Ohio Revised Code Search

... state 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.

... The auditor of state and attorney general, or their designees, may examine any records, whether in computer or printed format, in the possession of the medicaid director or any county director of job 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 recor...

...f the process of determining an 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...

...vised Code, the department or entity shall do both of the following on at least a quarterly basis and in accordance with federal regulations: (a) Review the information to determine whether it indicates a change in circumstances that 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 di...

... of 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.

...eviewing information related to 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.

...ated 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 assistanc...

...(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...

...: (1) "Chronic condition" means a medical condition that has persisted after reasonable efforts have been made to relieve or cure its cause and has continued, either continuously or episodically, for longer than six continuous months. (2) "Clinical peer" means a health care provider in the same, or in a similar, specialty that typically manages the medical condition, procedure, or treatment under review. (3) "Emer...

...evised Code: (A) "Information" means all of the following: (1) An individual's name, address, date of birth, and social security number; (2) The group or plan number, or other identifier, assigned by a third party to a policy held by an individual or a plan in which the individual participates and the nature of the coverage; (3) Any other data the medicaid director specifies in rules authorized by section...

...(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...

...ent of job and family services, a medical assistance recipient and the recipient's attorney, if any, shall cooperate with each medical provider of the recipient. Cooperation with a medical provider shall consist of disclosing to the provider all information the recipient and attorney, if any, possess that would assist the provider in determining each third party that is responsible for the payment or processin...

...lication 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 a...

...(A) A third party shall cooperate with the department of medicaid in identifying individuals for the purpose of establishing 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...

...ek excluding Saturday, Sunday, and a legal holiday, as defined in section 1.14 of the Revised Code. (B) Subject to divisions (C) and (D) of this section, a third party shall do all of the following: (1) Accept the department of medicaid's right of recovery under section 5160.37 of the Revised Code and the assignment of rights to the department that are described in section 5160.38 of the Revised Code; (2) Re...

...d Code on a claim for payment of a medical 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 ...

...No third party shall consider whether an individual is 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...

...160.41 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 business in this state. The governmental entity shall determine ...

...to 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 definitio...

... the Revised Code, "information" means all of the following: (1) Records, as defined in section 149.011 of the Revised Code; (2) Any other documents in any format; (3) Data derived from records and documents that are generated, acquired, or maintained by the department of medicaid, a county department of job and family services, or an entity performing duties on behalf of the department or a county departme...

...f the Revised Code, an authorization shall be made on a form that uses language understandable to the average person and contains all of the following: (1) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion; (2) The name or other specific identification of the person or class of persons authorized to make the requested use or disclos...

...(A) The department of medicaid shall do both of the following: (1) Enter into any necessary agreements with the United States department of health and human services and neighboring states to join and participate 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 i...

...(A) As used in this section: "Federal military-related health care benefits" means any of the health care benefits provided by the United States department of defense or the United States department of veterans affairs to current or former service members and their eligible dependents, including the benefits provided through the programs known as tricare and champva. (B) (1) The department of medicaid shall review ...

...(A) The medicaid director shall adopt rules under section 5160.02 of the Revised Code implementing sections 5160.45 to 5160.481 of the Revised Code and governing the custody, use, disclosure, and preservation of the information generated or received by the department of medicaid, county departments of job and family services, other state and county entities, contractors, grantees, private entities, or officials...

... or other information relating to medical assistance recipients is held by any agency other than the department of medicaid or a county department of job and family services, that other agency shall adopt rules consistent with sections 5160.45 to 5160.481 of the Revised Code to prevent the publication or disclosure of names, lists, or other information concerning those recipients.