5101:6-7-03. State hearings: implementation of the hearing decision

(A) Responsibility

(1) When the hearing decision orders action to be taken by the agency, the agency that is ordered to take the action is responsible for promptly and fully implementing the decision.

(2) State hearings is responsible for monitoring timely compliance with decisions.

(3) When the hearing decision orders action to be taken by a managed care plan or "MyCare Ohio" plan, the managed care plan or "MyCare Ohio" plan is responsible for promptly and fully implementing the decision.

The , Ohio department of medicaid (ODM) is responsible for timely compliance with decisions involving compliance by a managed care plan or "MyCare Ohio" plan.

(B) Promptness

(1) Decisions that order action favorable to the individual

(a) For decisions involving public assistance, social services or child support services, compliance shall be achieved within fifteen calendar days from the date the decision is issued, but in no event later than ninety calendar days from the date of the hearing request.

(b) For decisions involving food assistance, any increase in benefits must be reflected in the food assistance allotment within ten calendar days of receipt of the decision, even if the local agency must provide a supplement, outside the normal issuance cycle.

The local agency may take longer than ten days if it elects to make the decision effective in the assistance group's normal issuance cycle, provided that issuance will occur within sixty calendar days of the date of the hearing request. If the local agency elects to follow this procedure, the benefit increase may be reflected in the normal issuance cycle or with a supplementary issuance.

(c) Compliance shall be promptly reported to the bureau of state hearings, via a notice certifying the agency's compliance with the state hearing decision, and accompanied by appropriate documentation substantiating compliance is met.

When the hearing decision orders action to be taken by a managed care plan or a "MyCare Ohio" plan, each shall also send a copy of the notice certifying the agency's compliance with the state hearing decision, to ODM .

(2) Decisions that authorize action adverse to the individual

(a) The agency shall implement the decision promptly, if still appropriate.

(b) When the adverse action results in a decrease in the assistance group's food assistance benefits, the decrease shall be reflected in the next issuance cycle following receipt of the hearing decision.

(C) Date compliance is achieved

(1) For decisions involving public assistance, social services or child support services, compliance shall be considered achieved on the date eligibility, payment, or services are authorized or other action ordered by the hearing decision is taken.

(2) For decisions involving food assistance, compliance shall be considered achieved on the date the action is reflected in the assistance group's food assistance allotment.

(D) Underpayments/underissuances

(1) When the decision determines that the individual has been improperly denied benefits or has received fewer benefits than were due, any underpayments must be corrected in accordance with rules 5101:1-23-60, 5101:1-5-50 and /or 5101:4-8-03 of the Administrative Code.

(2) The local agency shall restore food assistance benefits to assistance groups that are leaving the county before the departure whenever possible. If benefits are not restored prior to departure, the local agency shall forward an authorization of the benefits to the assistance group or to the new county if this information is known.

The new county shall accept an authorization and issue the appropriate benefits whether the notice is presented by the assistance group or received directly from another county.

(E) Overpayments/overissuances

(1) Overpayments related to the appeal are subject to collection in accordance with rule 5101:1-23-70 of the Administrative Code.

(2) When the appeal involves food assistance, a claim against the assistance group for any overissuance related to the appeal must be prepared in accordance with rule 5101:4-8-15 of the Administrative Code.

(F) Prior authorization issues

(1) When a hearing decision reverses a denial of prior authorization for medical service and authorizes the service, the approval unit shall approve the prior authorization, using the normal prior authorization procedure. The approval notification sent to the provider shall be accompanied by a copy of the hearing decision.

(2) When a hearing decision reverses a denial of prior authorization for additional therapeutic leave days for a medicaid recipient with a developmental disabilities (DD) level of care in a long-term care facility, the bureau of state hearings shall send a copy of the decision to the long-term care facility. The hearing decision constitutes authorization for the additional leave days.

(G) Precertification issues

When a hearing decision changes a review agency's decision on a request for precertification of a hospital admission or medical procedure, the bureau of state hearings shall send a copy of the decision and a notice certifying the agency's compliance with the state hearing decision to the review agency.

The review agency shall certify those hospital days or medical procedures authorized by the decision using the normal precertification procedure, complete the notice certifying the agency's compliance with the state hearing decision, and send it to state hearings.

(H) Coordinated services program (CSP) issues

When a hearing decision changes a decision by the recipient monitoring and review section concerning proposed or continued enrollment in the CSP or denial of a request for a change of designated provider, the bureau of state hearings shall send a copy of the decision to the recipient monitoring and review section. The recipient monitoring and review section shall take the actions ordered by the decision, complete the notice certifying the agency's compliance with the state hearing decision, and send it to state hearings.

(I) Preadmission screening resident review (PASRR) issues

When a hearing decision changes a preadmission screening (PAS) or resident review (RR) determination made by the Ohio department of mental health and addiction services or the Ohio department of developmental disabilities, the hearing decision shall constitute the revised PAS or RR determination.

Effective: 1/1/2018
Five Year Review (FYR) Dates: 10/17/2017 and 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 3125.25, 5101.35
Rule Amplifies: 3125.25, 5101.35 , 5160.011, 5164.758, 5167.13
Prior Effective Dates: 09/01/1976, 10/01/1979, 06/01/1980, 06/02/1980, 10/01/1981, 05/01/1982, 05/02/1982, 10/01/1982, 07/01/1983, 08/01/1983, 11/01/1983 (Temp.), 01/01/1984, 03/01/1984 (Temp.), 06/01/1984, 10/01/1984 (Emer.), 10/03/1984 (Emer.), 12/22/1984, 02/01/1985 (Emer.), 04/01/1987, 04/01/1989, 10/01/1989, 11/01/1989 (Emer.), 01/29/1990, 04/01/1991, 10/01/1991, 06/01/1993, 06/01/1997, 05/15/1999, 06/01/2003, 09/01/2008, 07/01/2011 (Emer.), 01/01/2012, 02/28/2014