterly basis, a summary of requests for prior authorization received. DODD shall also systematically evaluate compliance with prior authorization requirements by verifying that each individual's funding level is maintained within the prior authorized amount. Results of this evaluation shall be provided in writing to OMA no less than quarterly.
(2) OMA shall periodically analyze the frequency and distribution of all requests for prior authorization to identify statistically significant patterns or trends.
(E) Due process.
Applicants for waiver enrollment or individuals enrolled on any waiver administered by DODD shall be afforded due process in accordance with section 5101.35 of the Revised Code through the state fair hearing process, and as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.
(F) OMA authority.
OMA retains the final authority to establish payment rates for waiver services approved under the individual options waiver, and to approve individual service plans, and has final approval of any policies and rules that govern any component of the medicaid program.
Replaces: Part of 5101:3-41-12