Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-27 - Review of provider records

Current through all regulations passed and filed through July 1, 2024
(A) As specified in
			 Chapter
								5160-1 of the Administrative Code, all medicaid
			 providers are required to keep such records as are necessary to establish
			 that conditions of payment for medicaid covered services
			 have been met, and to fully disclose the basis for the
			 
								type, frequency, extent, duration, and delivery setting
			 of services provided to medicaid recipients, and to document significant business
			 transactions. Medicaid providers are required to provide such records and
			 documentation to the Ohio department of medicaid (ODM) or its
			 designee, the secretary of the federal department of health and human
			 services, or the state medicaid fraud control unit upon request.
(B) For purposes of this rule, the following
			 definitions apply:
(1) "Audit" means a
			  postpayment examination, made in
			 
									consideration of generally accepted auditing
			 standards, of a medicaid provider's records and documentation to determine
			 program compliance, the extent and validity of services paid for under the
			 medicaid program and to identify any inappropriate payments. The department
			 shall have the authority to use statistical methods to conduct audits and to
			 determine the amount of overpayment. An audit may result in a final
			 adjudication order by the department.
(2) "Hold and Review" means a process of
			 prepayment review of a medicaid provider's claims, including client records,
			 medical records, or other supporting documentation, for determination of
			 appropriate claims payment or reimbursement.
(a) Hold and review administered by
			 ODM will
			 be done in accordance with rule 5160-1- 27.1 of the Administrative
			 Code.
(b) Hold and review
			 administered by state agencies other than ODM will be done
			 in accordance with rule 5160-1- 27.2 of the Administrative Code.
(3) "Review" means a
			 post-payment examination of a medicaid provider's paid
			 claims to determine program compliance, validity of payments and identification
			 of recovery of overpayments under the medicaid program. Review also means
									 special
			 projects or 
			 analysis to
			 determine quality of care, compliance with accepted standards of care,
			 and general program compliance
			 . A review may result in an
			 educational letter,  a request for a corrective
			 action plan subject to department approval, and/or recovery of inappropriate paid claims due to non-program
			 compliance.
(4) "Notice of operational deficiency" means
			 a written notice issued by the department that identifies provider conduct,
			 treatment or practices that are determined by the department not to be in the
			 best interests of the consumer or the medicaid program and/or are noncompliant
			 with the regulations governing the medicaid program and that must be corrected.
			 The notice states the nature of the deficiency, the time period that the
			 provider has to correct the deficiency and the person within the department the
			 provider is to contact to verify that the deficiency has been
			 corrected.