Ohio Revised Code Search

...The department of medicaid may appoint and commission any competent person to serve as a special agent, investigator, or representative to perform a designated duty for and on behalf of the department. Specific credentials shall be given by the department to each person so designated, and each credential shall state the following: (A) The person's name; (B) The agency with which the person is connected; (C) ...

...(A) The department of medicaid may conduct any audits or investigations that are necessary in the performance of the department's duties, and to that end, the department has the same power as a judge of a county court to administer oaths and to enforce the attendance and testimony of witnesses and the production of books or papers. The department shall keep a record of the department's audits and investigatio...

...ate may conduct an audit of any medical assistance recipient. If the auditor decides to conduct an audit under this section, the auditor shall enter into an interagency agreement with the department of medicaid that specifies that the auditor agrees to comply with section 5160.45 of the Revised Code with respect to any information the auditor receives pursuant to the audit.

...and family services, regarding medical assistance programs. The auditor of state and attorney general shall do both of the following regarding the records: (1) Provide safeguards that restrict access to the records to purposes directly connected with an audit or investigation, prosecution, or criminal or civil proceeding conducted in connection with the administration of the programs; (2) Comply, and ensure t...

...The auditor of state is responsible for the costs the auditor incurs in carrying out the auditor's duties under sections 5160.21 and 5160.22 of the Revised Code.

... individual's eligibility for a medical assistance program, at least all of the following information about the individual shall be verified: (1) Identity; (2) Citizenship and alien eligibility; (3) Social security number; (4) State residency status; (5) Disability status; (6) Gross nonexempt income; (7) Household status ; (8) Medical expenses; (9) Enrollment status in other state-administered publi...

...at may affect eligibility for a medical assistance program; (b) Take appropriate action. ( 2) Division (A)(1) of this section applies only to the extent information described in division (A) of section 5160.29 of the Revised Code is available to the department or entity. (B) If the department of medicaid or an entity with which the department has entered into an agreement under section 5160.30 of the Revised C...

... determining or redetermining a medical assistance recipient's eligibility, the case shall be referred for investigation to the county prosecutor of the county in which the medical assistance recipient resides, referred for an administrative disqualification hearing, or both.

... individuals' eligibility for a medical assistance program beyond the information specified in division (A) of section 5160.29 of the Revised Code; (B) Contracting with one or more independent vendors to provide such additional information for such purpose.

...d administrative activities for medical assistance programs. (B) The department may enter into agreements with one or more agencies of the federal government, the state, other states, and local governments of this or other states to accept applications, determine eligibility, redetermine eligibility, and perform related administrative activities on behalf of the department with respect to medical assistance p...

...(A) A medical assistance recipient may appeal a decision regarding the recipient's eligibility for a medical assistance program or services available to the recipient under a medical assistance program. (B) Regarding appeals authorized by this section, the department of medicaid shall do one or more of the following: (1) Administer an appeals process similar to the appeals process established under section 51...

...s any practice implemented by a medical assistance program in which coverage of a health care service, device, or drug is dependent upon a medical assistance recipient or a health care provider, receiving approval from the department of medicaid or its designee, including a medicaid managed care organization, prior to the service, device, or drug being performed, received, or prescribed, as applicable. "Prior authori...

...a medical item or service for a medical assistance recipient. (2) Except when otherwise provided by the "Social Security Act," section 1862(b), 42 U.S.C. 1395y(b), a person or governmental entity listed in division (C)(1) of this section is a third party even if the person or governmental entity limits or excludes payments for a medical item or service in the case of a public assistance recipient. (3) "Third pa...

...(A) A medical assistance recipient's enrollment in a medical assistance program gives an automatic right of recovery to the department of medicaid and a county department of job and family services against the liability of a third party for the cost of medical assistance paid on behalf of the recipient. When an action or claim is brought against a third party by a medical assistance recipient, any payment, settlement...

...ation for, or enrollment in, a medical assistance program constitutes an automatic assignment of rights specified in division (B) of this section to the department of medicaid. This assignment includes the rights of the medical assistance recipient and also the rights of any other member of the assistance group for whom the recipient can legally make an assignment. (B) Pursuant to this section, a medical assi...

...third party liability regarding medical assistance programs. (B) In furtherance of the requirement in division (A) of this section and to allow the department to determine any period that the individual or the individual's spouse or dependent may have been covered by the third party and the nature of the coverage, a third party shall provide, as the department so chooses, information or access to information,...

...claim form, or a failure by the medical assistance recipient who is the subject of the claim to present proper documentation of coverage at the time of service, if both of the following have occurred: (a) The claim was submitted by the department not later than six years after the date of the provision of the medical item or service. (b) An action by the department to enforce its right of recovery under section...

...l item or service provided to a medical assistance recipient is final on the date that is two years after the payment was made to the department of medicaid or the applicable medicaid managed care organization. After a claim is final, the claim is subject to adjustment only if an action for recovery of an overpayment was commenced under division (B) of this section before the date the claim became final and the recov...

...s eligible for or enrolled in a medical assistance program when either of the following applies: (A) The individual seeks to obtain a policy or enroll in a plan or program operated or administered by the third party; (B) The individual, or a person or governmental entity on the individual's behalf, seeks payment for a medical item or service provided to the individual.

...(A) If a third party violates section 5160.39, 5160.40, or 5160.41 of the Revised Code, a governmental entity that is responsible for issuing a license, certificate of authority, registration, or approval that authorizes the third party to do business in this state may impose a fine against the third party or deny, revoke, or terminate the third party's license, certificate, registration, or approval to do busi...

...obtain support or payments, or medical assistance payments, and when cooperation may be waived. (B) The department shall adopt rules under section 5160.02 of the Revised Code to do all of the following: (1) For purposes of the definition of "information" in division (A) of section 5160.35 of the Revised Code, any data other than the data specified in that division that should be included in the definition. ...

...sclose information regarding a medical assistance recipient for any purpose not directly connected with the administration of a medical assistance program. (C) Both of the following shall be considered to be purposes directly connected with the administration of a medical assistance program: (1) Treatment, payment, or other operations or activities authorized by 42 C.F.R. Chapter IV; (2) Any administrative fu...

...rollment, or eligibility for a medical assistance program cannot be conditioned on signing the authorization unless the authorization is necessary for determining eligibility for the program. (B) An authorization for the release of information regarding a medical assistance recipient to the recipient's attorney under division (D)(3) of section 5160.45 of the Revised Code may include a provision specifically au...

...ipate as an active member in the public assistance reporting information system; (2) Explore joining other multistate cooperatives, such as the national accuracy clearinghouse, to identify individuals enrolled in public assistance programs outside of this state. (B) The department may disclose information regarding a medical assistance recipient to the extent necessary to participate as an active member in the publ...

... shall review information in the public assistance reporting information system to determine whether an individual who is a medical assistance recipient may be eligible for federal military-related health care benefits. If the department determines that the individual may be eligible for federal military-related health care benefits, it shall notify the individual of the potential eligibility and encourage the indivi...