Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-13 - Utilization review

Current through all regulations passed and filed through July 1, 2024
(A)
								The Ohio
			 department of medicaid (ODM) will perform or contract with a medical review
			 entity to perform utilization review for medicaid inpatient services regardless
			 of the payment methodology used for reimbursement of those services. For the
			 purposes of this rule, "ODM" means ODM or its contracted medical review entity.
			 During the course of its analyses, ODM may request information or records from
			 the hospital and may conduct on-site medical record reviews.
(B)
								ODM will review a
			 statistical sample of all admissions retrospectively.
(1)
									While the nature
			 of the review will vary depending on the category of admission, all admissions
			 selected will be reviewed to determine whether care was medically necessary on
			 an inpatient hospital basis; to determine if the care was medically necessary
			 as defined in rule
			 5160-1-01
			 of the Administrative Code; to determine whether the discharge occurred at a
			 medically appropriate time; to assess the quality of care rendered as mandated
			 in
			 42 C.F.R.
			 456.3(b), in effect as of
			 October 1, 2021; and to assess compliance with agency 5160 of the
			 Administrative Code.
(2)
									If any of the cases reviewed for a hospital do not meet
			 the conditions described in paragraph (B)(1) of this rule, then ODM may deny
			 payment or recoup payment beginning with the first inappropriate admission or
			 discharge. Any negative determinations should be made by a
			 physician.
(3)
									If the diagnostic or procedural information on the
			 claim is found to be inconsistent with that found in the medical records in
			 conjunction with the physician attestation, then changes may be made in the
			 coding and payment may be adjusted as described in paragraph (D)(3) of this
			 rule.
(4)
									ODM may determine upon retrospective review, in
			 accordance with this rule, that the location of services was not medically
			 necessary, but that the services rendered were medically necessary. In such
			 instances:
(a)
										The hospital may bill the department on an outpatient basis
			 for those medically necessary services that were rendered on the date of
			 admission in accordance with rule
			 5160-2-75
			 of the Administrative Code.
(b)
										Only laboratory
			 and diagnostic radiology services rendered during the remainder of the
			 medically unnecessary admission may be billed in accordance with rule
			 5160-2-75
			 of the Administrative Code.
(c)
										The outpatient
			 bill will be submitted with a copy of the reconsideration affirming the
			 original decision or the administrative decision issued in accordance with rule
			 5160-2-12 of the Administrative Code.
(d)
										The outpatient
			 bill with attachments will be submitted to the department within sixty calendar
			 days from the date on the remittance advice recouping the DRG payment for the
			 medically unnecessary admission.