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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-80. Rights and Procedures Applicable to Medical Assistance Recipients |
5160-80-01. Hearings conducted under authority of section 5160.37 of the Revised Code: definitions and scope of applicability
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(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.