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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-71. Hearings for recovery of overpayments |
5160-71-01. Chapter 119 hearings conducted under authority of section 5111.914 of the Revised Code: definitions and scope of applicability
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(A) The following definitions apply to Chapter 5101:6-51 of the Administrative Code.
(1) "Affected party" means a person whose interests are subject to an adjudication by the Ohio department of job and family services (ODJFS) under authority of section 5111.914 of the Revised Code.
(2) "Appellant" means an affected party who has requested an adjudication hearing pursuant to Chapter 119. of the Revised Code.
(3) "Department" means ODJFS.
(4) "Depository agent" means the official mailing address of the office of legal and acquisition services of ODJFS for the purpose of receiving correspondence or filings for any hearing held under authority of section 5111.914 of the Revised Code.
(5) "Director" means the director of ODJFS or the director's designee.
(6) "Hearing" means a hearing held by an issuing state agency under authority of section 5111.914 of the Revised Code and that is in compliance with sections 119.06 to 119.13 of the Revised Code.
(7) "Issuing state agency" means a state agency that has entered into a contract with ODJFS under section 5111.91 of the Revised Code and that has issued a notice of overpayment under authority of section 5111.914 of the Revised Code. This shall not include a political subdivision directly or by contract.
(8) "ODJFS" means the Ohio department of job and family services.
(9) "Order" means an adjudication issued by ODJFS of the facts and/or sums in controversy in any hearing conducted by an issuing state agency under the authority of section 5111.914 of the Revised Code that is a final disposition of the director as regard to the rights, duties, privileges, benefits, legal relationships, jurisdictional status, or standing of any appellant of a proceeding initiated under authority of section 5111.914 of the Revised Code.
(10) "Person" means a person, firm, corporation, association, or partnership.
(11) "Provider" means any person, institution or entity, governmental or non-governmental, that furnishes medicaid services under a provider agreement with ODJFS pursuant to Title XIX of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1396, as amended.
(12) "Provider agreement" means a contract between ODJFS and a provider of medical services and supplies pursuant to rules contained in Chapter 5101:3-1 of the Administrative Code.
(13) "Repayment due date" means the date that payment is due to the state based upon notification of an identified overpayment. The repayment due date shall be established as follows:
(a) If a settlement is reached in accordance with section 5111.914 of the Revised Code, the repayment shall be due no later than the forty-fifth day after full execution of the settlement. A settlement is fully executed only after all parties to the settlement have signed the settlement and ODJFS has issued written approval of the settlement either by signing the settlement or by separate written approval.
(b) If settlement is not reached in accordance with section 5111.914 of the Revised Code, the repayment shall be due within forty-five days after the effective date of the adjudication order.
(B) Scope of applicability.
(1) Chapter 5101:6-51 of the Administrative Code prescribes the procedures to be followed in all hearings held before an issuing state agency pursuant to section 5111.914 of the Revised Code. The procedures set forth in Chapter 5101:6-51 of the Administrative Code shall be followed in all instances of notices of overpayments issued by the issuing state agency except as follows. The issuing state agency is not required to follow the procedures set forth in Chapter 5101:6-51 of the Administrative Code in cases where a provider requests one or more claims adjustments if all of the following conditions are met:
(a) The provider's request is not a request to negotiate, or to dispute a notice of overpayment, and
(b) The adjustments can be completed in full within forty-five days of the provider's request.
(2) An issuing state agency's proposed findings shall be limited to findings of overpayments for medicaid services where the alleged overpayments were made under the component of the medicaid program that the issuing state agency administers.
(3) Proposed findings issued under authority of section 5111.914 of the Revised Code are not a "final fiscal audit" as defined in rule 5101:6-50-01 of the Administrative Code.
(4) The right to a hearing pursuant to authority provided in section 5111.914 of the Revised Code is limited to an issuing state agency's proposal to recover a medicaid overpayment.
(5) The provisions of Chapter 5101:6-51 of the Administrative Code are to be interpreted and construed to achieve their general purpose of providing orderly and fair procedures for conducting hearings before a state agency.