5160-1-17.5 Suspension of medicaid provider agreements.

(A) Definitions:

(1) "Credible allegation of fraud" means an accusation of fraud as defined in section 5164.36 of the Revised Code.

(2) "Non-institutional provider" means any person or entity with a medicaid provider agreement other than a hospital, long-term care nursing facility, intermediate care facility for individuals with intellectual disabilities or medicaid contracting managed care plans.

(B) The Ohio department of medicaid (ODM) shall suspend a medicaid provider agreement when at least one of the following conditions apply:

(1) Upon determining there is a credible allegation of fraud for which an investigation is pending against a provider under the medicaid program, unless good cause to not suspend is found pursuant to 42 CFR 455.23(e) or (f), effective Feb. 2, 2011; or

(2) Upon receiving notice and copy of an indictment that charges a non-institutional provider, its owner or owners, officer, authorized agent, associate, manager, or employee with committing an offense as specified in division (E) of section 5164.37 of the Revised Code.

(C) Upon suspension of the provider agreement, the following conditions apply:

(1) If a provider is suspended pursuant to this rule, then any other provider agreements where the provider is an owner, officer, authorized agent, manager, or employee may also be suspended.

(2) A provider, its owner or owners, officer, authorized agent, associate, manager, or employee shall not own or provide services to any other medical provider or risk contractor or arrange for, render, or order services for medicaid recipients during the period of suspension.

(3) During the period of suspension, the provider owner or owners, officer, authorized agent, associate, manager, or employee shall not receive reimbursement in the form of direct payments from ODM or indirect payments of medicaid funds.

(4) The suspension shall continue until either of the following:

(a) The department or a prosecuting authority determines that there is insufficient evidence of fraud by the provider;

(b) The proceedings in any related criminal case are completed through dismissal of the indictment or through conviction, entry of a guilty plea, or finding of not guilty.

(5) If ODM commences a process to terminate the suspended provider agreement, the suspension shall continue in effect until the termination process is concluded.

(D) Reconsideration of suspension:

(1) A provider, owner, or owners subject to a suspension may request a reconsideration in accordance with section 5164.36 or 5164.37 of the Revised Code . A request for reconsideration is not subject to Chapter 119. of the Revised Code.

(2) The reconsideration shall be conducted by the ODM director or the director's designee in the office where the contestation arose provided that the designee was not involved in the original decision. Decisions made by the director or the director's designee are not appealable or subject to further reconsideration.

Replaces: 5160-1- 17.5

Effective: 3/22/2015
Five Year Review (FYR) Dates: 03/22/2020
Promulgated Under: 119.03
Statutory Authority: 5164.01, 5164.36
Rule Amplifies: 5164.36, 5164.37
Prior Effective Dates: 01/01/2008