Current through Register Vol. 46, No. 12, March 20, 2024
(a) In
determining whether to enter into a contract with a pharmacy-applicant, the
following factors shall be grounds for denial of an application:
(1) any false representation or omission of
any material fact in making the application;
(2) any previous or current suspension,
exclusion or involuntary withdrawal from participation in the medical
assistance program or the Medicaid program of any other state of the United
States or from participation in any other governmental or private medical
insurance program, including but not limited to Medicare, workers'
compensation, physically handicapped children's program and rehabilitation
services;
(3) the receipt of, but
not having made restitution for, a Medicaid or Medicare overpayment, as
determined to have been made pursuant to a final decision or determination of
an agency having the powers to conduct the proceeding and after an adjudicatory
proceeding in which no appeal is pending or after resolution of the proceeding
by stipulation or agreement; however, if a pharmacy-applicant has entered into
a plan of restitution of such overpayment, an application may not be denied
based solely on this factor unless the pharmacy-applicant has defaulted in
repayment;
(4) any false
representation or omission of a material fact in making application in any
state of the United States for any license, permit, certificate or registration
related to a profession or business;
(5) any previous failure to correct
deficiencies in the operation of a business or enterprise after having received
written notice of the deficiencies from a State or Federal licensing or
auditing agency;
(6) any failure to
supply further information concerning the application after receiving a written
request for such further information;
(7) the submission of an application which
conceals an ownership or control interest of any person who would otherwise be
ineligible to participate;
(8) an
outstanding indictment for, or prior conviction of, any crime relating to the
furnishing of, or billing for, medical care, services or supplies, or which is
considered an offense involving theft or fraud or an offense against public
administration or against public health and morals;
(9) a prior finding by a licensing,
certifying or professional standards board or agency of the violation of the
standards or conditions relating to licensing or certification or as to the
quality of services provided;
(10)
the pharmacy-applicant's prior pattern or practices in furnishing medical care,
services or supplies under any private or publicly funded program or policy of
insurance; and
(11) any other
factor having a direct bearing on the pharmacy-applicant's ability to provide
high-quality pharmaceutical services to participants in the program, or to be
fiscally responsible under the program, including actions by persons affiliated
with the pharmacy-applicant.
(b) If any application is denied, the
pharmacy-applicant shall be given a written notice of the denial, stating the
reason or reasons for the denial, within three days of the determination to
deny the application. The written notice of denial will be effective upon the
date it is mailed to the pharmacy-applicant.
(c) The pharmacy-applicant may request a
reconsideration of a denial by submitting a written request for a
reconsideration to the executive director within 30 days of the date of the
denial. The request shall include all arguments and documentation which the
pharmacy-applicant wishes to be considered in its behalf. A written
determination of acceptance or denial of the application shall be issued by the
executive director within 60 days of receipt of the request for
reconsideration, stating the basis for the determination and the reasons for
affirming or reversing the initial determination.
(d) If an application has been denied, the
pharmacy-applicant may reapply only upon correction of the factors leading to
its denial, or after one year if the factors relate to prior conduct of the
pharmacy-applicant or an affiliated person.
(e) Denial of an application shall preclude
the pharmacy-applicant from submitting claims for payment under the program
either directly, or indirectly through any other person. Any claims submitted
by such pharmacy-applicant or such other person and paid by the contractor
shall constitute overpayments.
