Current through Register No. 40, October 3, 2024
(a) NH medicaid providers and provider
applicants shall meet the provider participation requirements contained in He-W
530 through He-W 577, as applicable, for providers of the type of services they
will be providing, as well as requirements in
He-W
520.06.
(b) The following individuals and entities
shall be subject to a risk determination described in (c) below:
(1) NH medicaid providers enrolled as of
November 1, 2016 who submitted their provider enrollment application to the
department's fiscal agent on or after August 1, 2015 through October 31,
2016;
(2) NH medicaid provider
applicants;
(3) NH medicaid
providers who are applying to enroll a new practice location(s);
(4) NH medicaid providers who are
re-enrolling; and
(5) NH medicaid
providers being revalidated in accordance with
42 CFR
455.414.
(c) Individuals and entities in (b) above who
meet either of the following criteria shall be determined to be high risk
providers or high risk provider applicants:
(1) The individual or entity, with the
exception of those who are undergoing revalidation in accordance with
42 CFR
455.414, provides home health services or
durable medical equipment services; or
(2) The individual's or entity's risk level
was adjusted to high by the department as required by
42 CFR
455.450(e) (1) because any
of the following occurred:
a. The department
imposed a payment suspension on the individual or entity based on credible
allegation of fraud, waste, or abuse;
b. The individual or entity has an existing
medicaid overpayment;
c. The
individual or entity was excluded from participation in a federally funded
program by the office of inspector general or another state's medicaid program
within the 10 years preceding the date of application or date of revalidation;
or
d. In accordance with
42 CFR
455.450(e) (2) , NH medicaid
or the Centers for Medicare and Medicaid Services (CMS) in the previous 6
months lifted a temporary moratorium for the particular provider type and a
provider that was prevented from enrolling based on the moratorium applies for
enrollment as a provider within 6 months from the date the moratorium was
lifted.
(d)
The following individuals and entities shall be subject to a state and federal
criminal background check, including fingerprinting, in accordance with this
section:
(1) Persons with a direct or
indirect ownership interest in a high risk provider or high risk provider
applicant described in (c) (1) above; and
(2) High risk providers or high risk provider
applicants described in (c) (2) above.
(e) Those who meet the criteria in (d) above
shall not be subject to an additional criminal background check, including
fingerprinting, if, within the previous 36 months, they have undergone a
criminal background check as required by:
(1)
A Medicare administrative contractor;
(2) NH medicaid;
(3) Any other state's medicaid agency, and
the department is able to access the information from the other state's
medicaid agency; or
(4) Any other
state's children's health insurance program (CHIP), and the department is able
to access the information from the other state's CHIP.
(f) Those who meet the criteria in (d) above,
and who are not excluded in (e) above, shall be notified in writing of the
following by the department:
(1) That a state
and federal criminal background check, including fingerprinting, is
required;
(2) Where the criminal
background check, including fingerprinting, can be conducted as specified in
(h) (1) below; and
(3) The deadline
by which the criminal background check, including fingerprinting, shall be
conducted as specified in (g) below.
(g) The deadline for undergoing a criminal
background check, including fingerprinting, shall be 30 days from the date of
the notification in (f) above.
(h)
Those who meet the criteria in (d) above, and who are not excluded in (e)
above, shall undergo a state and federal criminal background check by:
(1) Having a complete set of electronic
fingerprints taken at any location maintained by the NH state police criminal
records unit that has electronic fingerprinting capability, or by any other in
or out of state law enforcement agency that conducts fingerprinting
electronically; and
(2) Completing
and submitting to the location in (1) above a notarized Form DSSP 417, "New
Hampshire Health and Human Services Criminal History Record Information
Authorization," incorporated by reference in
Saf-C
5703.10, Table 5700-1, which authorizes the release of
the individual's criminal history record, if any, to the department.
(i) Those who meet the criteria in
(d) above shall be terminated from, or denied enrollment in, the NH medicaid
program if:
(1) The individual fails to get
fingerprinted by the deadline in (g) above, as applicable; or
(2) The results of the criminal background
check indicate that the individual has been convicted of any of the following
federal or state felony offenses within the 10 years preceding the date of
application or date of revalidation of enrollment:
a. Felony crimes against persons, such as
murder, sexual assault, assault, interference with freedom, destruction of
property, unauthorized entries, robbery and theft, fraud and corruption, and
other similar crimes for which the individual was convicted, including guilty
pleas;
b. Financial crimes, such as
extortion, embezzlement, income tax evasion, insurance fraud, and other similar
crimes for which the individual was convicted, including guilty pleas;
or
c. Any felony that placed the
medicaid program or its recipients at immediate risk, such as a malpractice
suit that results in a conviction of criminal neglect or misconduct.
(j) An individual or
entity being terminated from, or denied enrollment in, the NH medicaid program
in accordance with (i) above shall receive a written notice from the department
of the denial or termination.
(k)
The notice in (j) above shall contain:
(1)
The reason for, and legal basis of, the denial or termination; and
(2) Information that an appeal of the denial
or termination may be requested, in accordance with He-C 200, within 30
calendar days of the date on the notice of the denial or termination.
(l) Appeals of the results of the
criminal background check shall be made in accordance with the department of
safety rules at Saf-C 5703.12.
