Ohio Admin. Code 5123-2-09 - Provider certification - independent providers
(A) Purpose
This rule establishes procedures and standards for certification of independent providers of supported living services, including home and community-based services provided in accordance with section 5123.045 of the Revised Code.
(B) Definitions
For the purposes of this rule, the following definitions apply:
(1) "Abuser registry" has the
same meaning as in rule
5123-17-03 of the Administrative
Code.
(2) "Agency provider" means
an entity that directly employs at least one person in addition to a director
of operations for the purpose of providing services for which the entity is
certified in accordance with rule
5123-2-08 of the Administrative
Code.
(3) "Certificate of high
school equivalence" has the same meaning as in section
3301.80 of the Revised Code and
includes the equivalent of a certificate of high school equivalence described
in division (C) of that section.
(4) "County board" means a county board of
developmental disabilities.
(5)
"Department" means the Ohio department of developmental disabilities.
(6) "Health-related activities" has the same
meaning as in rule
5123:2-6-01 of the
Administrative Code.
(7) "Home and
community-based services" has the same meaning as in section
5123.01 of the Revised
Code.
(8) "Independent provider"
means a self-employed person who provides services for which
he or she
the
person must be certified in accordance with this rule and
who shall
does not employ, either directly or through contract,
anyone else to provide the services.
(9) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or
her
the person's guardian in accordance
with section 5126.043 of the Revised Code or
other person authorized to give consent.
(10) "Individual service plan" means the
written description of services, supports, and activities to be provided to an
individual.
(11) "Major unusual
incident" has the same meaning as in rule
5123-17-02 of the Administrative
Code.
(12) "Provider network
management module" means a component of the Ohio medicaid enterprise system
platform, maintained by the Ohio department of medicaid at its website
(medicaid.ohio.gov), used by providers of services to
submit change requests online
initiate applications for certification and access the
provider services management system to submit required information and
documents.
(13) "Provider
services management system" means the electronic portal, maintained by the
department at its website (dodd.ohio.gov), used by providers of services to
apply for certification and submit required information and
documents.
(14) "Related party" has
the same meaning as in section
5123.16 of the Revised
Code.
(15) "Related to" means the
independent provider is the individual's:(d)(e) Aunt, uncle,
nephew, or niece;
(e)(f) Cousin;
or
(f)(g) Child or
stepchild.
(a)
Parent or stepparent;
(b) Sibling
or stepsibling;
(c)
Grandparent;
(d)
Grandchild;
(16) "Service
and support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration as set forth in section
5126.15 of the Revised Code and
who holds the appropriate certification in accordance with rule
5123:2-5-02
5123-5-02 of the Administrative Code.
(17) "Supported living" has the same meaning
as in section 5126.01 of the Revised
Code.
(18) "Unusual incident" has
the same meaning as in rule
5123-17-02 of the Administrative
Code.
(C) General
requirements for independent providers
(1) An
independent provider shall
will:
(a) Have a
valid birth certificate.
(b) Be at
least eighteen years of age.
(c)
Have a valid social security card and a valid government-issued photo
identification.
(d) Meet one of the
following:
(i) Hold a high school
diploma;
(ii) Hold a certificate of
high school equivalence;
(iii) On
September 30, 2009, held independent provider certification issued by the
department; or
(iv) On September
30, 2009, was employed by or under contract with an agency provider certified
by the department.
(e) Be
able to read, write, and understand English at a level sufficient to comply
with all requirements set forth in administrative rules governing the services
provided by the independent provider.
(f) Undergo a background investigation in
accordance with rule
5123-2-02 of the Administrative
Code and consent to be enrolled by the department in the Ohio attorney
general's retained applicant fingerprint database (also known as
"Rapback").
(g) Comply with the
requirements of this rule and other standards and assurances established in
Chapter 5123. of the Revised Code and rules adopted pursuant to that
chapter.
(h) Participate as
requested by the department in service delivery system data collection
initiatives.
(2) An
independent provider of home and community-based services
shall
must
obtain and maintain a medicaid provider agreement with the Ohio department of
medicaid.
(D) Training
requirements for independent providers
(1) An
independent provider shall
will successfully complete the training specified
in appendix A, appendix B, or appendix
C, or appendix D to this rule, as
applicable.
(2) An independent
provider of home and community-based services will comply with service-specific
training required by rules in Chapter 5123-9 of the Administrative Code for the
specific services provided.
(3)
After being selected by an individual to provide services and prior to
providing services to that individual, an independent provider
shall
will
meet with a representative of the county board to discuss:
(a) The independent provider's
responsibilities;
(b) Requirements
set forth in the individual service plan regarding what is important to the
individual and what is important for the individual (e.g., health and safety,
community integration, employment goals, behavioral support strategy,
management of the individual's funds, or medication administration/delegated
nursing needs);
(c) Service
documentation; and
(d) Billing for
services.
(E)
Standards of service provision
(1) An
independent provider shall
will:
(a)
Provide services only to individuals whose needs he
or she
the independent provider can
meet;
(b) Communicate effectively
with each individual for whom he or she
the independent provider provides
services;
(c) Be knowledgeable in
the individual service plan for each individual served prior to providing
services to the individual;
(d)
Implement services in accordance with the individual service plan and in a
person-centered manner;
(e) Comply
with the requirements of rule
5123-2-06 of the Administrative
Code; and
(f) Take all reasonable
steps necessary to prevent the occurrence or recurrence of major unusual
incidents and unusual incidents.
(2) An independent provider
shall
may
not:
(a) Provide services to
his or her
the
independent provider's minor child;
(b) Provide services to
his or her
the
independent provider's spouse;
(c) Provide services to an individual for
whom the independent provider serves as guardian unless the independent
provider is related to the individual and has been
approved by the probate court to provide the services;
(d) Engage in sexual conduct or have sexual
contact with an individual for whom he or she is
providing
the independent provider
provides services;
(e)
Administer medication or perform health-related activities for individuals who
receive services unless he or she
the independent provider meets the applicable
requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules
adopted pursuant to those chapters; or
(f) Use or be under the influence of the
following while providing services:
(i)
Alcohol;
(ii) Illegal
drugs;
(iii) Illegal chemical
substances; or
(iv) Controlled
substances that may adversely affect his or
her
the independent provider's ability
to furnish services.
(F) Required notifications to be made by
independent providers
(1) An independent
provider shall
will:
(a) Provide
and maintain in the provider services management system
or
and the
provider network management module, as applicable,
his or her
the independent provider's
current physical address, telephone number, and electronic mail
address.
(b) Notify the department
via the provider services management system or
provider network management module, as applicable, if he or she
if the independent provider is formally charged
with, is convicted of, pleads guilty to, or is found eligible for intervention
in lieu of conviction for any of the offenses listed or described in divisions
(A)(3)(a) to (A)(3)(e) of section
109.572 of the Revised Code
within fourteen calendar days after the date of such charge, conviction, guilty
plea, or finding.
(c) Notify the
department via the provider services management system
or provider network management module, as
applicable, within fourteen calendar days of determining that
he or she
the
independent provider is or has become a related party of a person or
government entity for which the department has refused to issue or renew or
revoked certification pursuant to section
5123.166 of the Revised
Code.
(d) Notify the department via
the provider services management system or provider
network management module, as applicable, within fourteen calendar
days if he or she
the independent provider has had a professional
registration, certification, or license (other than a driver's license)
suspended or revoked.
(2)
An independent provider, upon realization that he or
she
the independent provider may be
unable to continue to effectively provide services to an individual,
shall
will
immediately engage the individual and the individual's service and support
administrator to consider alternative strategies for serving the individual
that ensure the health and safety of the individual.
(3) An independent provider
shall
will
notify, in writing, an individual and the individual's service and support
administrator in the event that the independent provider intends to cease
providing services to the individual no less than thirty calendar days prior to
termination of services. If, however, an independent provider intends to cease
providing services to an individual because the health or safety of the
independent provider is at immediate risk of serious harm, the independent
provider shall
will immediately notify the individual's service and
support administrator or if after business hours, the county board's
twenty-four hour emergency telephone number, and other appropriate authorities
(e.g., law enforcement). An independent provider shall
will convey
documents and records to the individual's service and support administrator as
requested.
(G) Procedure
for obtaining initial independent provider certification
(1) An applicant for initial independent
provider certification shall
will submit an application via the provider
services management system, for supported living services and the specific home
and community-based services the applicant seeks to provide in accordance with
procedures prescribed by the department including:
(a) Required signatures and supporting
documentation to demonstrate that standards are met as required by this rule
and rules in Chapter 5123-9 of the Administrative Code for the specific home
and community-based services the applicant seeks to provide;
(b) The application fee specified in
paragraph (K) of this rule except when, based on the specific home and
community-based services to be provided, the applicant is exempted from paying
an application fee in accordance with appendix D
E to this rule;
and
(c) The applicant's criminal
records check by the Ohio bureau of criminal identification and investigation
and when applicable, by the federal bureau of
investigation.
(2) The
department will review an application within thirty calendar days of receipt of
all required components to determine if the applicant meets the standards for
the requested certification.
(a) When the
department determines an applicant seeking to provide home and community-based
services meets the standards for the requested certification, the department
will initiate the process for the applicant to obtain a medicaid provider
agreement from the Ohio department of medicaid.
(b) If, upon review of the application, the
department determines that supporting documentation does not demonstrate that
the applicant meets the standards for the requested certification, the
department will notify the applicant by electronic mail and advise that the
applicant has thirty calendar days to submit components needed to demonstrate
that the applicant meets the standards for the requested certification.
(i) When the department receives components
needed to demonstrate that the applicant meets the standards for the requested
certification within the specified thirty calendar days, the application will
be advanced for processing.
(ii)
When the applicant fails to submit components needed to demonstrate that the
applicant meets the standards for the requested certification within the
specified thirty calendar days, the department will take no further action with
respect to the application.
(3) When the department determines the
applicant meets the standards for the requested certification and, when
applicable, after the Ohio department of medicaid has issued a medicaid
provider agreement to an applicant seeking to provide home and community-based
services, the department will notify the applicant by electronic mail that
certification is approved. The notification will specify the effective date and
expiration date of the certification and the specific services for which the
applicant is certified.
(4) The
department's review of an application may extend beyond thirty calendar days
when:
(a) One or more of the submitted
documents requires verification; or
(b) The applicant:
(i) Has a conviction or notation on
his or her
the criminal records check by the Ohio bureau of
criminal identification and investigation or the federal bureau of
investigation;
(ii) Is included in
one or more of the databases described in paragraph (C)(2) of rule
5123-2-02 of the Administrative
Code;
(iii) Is the primary person
involved in a major unusual incident;
(iv) Is under consideration for placement on
the abuser registry; or
(v) Is a
related party to an agency provider or an independent provider whose
certification has been suspended or revoked or is proposed for
revocation.
(5)
When the department determines an applicant does not meet the standards for the
requested certification, the department will notify the applicant in accordance
with paragraph (M)(3) of this rule that certification is denied. The
notification will specify the reason for denial.
(H) Procedure for obtaining certification to
provide additional home and community-based services during the term of
existing department-issued certification
(1)
A certified independent provider seeking to provide additional home and
community-based services shall
will submit an application via the provider
services management system, for the additional home and community-based
services the independent provider seeks to provide including:
(a) Required signatures and supporting
documentation to demonstrate that standards are met as required by this rule
and rules in Chapter 5123-9 of the Administrative Code for the specific home
and community-based services the applicant seeks to provide; and
(b) The application fee specified in
paragraph (K) of this rule except when, based on the specific home and
community-based services to be provided, the applicant is exempted from paying
an application fee in accordance with appendix D
E to this
rule.
(2) The department
will review an application within thirty calendar days of receipt of all
required components to determine if the applicant meets the standards for the
requested certification. If, upon review of the application, the department
determines that supporting documentation does not demonstrate that the
applicant meets the standards for the requested certification, the department
will notify the applicant by electronic mail and advise that the applicant has
thirty calendar days to submit components needed to demonstrate that the
applicant meets the standards for the requested certification.
(a) When the department receives components
needed to demonstrate that the applicant meets the standards for the requested
certification within the specified thirty calendar days, the application will
be advanced for processing.
(b)
When the applicant fails to submit components needed to demonstrate that the
applicant meets the standards for the requested certification within the
specified thirty calendar days, the department will take no further action with
respect to the application.
(3) When the department determines the
applicant meets the standards for the requested certification, the department
will notify the applicant by electronic mail that certification is approved.
The notification will specify the effective date and expiration date of the
certification and the specific services for which the applicant is
certified.
(4) When the department
determines an applicant does not meet the standards for the requested
certification, the department will notify the applicant in accordance with
paragraph (M)(3) of this rule that certification is denied. The notification
will specify the reason for denial.
(I) Procedure for obtaining renewal
independent provider certification
(1) The
department will notify an independent provider by electronic mail to the
address in the provider services management system of required certification
renewal no later than ninety calendar days prior to the date the independent
provider's certification expires. The notification will describe the procedures
for submitting the certification renewal application in accordance with this
rule.
(2) An independent provider
shall
will
submit the certification renewal application via the provider services
management system including:
(a) Required
signatures and supporting documentation to demonstrate that standards are met
as required by this rule and rules in Chapter 5123-9 of the Administrative Code
for the specific home and community-based services the applicant seeks to
provide;
(b) The application fee
specified in paragraph (K) of this rule except when, based on the specific home
and community-based services to be provided, the applicant is exempted from
paying an application fee in accordance with appendix
D
E to this
rule; and
(c) The applicant's
criminal records check by the Ohio bureau of criminal identification and
investigation and when applicable, by the federal bureau of investigation,
unless the applicant has been enrolled without interruption in the Ohio
attorney general's retained applicant fingerprint database (also known as
"Rapback") for the entire previous certification term and has been a resident
of Ohio without interruption for the past five years.
(3) The department will review an application
within thirty calendar days of receipt of all required components to determine
if the applicant meets the standards for the requested certification.
(a) When the department determines the
applicant meets the standards for the requested certification, the department
will notify the applicant by electronic mail that certification is approved.
The notification will specify the effective date and expiration date of the
certification and the specific services for which the applicant is
certified.
(b) If, upon review of
the application, the department determines that supporting documentation does
not demonstrate that the applicant meets the standards for the requested
certification, the department will notify the applicant by electronic mail and
advise that the applicant has thirty calendar days to submit components needed
to demonstrate that the applicant meets the standards for the requested
certification.
(i) When the department
receives components needed to demonstrate that the applicant meets the
standards for the requested certification within the specified thirty calendar
days, the application will be advanced for processing.
(ii) When the applicant fails to submit
components needed to demonstrate that the applicant meets the standards for the
requested certification within the specified thirty calendar days, the
department will take no further action with respect to the
application.
(4) The department's review of an application
may extend beyond thirty calendar days when:
(a) One or more of the submitted documents
requires verification; or
(b) The
applicant:
(i) Has a conviction or notation on
his or her
the criminal records check by the Ohio bureau of
criminal identification and investigation or the federal bureau of
investigation;
(ii) Is included in
one or more of the databases described in paragraph (C)(2) of rule
5123-2-02 of the Administrative
Code;
(iii) Is the primary person
involved in a major unusual incident;
(iv) Is under consideration for placement on
the abuser registry; or
(v) Is a
related party to an agency provider or an independent provider whose
certification has been suspended or revoked or is proposed for
revocation.
(5)
When the department determines an applicant does not meet the standards for the
requested certification, the department will notify the applicant in accordance
with paragraph (M)(3) of this rule that certification is denied. The
notification will specify the reason for denial.
(6) When an independent provider submits an
application for renewal certification prior to certification expiration that
demonstrates the applicant meets the standards for the requested renewal
certification, the independent provider's certification will be renewed without
lapse.
(7) When an independent
provider submits an application for renewal certification fewer than forty-five
calendar days in advance of certification expiration that demonstrates the
applicant meets the standards for the requested renewal certification, the
independent provider may experience a gap in his or
her ability to bill for services provided between the date of
certification expiration and the date the renewal certification is approved.
Once the renewal certification is approved, however, the independent provider
may bill for services provided during that period.
(8) When an independent provider submits an
application for renewal certification after certification expiration, there
will be a lapse of certification from the date of certification expiration to
the date the department receives an application for renewal certification that
demonstrates the applicant meets the standards for the requested renewal
certification. The independent provider shall
may not provide
services nor be reimbursed for provision of services during the
lapse.
(9) An independent provider
shall
may not
provide services nor submit claims for reimbursement for services provided
subsequent to expiration of the independent provider's certification.
(J) Application for certification
subsequent to expiration
(1) An applicant
whose certification has been expired for less than one year
shall
will be
required to apply for and meet the requirements for renewal
certification.
(2) An applicant
whose certification has been expired for one year or more
shall
will be
required to apply for and meet the requirements for initial
certification.
(K)
Application fees
(1) Applicants seeking
certification to provide services, other than those exempted in accordance with
appendix D
E
to this rule, shall
will submit an application fee at the time of
application for initial certification, application for certification to provide
additional home and community-based services during the term of existing
department-issued certification, and application for renewal certification.
(a) The application fee for an independent
provider seeking initial certification or renewal certification is one hundred
twenty-five dollars.
(b) The
application fee for an independent provider seeking certification to provide
additional home and community-based services during the term of existing
certification is twenty-five dollars.
(2) Applicants shall
will pay
application fees by electronic check or credit card.
(3) Application fees are
non-refundable.
(4) The department
will invalidate a certification issued to an applicant whose application fees
cannot be collected due to non-sufficient funds available or for any other
reason. An independent provider whose certification is invalidated in
accordance with this paragraph shall
will be required to initiate and submit an
entirely new application via the provider services
network
management system.
(L)
Certification terms
(1) Initial certification
will be issued for a term of three years.
(2) Renewal certification will be issued for
a term of three years.
(3)
Certification to provide additional home and community-based services will be
issued for the remainder of the term of the applicant's existing
certification.
(M)
Denial, suspension, or revocation of certification
(1) Independent providers
shall be
are
subject to monitoring and compliance reviews as set forth in rules promulgated
by the department. Failure to comply with this rule or other rules governing
services provided by the independent provider may result in corrective action
by the department, up to and including suspension, summary suspension, denial,
or revocation of certification.
(2)
The department may deny, suspend, or revoke an independent provider's
certification for good cause pursuant to section
5123.166 of the Revised
Code.
(3) When denying, suspending,
or revoking certification pursuant to this rule, the department will comply
with the notice and hearing requirements of Chapter 119. of the Revised Code
and section 5123.166 of the Revised
Code.
(4) When the department
denies an application for renewal certification, the independent provider
shall
will
comply with the department's adjudication order within thirty calendar days of
the date of the mailing of the order.
(N) Department's authority to waive
provisions of this rule
(1) For good cause,
the department may waive a provision of this rule. The department's decision to
waive a provision of this rule will not be contrary to the rights, health, or
safety of individuals served.
(2)
An independent provider or applicant for independent provider certification may
initiate a request for the department to waive a provision of this rule by
submitting the request with justification in writing.
(a) The department may ask for input
regarding the request from individuals served, individuals' guardians, or
county boards.
(b) The department
will grant or deny a request within fourteen calendar days of receipt of the
request or within such longer period of time as the department deems necessary
and may put whatever conditions on approval as determined to be
necessary.
(c) The department's
decision regarding a request to waive a provision of this rule is not subject
to appeal.
Notes
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.1611
Rule Amplifies: 5123.04, 5123.045, 5123.16, 5123.161, 5123.162, 5123.163, 5123.164, 5123.165, 5123.166, 5123.168, 5123.169, 5123.1610, 5123.1611
Prior Effective Dates: 07/03/1989 (Emer.), 09/29/1989, 04/30/1990, 07/01/1991, 07/24/1995, 04/28/2003, 07/01/2005, 10/01/2009, 10/01/2015, 06/11/2020 (Emer.), 09/01/2021
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