Library: Policy

317:55-5-25. Claims processing and methodology; post payment audits

Revised 7-1-23

(a) Claims payment systems. The CE or DBM will maintain a claims payment system capable of processing and adjudicating claims for payment in an accurate and timely manner and in full compliance with all state and federal laws.

(b) Claim filing. A claim that is filed by a provider within six (6) months of the date the item or service was furnished will be considered timely, per OAC 317:30-3-11.

(1) The CE or DBM will ensure that at least ninety percent (90%) of clean claims received from all providers are paid within fourteen (14) days of receipt.

(2) A clean claim that is not processed within the time frame will bear simple interest at the monthly rate of one and one-half percent (1.5%), which is payable to the provider.

(d) Additional documentation. After a claim has been paid but not prior to payment, the CE or DBM may request medical records if additional documentation is needed to review the claim for medical necessity.

(e) Claim denials.

(1) A claim denial will include the following information:

(A) Detailed explanation of the basis for the denial; and

(B) Detailed description of the additional information necessary to substantiate the claim.

(2) The CE or DBM will establish a process for all claim denials by which the provider may identify and provide additional information to substantiate the claim.

(3) A provider will have six (6) months from the receipt of a claim denial to file an appeal per OAC 317:2-3-10.

(f) Post payment audits.

(1) In accordance with OAC 317:30-5-70.2, the CE or DBM will comply with the post payment audit process established by OHCA.

(2) The CE or DBM will adhere to limits set forth by OHCA regarding the percentage of claims that can be subjected to post payment audits.

(3) A CE or DBM who has a claims denial error rate of greater than five percent (5%) will be subject to damages as set forth by OHCA in the Contract.