Ohio Admin. Code 5160-1-27 - Review of provider records

(A) As specified in division Chapter 5101:3 5160-1 of the Administrative Code, all medicaid providers are required to keep such records as are necessary to establish medical necessity that conditions of payment for medicaid covered services have been met, and to fully disclose the basis for the type, extent, and level of the type, frequency, extent, duration, and delivery setting of services provided to medicaid recipients consumers, and to document significant business transactions. Medicaid providers are required to provide such records and documentation to the Ohio department of job and family services (ODJFS) medicaid (ODM) or its designee, the secretary of the federal department of health and human services, or the state medicaid fraud control unit upon request.
(B) For purposes of this rule, the following definitions apply:
(1) "Audit" means a formal postpayment examination, made in accordance with consideration of generally accepted auditing standards, of a medicaid provider's records and documentation to determine program compliance, the extent and validity of services paid for under the medicaid program and to identify any inappropriate payments. The department shall have the authority to use statistical methods to conduct audits and to determine the amount of overpayment. An audit may result in a final adjudication order by the department.
(2) "Hold and Review" means a process of prepayment review of a medicaid provider's claims, including client records, medical records, or other supporting documentation, for determination of appropriate claims payment or reimbursement.
(a) Hold and review administered by ODJFS ODM will be done in accordance with rule 5101:3-1- 27.1 5160-1- 27.1 of the Administrative Code.
(b) Hold and review administered by state agencies other than ODJFS ODM will be done in accordance with rule 5101:3-1- 27.2 5160-1- 27.2 of the Administrative Code.
(3) "Review" means a postpayment post-payment examination of a medicaid provider's paid claims to determine program compliance, validity of payments and identification of recovery of overpayments under the medicaid program. Review also means limited scope investigation, special projects and/or special analysis, examination or monitoring of a medicaid provider's records, claims and/or supporting documentation to determine quality of care, compliance with accepted standards of care, and general program compliance and/or validity of services rendered, billed, or paid for under the medicaid program. A review may result in an educational letter, the denial of invalid services or claims, a request for a corrective action plan subject to department approval, and/or recovery of inappropriate paid claims due to non-program compliance. the collection of overpayments under rule 5101:3-1-19.8 of the Administrative Code.
(4) "Notice of operational deficiency" means a written notice issued by the department that identifies provider conduct, treatment or practices that are determined by the department not to be in the best interests of the consumer or the medicaid program and/or are noncompliant with the regulations governing the medicaid program and that must be corrected. The notice states the nature of the deficiency, the time period that the provider has to correct the deficiency and the person within the department the provider is to contact to verify that the deficiency has been corrected.
(C) Records, documentation and information must be available regarding any services for which payment has been or will be claimed to determine that payment has been or will be made in accordance with applicable federal and state requirements. For the purposes of this rule, an invoice constitutes a business transaction but does not constitute a record which is documentation of a medical service.
(D) Various methods of audit and review will be utilized in all cases of suspected fraud, waste and abuse, in accordance with rule 5101:3-1-29 5160-1-29 of the Administrative Code. If fraud, waste and abuse are apparent, the department will take action to gain compliance and recoup inappropriate payments.
(E) The provider must maintain all records as stipulated in this rule and rule 5101:3-1- 17.2 5160-1- 17.2 or Chapter 5101:3-3 5160-3 of the Administrative Code, as applicable.
(F) All records, documentation and/or information requested in accordance with paragraph (B) of this rule shall be submitted to the department or its' designee, in an appropriate manner as determined by the department. Records subject to audit and review must be produced at no cost to the department.
(1) Records subject to audit and review must be made available for examination in the time period described in rule 5101:3-1- 17.2 5160-1- 17.2 of the Administrative Code, or as determined by the department or its' designee. Failure to supply requested records, documentation and/or information as indicated in this rule will result in no payment for outstanding services.
(2) In all situations, the department has the authority to conduct an on-site visit with the provider at the provider's location for the examination or collection of records, and/or for compliance verification. Upon such occasions, as deemed necessary by the department or its' designee, a member of the provider's staff is to be assigned to assist in collecting the information. Upon request from the department, the provider will photocopy or make the applicable records available for photocopying.
(3) Services billed to and reimbursed by the department, which are not validated in the consumers recipients' records, are subject to recoupment through the audit and review process described in this rule.


Ohio Admin. Code 5160-1-27
Effective: 9/3/2015
Five Year Review (FYR) Dates: 04/29/2015 and 09/03/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5166.02, 5162.10
Rule Amplifies: 5164.02, 5166.02, 5162.10
Prior Effective Dates: 4/7/77, 7/1/80, 10/1/84, 10/1/87, 7/1/90, 8/1/96, 5/30/02, 9/1/07

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