"Medicaid administrative agency" means a
state agency other than the Ohio department of
and family services (ODJFS)
Administers a component of the
medicaid program under the terms of a contract with
of the Revised
(2) Pays claims for
medicaid services or reimburses local entities for claims paid for medicaid
Review" is defined in accordance with rule
of the Administrative Code.
Hold and review may be initiated by
medicaid administrative agency for the following reasons:
(1) When the information is used to
complement or follow-up a provider or certification or other quality review
(2) In response to
allegations of fraud or willful misrepresentation of claims
(3) Upon the request of
the office of the attorney general, the office of inspector general, or the
auditor of state;
(4) When a
provider's medicaid provider agreement is subject to termination;
(5) When a provider has been indicted for a
criminal offense; or
reasons otherwise necessary to assure the basic integrity of claims submission
hold and review may be applied without regard to date of service.
Claims subject to the hold and review process, may
include any claims for payment received by ODJFS, the medicaid administrative
agency, or a local entity that pays medicaid providers directly, after the
effective date of the hold and review even if such claims are for dates of
service that occurred prior to the effective date of the hold and
Hold and review
initiated by medicaid administrative agencies.
The medicaid administrative agency shall
have formal written approval from
to initiate a hold and review process.
(2) The medicaid administrative agency may
recruit the assistance of local governmental entities to review records subject
to hold and review.
medicaid administrative agency may initiate hold and review without prior
notification to the provider when the medicaid administrative agency receives a
request to initiate hold and review from the office of the attorney general,
the office of inspector general, the auditor of state, or
When the medicaid administrative agency initiates hold and review without prior
notification to the provider, the medicaid administrative agency shall provide
written notice to the provider, including a copy of
approval within ten business days of initiating a hold and review.
(5) The medicaid administrative agency may
initiate hold and review with prior notification to the provider for any
purpose contained in paragraph (C) of this rule. The medicaid administrative
agency shall notify the provider at least ten business days prior to subjecting
the provider's claims to hold and review.
(6) For claims payment that the medicaid
administrative agency pays directly to the medicaid provider, the medicaid
administrative agency may subject the medicaid provider's claim(s) payment, in
part or in whole, to hold and review.
For reimbursements the medicaid
administrative agency makes to local entities for claims that the local entity
pays to the medicaid provider directly, the medicaid administrative agency:
(a) May require the local entity to hold the
medicaid provider's claim(s) payment for claims subject to hold and
(b) May deny reimbursement
to the local entity for the claims on which the hold and review was requested
after allowing the local entity a reasonable time to comply; and
(c) Shall not deny reimbursement to the local
entity for claims that the local entity paid prior to the request.
(8) A failure by the medicaid
administrative agency to notify a provider of a hold and review process shall
not impede the agency from taking actions under this rule.
Review of the medicaid provider's claims
and documentation for hold and review is subject to the provisions of rule
of the Administrative Code.
The notice from the medicaid
administrative agency shall:
(a) State the
general reasons for subjecting the medicaid provider's claims to hold and
review, but need not disclose any specific information concerning an ongoing
investigation involving alleged fraud and/or willful
(b) State the
date the medicaid administrative agency implements the hold and
(c) State the types of
services and claims that are subject to hold and review;
documentation required to submit to the medicaid administrative
(e) Inform the provider of
the right to submit evidence for consideration to the medicaid administrative
(f) State the contact
at the medicaid administrative agency for questions regarding the hold and
review and where to send the requested documentation.
(11) The medicaid administrative agency shall
send copies of the notice to all local, state, and federal entities that are
involved in the review or that need to be aware of the review in order to
assure the integrity of claims submission and payment.
(12) Providers who submit medical claims
electronically may be required under this rule to submit paper documentation
supporting each claim submitted electronically. These claims will not be
processed until both the claim and the supporting documentation are reviewed by
the medicaid administrative agency.
No later than
one hundred twenty days from the date the medicaid administrative agency holds
a claim for review, the medicaid administrative agency shall forward the claim
for adjudication if it is determined that the documentation submitted supports
the validity of the claim, or for denial if the documentation submitted does
not support that the claim would be in compliance with the law or if a provider
fails to submit the requested supporting documentation. If a review results in
the medicaid administrative agency concluding that the provider has a pattern
of submitting claims that are not in compliance with the law, the medicaid
administrative agency may request ODJFS to issue a 'notice of operational
deficiency' to the provider and may continue to hold and review the providers
claims until the ODJFS determines that the operational deficiency is
The medicaid administrative agency
has one hundred twenty days from the date each claim for payment is received to
review the claim and make a determination whether or not to do one of the
Forward the claim for adjudication;
claim for denial; or
Issue a "Notice of Operation
Hold and review process initiated by
may require a medicaid administrative agency
to initiate a hold and review described in this rule or to cooperate in a hold
and review initiated by
of the Administrative Code.
In cooperating with a request from
initiate a hold and review, medicaid administrative agencies shall:
(a) Comply with the provider notification
requirements of this rule; and
Suspend payment or reimbursement of the claims that are subject to hold and
(c) Require local
entities to suspend payment for the claims subject to hold and review;
Obtain provider records,
including client records, medical records, and other supporting documentation
requests as part of the review from local entities and providers; and
Participate in the review of records and
other supporting documentation when requested by
Provide any other
information requested by
in order to assure accurate tracking and timely
resolution of the claims subject to hold and review.
For claims associated with alcohol and
drug addiction services,
shall rely on the Ohio department
of alcohol and drug addiction services
mental health and addiction services
to obtain and
review provider records, including client records and medical records, as
necessary to assure the special confidentiality of these records required by 42
C.F.R., part 2
as amended through October 1, 2006.
After requesting a hold and review and
allowing the medicaid administrative agency a reasonable time to comply,
stop drawing from the centers for medicare and medicaid services, and passing
to the other agency, the federal match associated with the claims that are
subject to the review.
will not withhold federal match for claims that
other agencies or local entities paid prior to the
purposes of determining whether time limits for the submission of claims have
been met for claims subjected to hold and review, the date of claims submission
shall be the date that the medicaid administrative agency received the original
claim from the provider.
A provider is not entitled to a hearing under
Chapter 119. or section 5111.06 of the Revised Code for any action taken by
ODJFS or a medicaid administrative agency under this rule.
The hold and review process is not subject to Chapter
119. of the Revised Code or any other appeal.
Ohio Admin. Code
Five Year Review (FYR) Dates:
Effective Dates: 09/01/2007