Ohio Admin. Code 5160-1-17.5 - Suspension of medicaid provider agreements
(A)
Definitions:
(1)
"Credible allegation of fraud" means an accusation of
fraud as defined in section
5164.36 of the Revised
Code.
(2)
"Non-institutional provider" means any person or
entity with a medicaid provider agreement other than a hospital, long-term care
nursing facility, intermediate care facility for individuals with intellectual
disabilities or medicaid contracting managed care plans.
(B)
The
Ohio department of medicaid (ODM) shall suspend a medicaid provider agreement
when at least one of the following conditions apply:
(1)
Upon determining
there is a credible allegation of fraud for which an investigation is pending
against a provider under the medicaid program, unless good cause to not suspend
is found pursuant to
42 CFR
455.23(e) or (f), effective
Feb. 2, 2011; or
(2)
Upon receiving notice and copy of an indictment that
charges a non-institutional provider, its owner or owners, officer, authorized
agent, associate, manager, or employee with committing an offense as specified
in division (E) of section
5164.37 of the Revised
Code.
(C)
Upon suspension of the provider agreement, the
following conditions apply:
(1)
If a provider is suspended pursuant to this rule, then
any other provider agreements where the provider is an owner, officer,
authorized agent, manager, or employee may also be suspended.
(2)
A provider, its
owner or owners, officer, authorized agent, associate, manager, or employee
shall not own or provide services to any other medical provider or risk
contractor or arrange for, render, or order services for medicaid recipients
during the period of suspension.
(3)
During the
period of suspension, the provider owner or owners, officer, authorized agent,
associate, manager, or employee shall not receive reimbursement in the form of
direct payments from ODM or indirect payments of medicaid
funds.
(4)
The suspension shall continue until either of the
following:
(a)
The department or a prosecuting authority determines that there is insufficient
evidence of fraud by the provider;
(b)
The proceedings
in any related criminal case are completed through dismissal of the indictment
or through conviction, entry of a guilty plea, or finding of not
guilty.
(5)
If ODM commences a process to terminate the suspended
provider agreement, the suspension shall continue in effect until the
termination process is concluded.
(D)
Reconsideration
of suspension:
(1)
A provider, owner, or owners subject to a suspension
may request a reconsideration in accordance with section
5164.36 or
5164.37 of the Revised Code . A
request for reconsideration is not subject to Chapter 119. of the Revised
Code.
(2)
The reconsideration shall be conducted by the ODM
director or the director's designee in the office where the contestation arose
provided that the designee was not involved in the original decision. Decisions
made by the director or the director's designee are not appealable or subject
to further reconsideration.
Replaces: 5160-1- 17.5
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.01, 5164.36
Rule Amplifies: 5164.36, 5164.37
Prior Effective Dates: 01/01/2008
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