Summary
Requires automated checks for alternative primary insurance before Medicaid claims are paid. When the Department uses automated review tools for specified eligibility, claims and provider-integrity functions, an appropriate Department employee must review the findings before action. Directs rulemaking on insurance-discovery engines and processing.
Healthcare Implications
Ohio Medicaid and managed care claims workflows must screen for other primary coverage before payment. Covered Department decisions cannot take effect automatically from an AI or other automated tool; human review must confirm correctness. This is program-integrity governance, rather than a requirement for clinician review of medical necessity.
Operational Implications
- For the functions specified in R.C. 5162.90 and 5164.11, the Department of Medicaid must not act automatically on automated-review findings; the responsible Department employee must first review and confirm the determination.
- The Department of Medicaid must adopt implementing rules for R.C. 5162.19, including standards for approved insurance-discovery engines, claims-processing timelines and reporting.