Ohio Revised Code Search

...The department of medicaid shall establish a standardized onboarding process for all providers with a valid provider agreement with the department. The onboarding process shall provide a link to the relevant administrative rules that describe the provider agreement requirements for participation in the medicaid program.

...on, the department may implement best practices from other states' medicaid programs.

...(A) For the purpose of raising funds necessary to pay the expenses of implementing the provider screening requirements of subpart E of 42 C.F.R. Part 455 and except as provided in division (B) of this section, the department of medicaid shall collect an application fee from a medicaid provider before doing any of the following: (1) Entering into a provider agreement with a medicaid provider that seeks initial enroll...

...agreement expires before the department acts on the application or before the effective date of the department's decision on the application, the provider, subject to division (B)(3) of this section, may continue operating under the terms of the expired provider agreement until the effective date of the department's decision. (3) If a provider continues operating under the terms of an expired provider agreement pur...

... when the director determines that the action is in the best interests of medicaid recipients or the state: (1) Deny, refuse to revalidate, suspend, or terminate a provider agreement; (2) Exclude an individual, provider of services or goods, or other entity from participation in the medicaid program. (B) No individual, provider, or entity excluded from participation in the medicaid program under this section...

...ecessary, the department shall take the actions described in section 5164.302 of the Revised Code with regard to the individual or entity seeking initial enrollment as a provider.

...(A) The department of medicaid shall impose a temporary suspension of medicaid payments and conduct an investigation if the department determines there is a suspicious increase in the number of claims for payment submitted by a provider in the first sixty days of the provider entering into a provider agreement with the department. (B) The department shall flag and investigate any time the department determines that...

...nt benefits; (c) A civil or criminal action regarding the medicaid program. With respect to an administrative hearing dealing with the denial, suspension, or termination of a provider agreement, the report of a criminal records check may be introduced as evidence at the hearing and if admitted, becomes part of the hearing record. Any such report shall be admitted only under seal and shall maintain its status as...

... the bureau; (b) A civil or criminal action regarding the medicaid program. With respect to an administrative hearing dealing with the denial, suspension, or termination of a provider agreement, the report of a criminal records check may be introduced as evidence at the hearing and if admitted, becomes part of the hearing record. Any such report shall be admitted only under seal and shall maintain its status as...

...equest made under this section is not a public record for the purposes of section 149.43 of the Revised Code and shall not be made available to any person other than the following: (1) The applicant or employee who is the subject of the criminal records check or the representative of the applicant or employee; (2) The chief administrator of the waiver agency that requires the applicant or employee to request th...

...pose of this section when the provider, acting with actual knowledge of the representation or information involved, acting in deliberate ignorance of the truth or falsity of the representation or information involved, or acting in reckless disregard of the truth or falsity of the representation or information involved, deceives another or causes another to be deceived by any false or misleading representation, by wit...

...t charges the person with committing an act to which both of the following apply: (i) The act would be a felony or misdemeanor under the laws of this state or the jurisdiction within which the act occurred. (ii) The act relates to or results from furnishing or billing for medicaid services under the medicaid program or relates to or results from performing management or administrative services relating to furni...

...(A) The department of medicaid may suspend a medicaid provider's provider agreement without prior notice if the department has evidence that the provider presents a danger of immediate and serious harm to the health, safety, or welfare of medicaid recipients. The department also shall suspend all medicaid payments to the medicaid provider for services rendered, regardless of the date that the services were rendered, ...

... to either of the following: (1) Any action taken or decision made by the department of medicaid with respect to entering into or refusing to enter into a contract with a managed care organization pursuant to section 5167.10 of the Revised Code; (2) Any action taken by the department under division (D)(2) of section 5124.60, division (D)(1) or (2) of section 5124.61, or sections 5165.60 to 5165.89 of the Revise...

...In any action taken by the department of medicaid under section 5164.38 or 5164.57 of the Revised Code or any other state statute governing the medicaid program that requires the department to give notice of an opportunity for a hearing in accordance with Chapter 119. of the Revised Code, if the department gives notice of the opportunity for a hearing but the medicaid provider or other entity subject to the not...

...As used in sections 5164.40 to 5164.406 of the Revised Code: (A) "Electronic verification system" means an electronic system capable of recording and verifying data elements related to the delivery of health care services covered by the medicaid program. (B) "GPS-based verification" has the same meaning as in section 5164.42 of the Revised Code. (C) "Nonemergency medical transportation" means transportation for...

...ctronic verification system; (2) Contract with one or more vendors to establish an electronic verification system; (3) Integrate with existing electronic verification systems utilized by the department. (B) A system or systems developed, procured, certified, or approved in accordance with this section shall do all of the following: (1) Utilize a ride dispatch system that is similar to other private transporta...

...(A) Upon full implementation of the electronic verification systems developed, procured, certified, or approved in accordance with section 5164.401 of the Revised Code, no nonemergency medical transportation service provider shall be eligible to receive medicaid payment for transportation services provided to a medicaid recipient unless the provider submits all necessary data through an electronic verification system...

...ent at the time of transport. (3) The records are received by the department within an allowable timeframe established under division (B) of this section and reflect an encounter, claim, or billing activity for a service described in division (A)(1) or (2) of this section. (B) The department shall establish an allowable timeframe under which claims for medicaid payment for transportation claims may be cross-refer...

...pable of flagging irregular patterns of activity by medicaid providers that are required to utilize the electronic verification systems, including all of the following: (1) The seeking and approval of repeated exceptions under section 5164.402 of the Revised Code; (2) Anomalous or irregular patterns by nonemergency medical transportation service providers; (3) Discrepancies between location data and submitted c...

...onic verification systems; (F) Any impacts to medicaid recipient access to medicaid services that result from the use of electronic verification systems; (G) Any additional information or data the department considers relevant concerning electronic verification systems.

...The department of medicaid shall adopt rules in accordance with Chapter 119. of the Revised Code to implement sections 5164.40 to 5164.406 of the Revised Code. The rules shall address all of the following: (A) Technical standards for electronic verification systems developed, procured, certified, or approved under section 5164.401 of the Revised Code including GPS intervals, and criteria for certification of electr...

...(A) As used in this section, "home and community-based services medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code. (B) The department of medicaid shall establish oversight mechanisms concerning services provided by a family caregiver under a home and community-based services medicaid waiver component. Oversight may include any of the following: (1) Quarterly audits; (2) E...

...ayment to electronic visit verification records. The standards and procedures shall identify the data elements necessary to validate that the service billed was delivered to a medicaid recipient, including the type of service performed, the individual receiving the service, the date of service, the location of service delivery, the individual providing the service, and the time the service began and ended. (3) The ...

...(A) In addition to the electronic visit verification system described in section 5165.42 of the Revised Code, the department of medicaid shall establish requirements under which high risk in-home care service providers are required to verify data regarding the services provided to a medicaid recipient. (B) The department shall establish criteria under which an in-home care service provider is considered to be a hig...