5160-1-57 Process for provider appeals from proposed departmental actions.

(A) The appeals process is designed to provide a hearing under Chapter 119. of the Revised Code (Administrative Procedures Act) whereby a provider may appeal the proposed decision of the Ohio department of job and family services (ODJFS) to deny, terminate, or not renew a "Provider Agreement," or to implement a final fiscal audit.

(1) The appeals process does not apply in the following circumstances:

(a) Whenever the terms of a provider agreement require the provider to hold a valid and current license, permit, certificate or maintain a certification issued by an official, board, commission, department, division or bureau, or other agency of state or federal government other than ODJFS, and the license, permit, or certificate, or certification has been denied, suspended, revoked, not renewed, or is otherwise limited and the provider has been afforded the opportunity for a hearing in accordance with the hearing process established by the official, board, commission, department, division, bureau, or other agency of state or federal government.

(b) Whenever the terms of a provider agreement require the provider to hold a license, permit, or certificate or maintain certification issued by an official, board, commission, department, division, bureau, or other agency of state or federal government other than ODJFS, and the provider has not obtained the license, permit, certificate, or certification.

(c) Whenever the provider agreement is denied, terminated, or not renewed due to the termination, refusal to renew, or denial of a license, permit, certificate, or certification by an official, board, commission, department, division, bureau, or other agency of this state other than ODJFS, notwithstanding the fact that the provider may hold a license, permit, certificate, or certification from an official, board, commission, department, division, bureau, or other agency of another state.

(d) Whenever a judgment has been entered in either a criminal or civil action against a medicaid provider or its owner, officer, authorized agent, associate, manager, or employee in an action brought pursuant to section 109.85 of the Revised Code, except if the provider or owner can demonstrate to the department that the provider or owner did not directly or indirectly sanction the action of its authorized agent, associate, manager, or employee which resulted in the entry of judgment.

(e) The attorney general on behalf of the state has commenced proceedings in any court of competent jurisdiction and settled or compromised any such case brought under section 5111.03 of the Revised Code.

(f) Whenever the "Provider Agreement" is denied, terminated, or not renewed due to provider termination, suspension, or exclusion by the medicare program and/or by the federal department of health and human services and that action is binding on the provider's participation in the medicaid program or renders federal financial participation unavailable for the provider's participation in the medicaid program.

(g) Whenever the "Provider Agreement" is denied, terminated, or not renewed due to the provider's pleading guilty to, or being convicted of, a criminal activity materially related to either the medicare or medicaid program.

(h) Whenever the provider agreement is suspended pursuant to rule 5101:3-1-17.5 of the Administrative Code pending indictment of the provider.

(i) Whenever the provider agreement is denied, terminated, or not renewed because the provider has been convicted of one of the offenses that caused the provider agreement to be suspended pursuant to rule 5101:3-1-17.5 of the Administrative Code.

(j) Whenever the provider agreement is converted under section 5111.028 of the Revised Code from a provider agreement that is not time-limited to a provider agreement that is time-limited.

(k) Whenever the provider agreement is terminated or an application for re-enrollment is denied because the provider has failed to apply for re-enrollment within the time or in the manner specified for re-enrollment pursuant to section 5111.028 of the Revised Code.

(l) Whenever the provider agreement is terminated or not renewed because the provider has not billed or otherwise submitted a medicaid claim to ODJFS for two years or longer, and ODJFS has determined that the provider has moved from the address on record with ODJFS without leaving an active forwarding address with ODJFS.

(2) If a provider objects to a proposed adjudication order of the department which would result in the denial, termination, suspension, or nonrenewal of a provider agreement not otherwise excluded from the process by paragraph (A)(1) of this rule or if the provider wishes to contest a final fiscal audit, the provider may request a formal hearing which shall be governed by Chapter 119. of the Revised Code. Such requests must be submitted in writing to the ODJFS office of legal services. In any medicaid hospital final settlement in which Title V monies are offset against medicaid monies, the department will offer a right of appeal pursuant to Chapter 119. of the Revised Code for both program areas.

(3) During the appeal of an ODJFS-proposed termination or nonrenewal of a "Provider Agreement," payment will occur as follows:

(a) Payments under department rules and regulations will continue unless the provisions of paragraphs (A)(3)(b)(i) to (A)(3)(b)(iii) of this rule apply.

(b) Payments under department rules and regulations may be withheld if each of the following conditions has been met by the department:

(i) Compliance with the provisions of section 119.07 of the Revised Code;

(ii) A hearing continuance has not been requested; and

(iii) A decision has been issued within thirty days after the hearing is completed.

(c) If the appeal is to be a final fiscal audit and the department complies with paragraph (A)(3)(b) of this rule, the department may withhold payments only to the extent that they do not exceed the amounts determined in that final fiscal audit.

(d) The provisions of paragraphs (A)(3) to (A)(3)(c) of this rule do not apply to long-term care facilities (LTCFs). Payment made to LTCFs during an appeal to ODJFS will occur as described in Chapter 5101:3-3 of the Administrative Code.

(B) Actions taken that meet the exceptions of paragraph (A)(1) of this rule and other administrative actions affecting the provider's medicaid program status that are not subject to hearings under Chapter 119. of the Revised Code, and those individuals or providers who do not have medicaid provider agreements and are proposed for exclusion from participation may be reconsidered by the deputy director in the office where the contestation arose. The deputy director may designate a third party to hear the reconsideration provided that the designee was not involved in the original decision or contestation. Decisions made by the ODJFS deputy director are not appealable or subject to further reconsideration.

(C) See Chapter 5101:3-2 of the Administrative Code for additional information concerning the applicability of the appeals process to hospital services.

(D) See Chapter 5101:3-3 of the Administrative Code for additional provisions specific to LTCFs.

(E) See Chapter 5101:3-26 of the Administrative Code for additional provisions specific to managed care plans (MCPs).

Effective: 01/01/2008
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.028 , 5111.031
Rule Amplifies: 5111.01 , 5111.02 , 5111.028 , 5111.031 , 5111.06
Prior Effective Dates: 4/7/77, 8/31/79, 7/1/80, 8/8/81, 10/1/84, 3/18/88 (Emer), 6/16/88, 5/30/02, 7/1/05