Ohio Admin. Code 5101:6-2-30 - State hearings: notice of medical determination

(A) The JFS 04022 "Notice of Medical Determination and a Right to a State Hearing," (rev.3/2002), or its computer-generated an Ohio department of medicaid (ODM) approved equivalent shall will be mailed or personally delivered to the individual and authorized representative in the following situations:

(1) When, as the result of a preadmission review for long-term care, the local agency receives an authorization of a level of care that assigns a noninstitutional level of care, or a level of care that is different from the specific level of care certified by the individual's physician, the local agency shall will send notice to the individual and authorized representative, with a copy of the notice filed in the individual's case record.

Notice is not required when the assigned level of care is different from the level of care certified by the individual's physician, but the individual is or will be placed in a facility with dual certification to provide the assigned level of care.

(2) When a request for prior authorization for additional hospital stays, visits, or therapeutic leave days beyond thirty days for a medicaid individual with a developmental disability level of care is denied, the local agency shall will send the notice to the individual and authorized representative, with a copy of the notice filed in the individual's case record.

(3) When a review agency denies or modifies a request for precertification of a hospital admission or medical procedure, the review agency shall will send the notice to the individual and authorized representative, with a copy of the notice sent to the local agency.

(B) The notice shall will contain:

(1) A clear and understandable statement of the decision and the reasons for it.

(2) Citations of the applicable regulations.

(3) An explanation of the individual's right to and the method of obtaining a state hearing.

(4) A telephone number to call about free legal services.

Notes

Ohio Admin. Code 5101:6-2-30

Effective: 1/17/2025
Five Year Review (FYR) Dates: 10/31/2024 and 01/17/2030
Promulgated Under: 119.03
Statutory Authority: 5101.35
Rule Amplifies: 5101.35, 5160.011
Prior Effective Dates: 09/01/1976, 04/01/1980, 10/01/1981, 05/01/1982, 07/01/1982, 04/01/1983, 09/24/1983, 11/01/1983 (Temp.), 12/01/1983, 01/01/1984, 03/01/1984 (Temp.), 06/01/1984, 10/03/1984 (Emer.), 12/22/1984, 04/01/1986, 04/01/1987, 09/01/1987, 07/01/1988 (Emer.), 09/25/1988, 10/01/1989, 02/01/1990, 04/01/1991, 06/01/1993, 11/01/1994, 06/01/2003, 09/01/2008, 02/28/2014, 03/01/2019