Section 5164.404
(A) The department of medicaid shall develop and implement automated fraud-detection tools to assist with identifying fraud through the use of the electronic verification systems developed, procured, certified, or approved under section 5164.401 of the Revised Code. Any fraud-detection tools shall be capable 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 claims.
(B) The department shall conduct periodic audits and investigations concerning data collected through use of the electronic verification systems under section 5164.401 of the Revised Code and fraud-detection tools implemented under this section. The department may suspend a medicaid provider's provider agreement for failing to comply with an audit or investigation conducted under this section.
(C) If an audit or investigation conducted in accordance with this section results in a credible allegation of fraud as defined in section 5164.36 of the Revised Code, the department shall handle the credible allegation in accordance with that section and refer the credible allegation to the attorney general for investigation.
Last updated August 12, 2026 at 4:33 PM
Available Versions of this Section
- October 6, 2026 – Enacted by Senate Bill 315 - 136th General Assembly [ View October 6, 2026 Version ]