Ohio Admin. Code 5160-28-04 - FQHC and RHC services: submission of a cost report
(A)
Data entered into
a cost report should represent "reasonable and allowable costs," which are
defined in "Principles of reasonable cost reimbursement," 42 C.F.R. part 413
(October 1, 2021).
(B)
For purposes of payment determination, an FQHC or RHC
submits a cost report in any of the following circumstances:
(1)
An FQHC or RHC
that is newly enrolled as a medicaid provider submits a cost report covering
the twelve-month period beginning either on the first day of the first calendar
month or on the first day of the first full fiscal year after
enrollment.
(2)
An FQHC or RHC that requests an adjustment of a
per-visit payment amount (PVPA) based on a change in scope of an existing FQHC
or RHC PPS service submits a cost report for that service covering the
twelve-month period beginning either on the first day of the first calendar
month or on the first day of the first full fiscal year after the change in
scope. If the adjustment is granted, the PVPA derived from the cost report
becomes the new PVPA.
(3)
An FQHC or RHC that has chosen to provide an additional
PPS service (other than transportation) submits a cost report for that service
covering the twelvemonth period beginning either on the first day of the first
calendar month or on the first day of the first full fiscal year after addition
of the service.
(4)
A government-operated FQHC that requests the alternate
payment method (APM) described in rule
5160-28-07.1 of the
Administrative Code submits cost reports in accordance with that
rule.
(C)
The Ohio department of medicaid (ODM) or its designee
may perform a desk review or conduct a field audit of any cost report submitted
and may request any supporting documentation it deems
necessary.
(D)
No extension will be granted for submission of cost
reports. If an FQHC or RHC fails to submit a complete and accurate cost report
within one hundred twenty days after the end of a reporting period, ODM may
choose to take either or both of two courses of action:
(1)
It may decline to
make any adjustments to the established PVPA or PVPAs.
(2)
It may impose a
penalty of not more than five hundred dollars for each business day on which
the cost report is late.
(E)
An FQHC or RHC
may request adjustment of a PVPA.
(1)
In its request, it addresses in writing the following
topics:
(a)
It
specifies the basis for the request, such as a change in scope of an existing
service or the addition of a new service.
(b)
It specifies
which cost centers have been affected and why.
(c)
It describes the
steps it took to arrive at the conclusion that an adjustment would be the most
efficient means of responding to cost changes.
(d)
It provides
documentation to support its request, such as a community needs assessment or
other analysis.
(e)
If the change in scope is directly attributable to a
change in the intensity of services provided, then the FQHC or RHC provides
evidence such as a change in the acuity of care caused by a shift in the
distribution of diagnoses or a change in the relative-value components of the
services provided.
(f)
An FQHC that is adding a PPS service submits to ODM a
copy of the notice of grant award authorization from the federal health
resources and services administration (HRSA) confirming that its sites satisfy
HRSA criteria for providing the new PPS service it plans to
render.
(2)
ODM has sole discretion over whether to grant a request
for adjustment of a PVPA.
(F)
ODM will respond
in writing within sixty days after it receives a request for an adjustment of a
PVPA based on a change in scope or after it receives additional information
needed to determine whether an adjustment is warranted.
(G)
The following
conditions apply to any adjustment of a PVPA based on a change in scope:
(1)
Such an
adjustment can be granted only once for a particular circumstance for a
particular FQHC or RHC service site .
(2)
No adjustment
will be made if the percentage of change represented by the calculated PVPA for
the service is not at least twice the medicare economic index (MEI) for the
relevant year.
(3)
No adjusted PVPA may exceed any limit, ceiling, or
other maximum set forth in agency 5160 of the Administrative Code.
Replaces: 5160-28- 04.1, 5160-28- 04.3
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 10/25/2001, 07/01/2006, 10/01/2016
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