Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-80 - Rights and Procedures Applicable to Medical Assistance Recipients › Section 5160-80-01 - Hearings conducted under authority of section 5160.37 of the Revised Code: definitions and scope of applicability

Current through all regulations passed and filed through July 1, 2024
(A)
								Rules 5160-80-01
			 to
			 5160-80-09
			 of the Administrative Code describe the hearing rights, appeal rights, and
			 procedures applicable to medical assistance recipients under section
			 5160.37 of the Revised Code for
			 contesting the amount of the department's or county department's claims for
			 reimbursement under section
			 5160.37 of the Revised Code for
			 medical assistance paid.
(B)
								Definitions
As used in rules 5160-80-01 to
				5160-80-09
				of the Administrative Code, the following terms shall have the following
				meanings unless otherwise specified.
(1)
									"Appellant" means
			 a medical assistance recipient who is utilizing the hearing process under
			 Chapter 5160-80 of the Administrative Code.
(2)
									"Authorized
			 representative" means an individual at least eighteen years of age or a legal
			 entity that is appointed by the medical assistance recipient to assist or stand
			 in the place of the medical assistance recipient for the purpose of the hearing
			 process or an appeal to the director. The department may request proper
			 verification from the authorized representative of the
			 appointment.
(3)
									"County department" means any of the local county
			 department of job and family services.
(4)
									"Depository
			 agent" means the department's office at its official mailing address for
			 purpose of receiving correspondence or filings for a hearing or administrative
			 appeal conducted under authority of Chapter 5160-80 of the Administrative
			 Code.
(5)
									"Department" means the Ohio department of
			 medicaid.
(6)
									"Director" means the director of the Ohio department of
			 medicaid or that person's designee.
(7)
									"Electronic" has
			 the same meaning as in section
			 1306.01 of the Revised
			 Code.
(8)
									"Final lien amount" is the amount the department or
			 county department determines in writing that the medical assistance recipient
			 owes for reimbursement for medical assistance paid on the medical assistance
			 recipient's behalf, subject to the right to collect additional reimbursement as
			 set forth in division (F) of section
			 5160.37 of the Revised
			 Code.
(9)
									"Good cause" is defined as death in the immediate
			 family, sudden illness or injury of a participant in the hearing or that
			 person's immediate family, or other circumstances that reasonably prevents or
			 prevented attendance at the hearing.
(10)
									"Medical
			 assistance recipient" or "recipient" means a recipient or former recipient of a
			 medical assistance program who has had some or all of his or her medical
			 expenses paid by the department or county department.
(11)
									"Party" includes
			 (a) a medical assistance recipient who requests a hearing or an administrative
			 appeal under Chapter 5160-80 of the Administrative Code, or the executor or
			 administrator of an medical assistance recipient's estate authorized to make or
			 pursue such a request and (b) the department or county department that has
			 claim for medical reimbursement involved in those proceedings.
(12)
									"Request for
			 hearing" is a clear expression in writing by a medical assistance recipient or
			 the recipient's authorized representative or attorney stating that medical
			 assistance recipient wants to dispute the amount of the department's or county
			 department's claim for reimbursement or to seek recovery of money that the
			 department or county department received pursuant to section
			 5160.37 or
			 5160.38 of the Revised Code or
			 former section 5101.58 or
			 5101.59 of the Revised
			 Code.
(13)
									"Request for an administrative appeal" is a clear
			 expression by the medical assistance recipient or the medical assistance
			 recipient's authorized representative or attorney to the effect that the
			 appellant wants to have the hearing decision or a decision to deny or dismiss a
			 hearing request reviewed by the director. The request must be in writing and
			 signed by the appellant or the appellant's authorized representative or
			 attorney.
(14)
									"Third party" means the entity which has provided funds
			 to the medical assistance recipient, or to whom the recipient has initiated
			 informal recovery activity or filed a legal recovery action, that gives rise to
			 the department's or county department's right of recovery.