Ohio Administrative Code|Rule 5160-57-04 | Medicaid provider incentive program (MPIP): program integrity and provider appeals.

                                                
(A) Program integrity.
(1) MPIP legal
			 notice.
(a) All eligible professionals and eligible hospitals submitting
				an application to receive an MPIP payment are required to sign the MPIP legal
				notice before confirming and submitting their application.
(b) All program applicants are bound by the requirements of the
				MPIP legal notice.
(2) Eligible professional
			 and eligible hospital MPIP applications and attestations are subject to
			 verification by the Ohio department of medicaid (ODM).
(3) For any given payment
			 year an eligible professional and eligible hospital must register for MPIP by
			 the end of the calendar year (CY) for an eligible professional and federal
			 fiscal year (FFY) for an eligible hospital.
(4) An eligible
			 professional and eligible hospital will have sixty days after the end of the CY
			 for an eligible professional and FFY for and eligible hospital to complete
			 attestation via the MPIP system for a given payment year.
(5) Post payment audits
			 and record retention.
(a) An eligible professional's and eligible hospital's
				MPIP application and attestation are subject to a post payment
				audit.
(b) ODM or its designee, the state auditor's office, the
				state attorney general's office and the federal centers for medicare and
				medicaid services (CMS) may conduct reviews and audits of MPIP applications for
				the purpose of determining compliance with the requirements of this chapter as
				well as with applicable state and federal requirements.
(c) Audits and reviews may be conducted on-site as determined
				necessary based on periodic analysis of medical, financial, and other
				information.
(d) Records stored electronically must be produced at the
				eligible professional's or eligible hospital's expense, upon request,
				in the format specified by ODM.
(e) All records must be maintained for a minimum of seven years
				following the last day of the CY for eligible professionals or FFY for eligible
				hospitals in which payment related to the attestation has been received, or in
				the event that the eligible professional or eligible hospital has been notified
				that state or federal authorities have commenced an audit or investigation of
				their MPIP application, until such time as the matter under audit, appeal or
				investigation has been resolved.
(f) An eligible professional and eligible hospital must comply
				with all audit recoveries.
(6) Fraud, waste, and
			 abuse.
(a) Suspicion or detection of fraud and abuse by ODM will be
				referred to the medicaid fraud control unit (MFCU) in the office of the
				attorney general (AG). Referrals to the MFCU will be investigated for
				prosecutorial merit.
(b) Substantiated cases of fraud and abuse will be prosecuted
				according to federal and state regulations.
(B) Provider appeals.
(1) An eligible
			 professional or eligible hospital may appeal the following issues related to
			 MPIP, by first requesting an informal review:
(a) Incentive payment amounts.
(b) Provider eligibility determinations (i.e. patient volume,
				hospital-based).
(c) Demonstration of adoption, implementation, or upgrade, and
				meaningful use eligibility.
(2) Appeals filed after
			 the deadlines specified in paragraphs (B)(3)(a) and (B)(4)(a) of this rule,
			 will be dismissed without the ability to refile. If the deadline falls on a
			 saturday, sunday, state or federal holiday, the period for requesting an appeal
			 will be extended to the next business day.
(3) Informal review.
(a) If the MPIP system has made a preliminary determination that
				may be adverse regarding the incentive payment application of an eligible
				professional or eligible hospital, the eligible professional or eligible
				hospital may request an informal review of the preliminary determination via
				the MPIP system, within fifteen calendar days of notification of an adverse
				preliminary determination.
(b) A request for informal review shall be made via the MPIP
				system and may include supporting documentation to support the
				request.
(c) An eligible professional or eligible hospital will be
				notified of the informal review decision via email and will be advised to log
				into the MPIP system to see the details of the review decision.
(d) An eligible professional or eligible hospital may withdraw
				the request for an informal review via the MPIP system, without reason, at any
				time, after the initial filing and before an informal review decision is
				issued.
(4) Request for
			 reconsideration.
(a) If the informal review upholds the preliminary adverse
				determination and the eligible professional or eligible hospital does not agree
				with the informal review decision, the eligible professional or eligible
				hospital may submit a written request for reconsideration no later than fifteen
				calendar days after the date of notification of determination via the MPIP
				system.
(b) The request for reconsideration shall be initiated via the
				MPIP system and must include a written and signed letter from the eligible
				professional or eligible hospital containing the following
				information:
(i) Clear identification
				  of the affected eligible professional or eligible hospital;
(ii) The proposed action
				  being contested;
(iii) The basis for
				  requesting reconsideration; and
(iv) Supporting
				  documentation being submitted.
(c) The written request for reconsideration must be signed,
				dated, include any supporting documentation and must be uploaded via the MPIP
				system.
(d) An eligible professional or eligible hospital will be
				notified in writing, by certified mail, of the reconsideration
				decision.
(5) In accordance with Chapter 2505. of
			 the Revised Code, an eligible professional or eligible hospital may appeal the
			 reconsideration decision by filing a notice of appeal with the court of common
			 pleas of Franklin county. The notice shall identify the decision being appealed
			 and the specific grounds for the appeal. The notice of appeal shall be filed
			 not later than fifteen days after the department mails its notice of the
			 reconsideration decision. A copy of the notice of appeal shall be filed with
			 the department not later than three days after the notice is filed with the
			 court.