Rule 5160-1-17.51 | Suspension of medicaid provider claims payments during a pending audit or investigation.
(A) Definitions, for purposes of this rule the definitions below apply:
(1) "Credible allegation of fraud" as defined in section 5164.36 of the Revised Code.
(2) "Non-institutional provider" as defined in rule 5160-1-17.5 of the Administrative Code.
(B) The Ohio department of medicaid (ODM) shall suspend medicaid provider claims payments without suspending the provider agreement, in accordance with division (I) of section 5164.36 of the Revised Code when at least one of the following conditions apply and the department determines that the suspension of the provider agreement would cause risk of harm to medicaid members:
(1) Upon determining there is a credible allegation of fraud for which an audit or investigation is pending against a provider under the medicaid program; 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's claims payments, the following conditions apply:
(1) If a provider's claims payments are suspended pursuant to this rule, then claims payments to any other entity where the provider or provider's owner or owners, officer, authorized agent, manager, or employee is an owner, officer, authorized agent, manager, or employee may also be suspended.
(2) During the period of suspension, the provider, its 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 from managed care entities or other entities delegated by ODM to administer any portion of the medicaid program.
(3) ODM will provide notice to the provider whose payments are suspended, in accordance with 42 CFR 455.23(b), (effective October 1, 2025).
(4) The provider must fully and completely cooperate with ODM's audit and review process including responding to requests for information and records within specified timeframes.
(D) ODM may lift the payment suspension, in whole or in part, under any of the following circumstances:
(1) ODM or a prosecuting authority determines that there is insufficient evidence of fraud, waste, or abuse by the provider;
(2) 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.
(3) Good cause exists to not suspend payments pursuant to 42 CFR 455.23(e) or (f), (effective October 1, 2025), determined upon:
(a) Receipt of a reconsideration request from the provider or provider owner or owners under paragraph (E) of this rule that demonstrates good cause; or
(b) Upon ODM's own determination of good cause.
(E) Reconsideration of suspension;
(1) A provider, owner, or owners subject to a suspension of payments may request a reconsideration in writing, along with written information and documentation supporting the request, no later than thirty Calendar days after receiving the notice in paragraph (C) of this rule. 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.
(3) The ODM director may grant a reconsideration request in whole or in part and may lift a payment suspension temporarily for good cause shown.
(F) If ODM commences a process to terminate the provider agreement, the payment suspension shall continue in effect until the termination process is concluded.
(G) If a payment suspension is lifted, payments owed to a provider will be offset against any debts owed to the medicaid program. Any amount remaining will be released to the provider.
Last updated June 4, 2026 at 8:46 AM
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