5160-1-27.1 Hold and review process.

(A) "Hold and Review" is defined in accordance with rule 5101:3-1-27 of the Administrative Code.

(1) Hold and review without prior notification.

(a) The Ohio department of job and family services (ODJFS) may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, without first notifying the provider for the following reasons:

(i) In response to allegations of fraud or other willful misrepresentation of claims submission; or

(ii) When a provider has been indicted for a criminal offense.

(b) ODJFS shall notify the provider in writing within ten business days that the provider's claims have been, and will continue to be, subject to hold and review. The notice shall describe the documentation needed to review the claims placed on hold and review along with the items stated in paragraphs (E)(1) to (E)(6) of this rule.

(2) Hold and review with prior notification.

(a) ODJFS may place a medicaid provider's claim(s) payment on hold and review, in whole or in part, with prior notice to the provider under the following circumstances:

(i) When the information is used to complement or follow up a provider certification or other quality review process;

(ii) Upon request from the office of the attorney general, the office of inspector general or the auditor of state;

(iii) A medicaid provider's agreement has been proposed for termination for reasons other than those stated in paragraph (A) of this rule; or

(iv) For reasons otherwise necessary to assure the basic integrity of claims submission and payment.

(b) ODJFS will notify the provider in writing within ten business days before the effective start date of the hold and review.

(B) Review of the medicaid provider's claims and documentation for the hold and review process is subject to the provisions of rule 5101:3-1-27 of the Administrative Code.

(C) The hold and review may be applied without regard to date of service. Claims subject to the hold and review process include any claims for payment received by ODJFS after the effective date of the hold and review even if such claims are for dates of service that occurred prior to the effective date of the hold and review.

(D) Failure by ODJFS to notify a provider of a hold and review shall not impede the agency from taking actions under this rule.

(E) The notice from ODJFS shall:

(1) State the general reasons for the withholding of the medicaid provider's claims payments, but need not disclose any specific information concerning an ongoing investigation involving alleged fraud and/or willful misrepresentation;

(2) State the effective date ODJFS implements the hold and review process;

(3) State the types of services and claims, in whole or in part, that will be subject to the hold and review process. Any claims received by ODJFS on or after the date of written notification may be subject to hold and review even if such claims are for dates of service that occurred prior to the effective date of the hold and review;

(4) State the documentation required to be submitted to ODJFS by the provider:

(a) Except for medicaid providers required to submit medical claims to ODJFS electronically, all claims from providers placed on hold and review must be submitted in non-electronic (paper) format.

(b) Providers who must submit medical claims electronically must submit paper documentation supporting each claim submitted electronically. These claims will not be processed until both the claim and the supporting documentation are reviewed by ODJFS.

(5) Inform the provider of the right to submit evidence for consideration to ODJFS;

(6) State the contact at ODJFS for questions regarding the hold and review process.

(F) ODJFS may, if appropriate, send copies of the notice to local, state and federal entities that are involved in the review or that need to be aware of the review in order to assure the integrity of claims submission and payment.

(G) No later than one hundred twenty days from the date ODJFS holds a claim for review, ODJFS shall forward the claim for adjudication if it is determined that the documentation supports the validity of the claim, or for denial processing if the documentation submitted does not support that paying the claim would be in compliance with law or if the provider fails to submit the requested supporting documentation to ODJFS. If the review results in ODJFS concluding that the provider has a pattern of submitting claims that are not in compliance with law, ODJFS may issue a "Notice of Operation Deficiency" to the provider and continue to hold and review the provider's claims until the operational deficiency is eliminated.

(H) Medicaid providers are not entitled to a hearing under Chapter 119. or section 5111.06 of the Revised Code for any action taken by ODJFS under this rule.

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.10 , 5111.85
Rule Amplifies: 5111.10 , 5111.02 , 5111.85