Library: Policy

317:2-3-7. Obligation to pay costs of services

Revised 7-1-23

(a) In accordance with 42 C.F.R. § 438.420(d), the CE and DBM may recover from the member the costs of services provided to the member while an appeal or state fair hearing is pending:

(1) To the extent the services were continued solely due to the requirements set forth in 42 C.F.R. §§ 438.420 or §431.230(b); and

(2) The final resolution of the appeal or state fair hearing upholds the CE or DBM's adverse benefit determination.

(b) If OHCA or the CE and DBM reverses a decision to deny, limit, or delay services and these services were not furnished while the appeal or state fair hearing was pending, the CE and DBM will authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires.

(c) If OHCA or the CE and DBM reverses a decision to deny, limit, or delay services and the member received the disputed services while the appeal or state fair hearing was pending, the CE and DBM will pay for these services.