(A)
Each managed
care plan (MCP)
A managed care entity
(MCE) must have administrative and management arrangements or procedures,
including a mandatory compliance plan, to guard against fraud, waste and abuse
as required in the
managed care plan
MCE provider agreement
or
contract with the Ohio department of medicaid (ODM) located at
http://medicaid.ohio.gov/.
(1) These arrangements or procedures must be
made available to
the Ohio department of medicaid
(ODM)
ODM upon request.
(2) The
MCP
MCE must annually
submit to ODM a report that summarizes the
MCP's
MCE's fraud, waste
, and abuse activities for the previous year and
identifies any proposed changes to the
MCP's
MCE's fraud,
waste
, and abuse program for the coming
year.
(B) ODM or its
designee, the state auditor's office, the state attorney general's office, and
the U.S. department of health and human services may evaluate or audit
a contracting MCP's
the MCE's performance for the purpose of determining
compliance with the requirements of Chapter 5160-26 of the Administrative Code,
fraud, waste
, and abuse statutes, applicable
state and federal regulations
, or requirements
under federal waiver authority.
(C)
ODM or its designee may conduct on-site audits and reviews as deemed necessary
based on periodic analysis of financial, utilization, provider
panel
network,
and other information.
(D) The
MCP
MCE must
submit required reports and additional information, as requested by ODM, as
related to its duties and obligations and where needed to ensure operation in
accordance with all state and federal regulations or requirements.
(E) If the
MCP
MCE fails to
submit any ODM-requested materials, as specified in paragraph (D) of this rule,
without cause as determined by ODM, on or before the due date, ODM may impose
any or all of the sanctions listed in rule
5160-26-10
of the Administrative Code
or the MCE's provider
agreement or contract with ODM.
(F) Record retention.
The MCP
MCE and its contracted
providers and subcontractors shall retain and safeguard all hard copy or
electronic records originated or prepared in connection with the
MCP's
MCE's
performance of its obligations under the MCO
provider agreement or the SPBM contract,
including but not limited to working papers or information related to the
preparation of reports, medical records, progress notes, charges, journals,
ledgers, and fiscal reports, in accordance with applicable sections of the
federal regulations, the Revised Code, and the Administrative Code. Records
stored electronically must be produced at the MCP's
MCE's expense,
upon request, in the format specified by state or federal authorities. As
specified in
42 C.F.R.
438.3 (October 1, 2018
2021), such
records must be maintained for a minimum of ten years from the renewal,
amendment or termination date of the provider agreement. In the event the
MCP
MCE has
been notified that state or federal authorities have commenced an audit or
investigation of the MCO provider agreement
or the SPBM contract, records must be maintained
until such time as the matter under audit or investigation has been resolved.
For the initial three years of the retention period, the
MCP
MCE and
its contracted providers and subcontractors must
store the records in a manner and place that provides readily available
access.
Notes
Ohio Admin. Code
5160-26-06
Effective:
7/18/2022
Five Year Review (FYR) Dates:
4/15/2022 and
07/18/2027
Promulgated
Under:
119.03
Statutory Authority:
5167.02
Rule
Amplifies:
5162.03,
5167.10,
5167.03,
5164.70,
5164.02
Prior Effective Dates: 04/01/1985, 02/15/1989 (Emer.), 05/08/1989,
05/01/1992, 05/01/1993, 11/01/1994, 07/01/1996, 07/01/1997 (Emer.), 09/27/1997,
12/10/1999, 07/01/2000, 07/01/2001, 07/01/2003, 07/01/2004, 10/31/2005,
06/01/2006, 07/01/2013, 02/01/2015, 07/01/2017,
02/14/2019
