2006 Ohio Revised Code - 5111.06. Department to act by adjudication order; appeals; exceptions; withholding payment.

§ 5111.06. Department to act by adjudication order; appeals; exceptions; withholding payment.
 

(A) (1)  As used in this section and in sections 5111.061 [5111.06.1] and 5111.062 [5111.06.2] of the Revised Code: 

(a) "Provider" means any person, institution, or entity that furnishes medicaid services under a provider agreement with the department of job and family services pursuant to Title XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended. 

(b) "Party" has the same meaning as in division (G) of section 119.01 of the Revised Code. 

(c) "Adjudication" has the same meaning as in division (D) of section 119.01 of the Revised Code. 

(2) This section does not apply to any action taken by the department of job and family services under sections 5111.35 to 5111.62 of the Revised Code. 

(B)  Except as provided in division (D) of this section and section 5111.914 [5111.91.4] of the Revised Code, the department shall do either of the following by issuing an order pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code: 

(1) Enter into or refuse to enter into a provider agreement with a provider, or suspend, terminate, renew, or refuse to renew an existing provider agreement with a provider; 

(2) Take any action based upon a final fiscal audit of a provider. 

(C)  Any party who is adversely affected by the issuance of an adjudication order under division (B) of this section may appeal to the court of common pleas of Franklin county in accordance with section 119.12 of the Revised Code. 

(D)  The department is not required to comply with division (B)(1) of this section whenever any of the following occur: 

(1) The terms of a provider agreement require the provider to have a license, permit, or certificate issued by an official, board, commission, department, division, bureau, or other agency of state government other than the department of job and family services, and the license, permit, or certificate has been denied or revoked. 

(2) The provider agreement is denied, terminated, or not renewed pursuant to division (C) or (E) of section 5111.03 of the Revised Code; 

(3) The provider agreement is denied, terminated, or not renewed due to the provider's termination, suspension, or exclusion from the medicare program established under Title XVIII of the "Social Security Act," and the termination, suspension, or exclusion is binding on the provider's participation in the medicaid program; 

(4) The provider agreement is denied, terminated, or not renewed due to the provider's pleading guilty to or being convicted of a criminal activity materially related to either the medicare or medicaid program; 

(5) The provider agreement is denied, terminated, or suspended as a result of action by the United States department of health and human services and that action is binding on the provider's participation in the medicaid program; 

(6) The provider agreement is terminated or not renewed because the provider has not billed or otherwise submitted a medicaid claim to the department for two years or longer, and the department has determined that the provider has moved from the address on record with the department without leaving an active forwarding address with the department. 

In the case of a provider described in division (D)(6) of this section, the department may terminate or not renew the provider agreement by sending a notice explaining the department's proposed action to the address on record with the department. The notice may be sent by regular mail. 

(E)  The department may withhold payments for services rendered by a medicaid provider under the medical assistance program during the pendency of proceedings initiated under division (B)(1) of this section. If the proceedings are initiated under division (B)(2) of this section, the department may withhold payments only to the extent that they equal amounts determined in a final fiscal audit as being due the state. This division does not apply if the department fails to comply with section 119.07 of the Revised Code, requests a continuance of the hearing, or does not issue a decision within thirty days after the hearing is completed. This division does not apply to nursing facilities and intermediate care facilities for the mentally retarded as defined in section 5111.20 of the Revised Code. 
 

HISTORY: RC § 5101.51.4, 138 v H 204 (Eff 7-30-79); RC § 5111.06, 138 v H 176 (Eff 7-1-80); 141 v H 428 (Eff 12-23-86); 142 v S 196 (Eff 10-20-87); 143 v H 822 (Eff 12-13-90); 148 v H 471. Eff 7-1-2000; 150 v H 95, § 1, eff. 6-26-03; 151 v H 66, § 101.01, eff. 7-1-05, 10-1-05.
 

The effective date is set by § 612.57 of 151 v H 66. 

The effective date is set by section 182 of H.B. 95 (150 v  - ). 

Not analogous to former RC § 5111.06 (GC § 6289-5; 119 v 384; Bureau of Code Revision, 10-1-53), repealed 128 v 645, § 2, eff 9-7-59.

 

Effect of Amendments

151 v H 66, effective October 1, 2005, except the amendment to (A)(1) that inserts the reference to 5111.061, effective June 30, 2005, added "and in sections 5111.061 and 5111.062 of the Revised Code" to the end of the introductory language of (A)(1); inserted "and section 5111.914 of the Revised Code" in the introductory language of (B); and added (D)(6). 

H.B. 95, Acts 2003, effective June 26, 2003, substituted "as defined in section 5111.20" for "subject to sections 5111.20 to 5111.32" in (E).