Section 5167.23
(A) As used in this section, "deconfliction" means the systematic coordination between medicaid managed care organizations and multiple state and federal oversight agencies to share investigative data, eliminate overlapping inquiries, and streamline the prosecution of fraudulent medicaid providers.
(B) Upon the identification of credible indicators of fraud, waste, or abuse, a medicaid managed care organization may implement reasonable and timely payment integrity actions, including payment suspension and prepayment review and denial.
(C)(1) A medicaid managed care organization shall not initiate prepayment review for a medicaid provider without first obtaining approval from the department of medicaid. Notwithstanding any provision of law to the contrary, a prepayment review initiated under this section may remain in effect for longer than six months without renewal.
(2) A medicaid managed care organization may place suspected high-risk providers, as determined by the medicaid managed care organization, on claims payment suspension during any open investigation or stand-down period. A medicaid managed care organization shall notify and obtain approval from the department or the attorney general prior to implementing claims payment suspension under this section.
(3) A medicaid managed care organization shall provide a provider placed on prepayment review under division (C)(1) of this section or claims payment suspension under division (C)(2) of this section with written notice of the decision and an opportunity for the provider to participate in the organization's grievance process established in accordance with section 5167.11 of the Revised Code. Upon completion of any grievance process, an affected provider may seek an appeal of a medicaid managed care organization's decision with the department of medicaid.
(D) Following the initiation of payment integrity actions, a medicaid managed care organization shall complete all applicable deconfliction procedures in accordance with procedures established by the department. A medicaid managed care organization may take an action described in this section prior to the completion of deconfliction procedures when necessary to prevent continued improper payments and to mitigate a program integrity risk.
(E) A medicaid managed care organization shall maintain documented evidence of credible indicators of fraud, waste, and abuse that are the basis for an action taken under this section. The department shall ensure that all actions taken under this section are consistent with state and federal law.
Last updated August 12, 2026 at 4:39 PM
Available Versions of this Section
- October 6, 2026 – Enacted by Senate Bill 315 - 136th General Assembly [ View October 6, 2026 Version ]