Ohio Revised Code
Chapter 5165 | Medicaid Coverage of Nursing Facility Services
Section 5165.193 | Exception Review of Assessment Data.

Effective: September 29, 2013
Latest Legislation: House Bill 59 - 130th General Assembly
(A) The department of medicaid may, pursuant to rules authorized by this section, conduct an exception review of resident assessment data submitted by a nursing facility provider under section 5165.191 of the Revised Code. The department may conduct an exception review based on the findings of a medicaid certification survey conducted by the department of health, a risk analysis, or prior performance of the provider.
Exception reviews shall be conducted at the nursing facility by appropriate health professionals under contract with or employed by the department. The professionals may review resident assessment forms and supporting documentation, conduct interviews, and observe residents to identify any patterns or trends of inaccurate resident assessments and resulting inaccurate case-mix scores.
(B) If an exception review is conducted before the effective date of a nursing facility's rate for direct care costs that is based on the resident assessment data being reviewed and the review results in findings that exceed tolerance levels specified in the rules authorized by this section, the department, in accordance with those rules, may use the findings to redetermine individual resident case-mix scores, the nursing facility's case-mix score for the quarter, and the nursing facility's annual average case-mix score. The department may use the nursing facility's redetermined quarterly and annual average case-mix scores to determine the nursing facility's rate for direct care costs for the appropriate calendar quarter or quarters.
(C) The department shall prepare a written summary of any exception review finding that is made after the effective date of a nursing facility's rate for direct care costs that is based on the resident assessment data that was reviewed. Where the provider is pursuing judicial or administrative remedies in good faith regarding the finding, the department shall not withhold from the provider's current payments any amounts the department claims to be due from the provider pursuant to section 5165.41 of the Revised Code.
(D)(1) The medicaid director shall adopt rules under section 5165.02 of the Revised Code as necessary to implement this section. The rules shall establish an exception review program that does all of the following:
(a) Requires each exception review to comply with Title XVIII and Title XIX;
(b) Requires a written summary for each exception review that states whether resident assessment forms have been completed accurately;
(c) Prohibits each health professional who conducts an exception review from doing either of the following:
(i) During the period of the professional's contract or employment with the department, having or being committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of nursing facilities in this state;
(ii) Reviewing any provider that has been a client of the professional.
(2) For the purposes of division (D)(1)(c)(i) of this section, employment of a member of a health professional's family by a nursing facility that the professional does not review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of the nursing facility.

Structure Ohio Revised Code

Ohio Revised Code

Title 51 | Public Welfare

Chapter 5165 | Medicaid Coverage of Nursing Facility Services

Section 5165.01 | Definitions.

Section 5165.011 | Nursing Facility References.

Section 5165.02 | Rules.

Section 5165.03 | Admission of Mentally Ill Person to Nursing Facility.

Section 5165.031 | Hearing.

Section 5165.04 | Assessment to Determine Level of Care.

Section 5165.06 | Nursing Facility Eligibility.

Section 5165.07 | Provider Agreement Requirements.

Section 5165.071 | Facility Operator May Contract With More Than One Provider.

Section 5165.072 | Revalidation.

Section 5165.073 | Termination for Non-Compliance With Installation of Fire Extinguishing and Fire Alarm Systems.

Section 5165.08 | Nursing Facilities' Provider Agreement Terms.

Section 5165.081 | Action Against Facility for Breach of Provider Agreement or Other Duties.

Section 5165.082 | Qualification of Beds.

Section 5165.10 | Annual Cost Report.

Section 5165.101 | Cost of Franchise Permit Fee Not Reimbursable Expense.

Section 5165.102 | Fines Excluded From Cost Report.

Section 5165.103 | Completion of Cost Reports.

Section 5165.104 | Form of Cost Reports; Guidelines.

Section 5165.105 | Addendum for Disputed Costs.

Section 5165.106 | Termination for Failure to File Report.

Section 5165.107 | Amendments to Cost Reports.

Section 5165.108 | Desk Review of Cost Report.

Section 5165.109 | Audit.

Section 5165.1010 | Nursing Facility Fines.

Section 5165.15 | Calculation of Payments to Nursing Facility Providers.

Section 5165.151 | Initial Rates for New Nursing Facilities.

Section 5165.152 | Payments for Services Provided to Low Resource Utilization Residents.

Section 5165.153 | Rates for Outlier Facilities or Units.

Section 5165.154 | Calculating Prospective Rates for Facilities With Residents Whose Care Costs Are Not Adequately Measured.

Section 5165.155 | Amount of Payments for Dual Eligible Individuals.

Section 5165.156 | Centers of Excellence Component.

Section 5165.157 | Alternative Purchasing Model for Nursing Facility Services.

Section 5165.16 | Per Medicaid Day Payment Rate for Ancillary and Support Costs; Peer Groups.

Section 5165.17 | Per Medicaid Day Payment Rate for Reasonable Capital Costs.

Section 5165.19 | Per Medicaid Day Payment Rate for Direct Care Costs.

Section 5165.191 | Resident Assessment Data.

Section 5165.192 | Case-Mix Scores for Nursing Facilities.

Section 5165.193 | Exception Review of Assessment Data.

Section 5165.21 | Per Medicaid Day Payment Rate for Tax Costs.

Section 5165.23 | Critical Access Incentive Payments to Qualified Facilities.

Section 5165.26 | Nursing Facility's per Medicaid Day Quality Incentive Payment Rate.

Section 5165.261 | Nursing Facility Payment Commission.

Section 5165.28 | Rate for Added, Replaced, or Renovated Beds.

Section 5165.29 | Cost of Operating Rights for Relocated Beds Not Allowable Cost.

Section 5165.30 | Related Party Costs to Pass Through.

Section 5165.32 | Reduction in Rate Not Permitted.

Section 5165.33 | No Payment for Discharge Date.

Section 5165.34 | Payments Made to Reserve Bed During Temporary Absence.

Section 5165.35 | Payments Made to Facility for Services Provided After Involuntary Termination.

Section 5165.36 | Rebasing.

Section 5165.37 | Calculating Rates and Making Payments.

Section 5165.38 | Reconsideration of Rate.

Section 5165.40 | Adjustment of Rates.

Section 5165.41 | Redetermination of Rates.

Section 5165.42 | Additional Penalties.

Section 5165.43 | Determination of Interest Rate.

Section 5165.44 | Deductions.

Section 5165.45 | Deposits to General Revenue Fund.

Section 5165.46 | Administrative Adjudication.

Section 5165.47 | Claim for Medicaid Payment for Service Provided to Nursing Facility Resident.

Section 5165.48 | Nursing Facility Not Required to Submit Medicaid Claim for Medicare Cost-Sharing Expenses Under Certain Circumstances.

Section 5165.49 | Post-Payment Reviews of Nursing Facility Medicaid Claims.

Section 5165.50 | Notice of Facility Closure or Withdrawal of Participation.

Section 5165.501 | Compliance With Social Security Act Required.

Section 5165.51 | Notice of Change of Operator.

Section 5165.511 | Agreements With Entering Operators Effective on Date of Change of Operator.

Section 5165.512 | Agreements With Entering Operators Effective on a Later Date.

Section 5165.513 | Entering Operator Duties Under Provider Agreement.

Section 5165.514 | Exiting Operator Deemed Operator Pending Change.

Section 5165.515 | Provider Agreement With Operator Not Complying With Prior Agreement.

Section 5165.516 | Medicaid Reimbursement Adjustments; Change of Operator.

Section 5165.517 | Determination of Change of Operator for Purposes of Licensure Not Controlling.

Section 5165.52 | Overpayment Amounts Determined Following Notice of Closure, Etc.

Section 5165.521 | Withholding Amounts Owed From Medicaid Payments to Exiting Operator.

Section 5165.522 | Cost Report by Exiting Operator; Waiver.

Section 5165.523 | Failure to File Cost Report; Payments Deemed Overpayments.

Section 5165.524 | Final Payment Withheld Pending Receipt of Cost Reports.

Section 5165.525 | Determination of Debt of Exiting Operator; Summary Report.

Section 5165.526 | Release of Amount Withheld Less Amounts Owed.

Section 5165.527 | Release of Amount Withheld on Postponement of Change of Operator.

Section 5165.528 | Disposition of Amounts Withheld From Payment Due an Exiting Operator.

Section 5165.53 | Adoption of Rules Regarding Change in Operators.

Section 5165.60 | Definitions for Sections 5165.60 to 5165.89.

Section 5165.61 | Adoption of Rules.

Section 5165.62 | Enforcement of Provisions.

Section 5165.63 | Contracts With State Agencies for Enforcement.

Section 5165.64 | Annual Standard Surveys.

Section 5165.65 | Exit Interview With Administrator.

Section 5165.66 | Citations for Failure to Comply With One or More Certification Requirements.

Section 5165.67 | Survey Results.

Section 5165.68 | Statement of Deficiencies.

Section 5165.69 | Plan of Correction.

Section 5165.70 | On-Site Monitoring.

Section 5165.71 | Deficiencies Not Substantially Corrected.

Section 5165.72 | Uncorrected Deficiencies Constituting Severity Level Four Findings.

Section 5165.73 | Uncorrected Deficiencies Constituting Severity Level Three and Scope Level Three or Four Findings.

Section 5165.74 | Uncorrected Deficiencies Constituting Severity Level One or Two or Severity Level Three, Scope Level Two Finding.

Section 5165.75 | Imposing Remedies and Fines.

Section 5165.76 | Fine Collected if Termination Order Does Not Take Effect.

Section 5165.77 | Emergency Remedies.

Section 5165.771 | Special Focus Facility Program.

Section 5165.78 | Appointment of Temporary Resident Safety Assurance Manager.

Section 5165.79 | Terminating Provider Agreements.

Section 5165.80 | Transfer of Residents to Other Appropriate Care Settings.

Section 5165.81 | Qualifications of Temporary Manager of Nursing Facility.

Section 5165.82 | Residents to Whom Denial of Medicaid Payments Applies.

Section 5165.83 | Fines.

Section 5165.84 | Order Denying Payment When Deficiency Is Not Corrected Within Time Limits.

Section 5165.85 | Termination of Participation for Failure to Correct Deficiency Within Six Months.

Section 5165.86 | Delivery of Notices.

Section 5165.87 | Appeals.

Section 5165.88 | Confidentiality.

Section 5165.89 | Hearing on Transfer or Discharge of Resident Who Medicaid or Medicare Beneficiary.

Section 5165.99 | Penalty.