Library: Policy
317:55-5-2. Program integrity, data and reporting
Revised 7-1-23
(a) Program integrity standards. The CE and DBM shall comply with all state and federal laws, regulations, and mandates including but not limited to 42 C.F.R. § 438.608. The CE and DBM shall have and implement written policies and procedures that are designed to detect and prevent fraud, waste, and abuse pursuant to the Contract and federal regulations. The CE and DBM shall:
(1) Provide a monthly report (by close of the last calendar day of each month), of all open Program Integrity related audits and investigations related to fraud, waste, and abuse activities for identifying and collecting potential overpayments, utilization review, and provider compliance.
(2) Refer credible allegations of fraud to OHCA's Legal Division in writing within three (3) business days of discovery.
(3) Suspend all payments to the provider when a credible allegation of fraud exists.
(4) Participate in good faith at monthly Program Integrity meetings held jointly with MFCU and OHCA.
(5) Participate in good faith at monthly meetings with OHCA Program Integrity and Accountability Unit.
(6) Disclose any change in ownership and control information to OHCA within thirty-five (35) calendar days.
(7) Submit to OHCA or HHS, within thirty-five (35) days of request, full and complete information about:
(A) The ownership of any subcontractor with whom the CE/DBM has had business transactions totaling more than twenty-five thousand dollars ($25,000) during the twelve (12-month) period ending on the date of the request; and
(B) Any significant business transactions between the CE/DBM and any wholly owned supplier, or between the provider and any subcontractor, during the five (5-year) period ending on the date of request.
(b) Data and reporting standards.
(1) The CE and DBM shall:
(A) Provide information responsive to specific requests made by OHCA, MFCU, or other authorized state and federal authorities (including, but not limited to, requests for records of Health Plan Enrollee and provider interviews), within three (3) business days of said request, unless otherwise agreed upon by OHCA.
(B) Submit weekly encounter data by the deadline established by OHCA and in accordance with OHCA accuracy standards.
(C) Submit a required report timely and/or accurately.
(2) The CE or DBM shall not falsify or misrepresent information that it furnishes to CMS or OHCA.
(c) Request for information. The CE or DBM shall provide and prioritize requests for information made by OHCA, MFCU, or other authorized state and federal authorities. The CE or DBM shall respond to urgent requests from OHCA within twenty-four hours (24-hours) and according to guidance and timelines provided by OHCA.
(d) Record retention. The CE or DBM shall retain records for a period of ten (10) years as well as comply with all state and federal regulations and contractual requirements.
(e) Non-compliance actions. If the CE or DBM fails to submit any OHCA-requested materials, as specified in this Section, without cause as determined by OHCA, on or before the due date, OHCA may impose any or all the CE sanctions, found at OAC 317:55-5-10 and the CE Contract, or DBM administrative penalties, found at OAC 317:55-5-11 and the DBM Contract.
