Structural Reviews
PCG is the Ohio Department of Medicaid’s (ODM) designee responsible for conducting various provider oversight activities for the state of Ohio. PCG conducts onsite visits, incident investigations, and structural reviews for ODM-Administered Waiver services.
Learn more about structural reviews conducted by PCG.
PCG conducts periodic reviews of all ODM-Administered Waiver providers. These reviews can be announced or unannounced. Providers may also be required to participate in a structural review when there are health or welfare issues involving the provider and an ODM-administered individual on a waiver program or for any other provider performance issue.
Agency providers that are not certified by Medicare or another accrediting organization must have a structural review every two years. This includes all providers that perform specialty services (out of home respite, respite, home modifications, home-delivered meals, etc.)
Non-agency providers must participate in structural reviews annually.
Structural reviews are meetings between PCG and the provider, which include review of the provider’s documentation and supporting evidence to ensure:
Compliance with the Ohio Administrative Code (OAC) rules for provider performance for the delivery of the services,
Adherence to providing and billing for services as authorized, and
Review of the clinical documentation to support reimbursement of services.
Reviews are also a time for providers to learn about any recent rule changes or initiatives from ODM. If PCG identifies rule violations or other non-compliance during the review, the provider will be required to submit a Plan of Correction.
Tips to Prepare for Your Structural Review
1. Secure and retain all required documentation throughout the year.
If you regularly keep track of your clinical documentation, it will be easier to gather and submit the requested documents during your review. Additionally, be sure to carefully review all documentation to ensure it has been completed thoroughly and in accordance with OAC rule requirements.
2. Communicate changes and obtain authorizations at the time of service with the Case Manager.
Ensure that any modifications and authorizations are promptly communicated and recorded in the Person-Centered Service Plan. It is a good idea to keep a copy of your conversation with the Case Manager in your clinical record.
3. Confirmation letter for scheduled review.
You will receive a confirmation letter once your review is scheduled. Before the review, your Reviewer will email you with a list of documents you will need to send prior to your review.
4. Seek clarification and ask questions during the review.
If something is unclear or if you have questions, don’t be afraid to ask for more information. If you have questions about the structural review process, feel free to reach out to your Reviewer or PCG at 877-908-1746.
5. Non-compliance findings and Structural Review Report.
If any non-compliance issues are identified during your review, you will receive a Structural Review Report with these issues explained. You will have 45 days to complete a Plan of Correction. This plan should outline how you will ensure compliance going forward.
6. Keep your Provider Agreement in good standing.
Providers are required to participate in a structural review, even if you are not currently providing services. Keep your contact information up to date in the Provider Network Management (PNM) system so PCG is able to contact you when it’s time for your review.
Interested in learning more about preparing for your structural review? Review our CE training course Managing Your Provider Business here.