Current through Reg. 49, No. 38; September 20, 2024
(a) A person excluded from the Medicaid
program, Titles V, XVIII, XIX, XX, CHIP, or any other HHS program may submit to
the OIG a written request for reinstatement at any time after the period of
exclusion has ended. The request for reinstatement must establish good cause
for granting reinstatement.
(b) The
OIG may require the requestor to furnish specific information and authorization
for the OIG to obtain information from private health insurers, peer review
bodies, probation officers, professional associates, investigative agencies,
and others as may be necessary to determine whether reinstatement should be
granted.
(c) The request for
reinstatement may be approved, abated, postponed, or denied by the OIG. The OIG
grants reinstatement only if it is reasonably certain that the types of actions
that formed the basis for the original exclusion have not recurred and will not
recur. In making this determination, the OIG considers:
(1) the conduct of the provider or person
before and after the date of the notice of exclusion;
(2) whether all fines, damages, penalties,
and any other debts due and owing to any federal, state, or local government
have been paid, or satisfactory arrangements have been made that fulfill these
obligations;
(3) the accessibility
of other health care to the recipient population that would be served by the
person who has been excluded;
(4)
the person's previous conduct, including conduct during participation in the
Titles V, XVIII, XIX, XX, CHIP, and any HHS programs in any state, or any
conduct or action for which a sanction could have been taken, as described in
this subchapter;
(5) any previous
criminal convictions of the person regardless of its relation to Titles V,
XVIII, XIX, XX, CHIP, or other HHS programs;
(6) whether the person complies with or has
made satisfactory arrangements to fulfill the applicable conditions of
participation or supplier conditions for coverage under the statutes and
regulations;
(7) whether the person
has, during the period of exclusion, submitted claims, or caused claims to be
submitted or payment to be made by the Medicaid program or any state health
care program, for items or services the excluded party furnished, ordered or
prescribed, including health care administrative services;
(8) whether a person has, during the period
of exclusion, submitted claims or caused claims to be submitted or payments to
be made by the Medicaid program or any state health care program for items or
services furnished, ordered, or prescribed, including administrative and
management services or salary, during the period of exclusion and before
reinstatement has been granted and re-enrollment completed; and
(9) any other factors or circumstances deemed
by the OIG to be relevant to the determination of reinstatement.
(d) If an entity, association, or
affiliation seeks reinstatement, and any affiliate of that entity, as defined
by §RSA
371.1607 of this subchapter (relating to
Definitions), was also excluded on grounds arising out of the same program
violations, the OIG may approve reinstatement of the entity, association, or
affiliation if the OIG determines that the excluded principal for the entity or
association:
(1) has terminated its ownership
or control interest in the entity;
(2) is no longer an officer, director, agent,
consultant, managing employee, or bears any other title with the same duties,
ownership, or control of the entity; or
(3) has been reinstated in accordance with
this section.
(e)
Notice.
(1) Approval of request for
reinstatement. If the OIG approves the request for reinstatement, the OIG
provides written notice to the excluded person and enters the fact of that
person's reinstatement into the OIG exclusion database. The OIG must support a
determination granting reinstatement after termination with written findings
that support the decision. The notice of approval includes :
(A) any conditions precedent to reinstatement
and the date by which they must be satisfied;
(B) any limiting conditions on the person's
continued participation in the Medicaid program;
(C) the provider's obligations to re-enroll
as a Medicaid provider; and
(D) the
effective date of reinstatement.
(2) Denial of request for reinstatement. If
the OIG denies a request for reinstatement, it gives written notice to the
requesting person, which includes :
(A)
notice of the denial; and
(B) a
description of the person's right to a desk review.
(3) Desk review results. After concluding a
desk review, the OIG issues written notice to the provider which includes :
(A) notice of approval of reinstatement as
specified in paragraph (1) of this subsection; or
(B) notice the request was denied and that a
subsequent request for reinstatement will not be considered until at least one
year after the date of denial.
(f) Due process.
(1) The excluded person may submit a request
for a desk review of a denial of reinstatement. The request must be received by
the OIG within 30 calendar days of receipt of the notice of denial. The request
must include any documentary evidence and written argument against the
continued exclusion. Upon timely receipt of a request for desk review, the OIG
reviews the evidence and argument and notify the person of the
results.
(2) The denial of
reinstatement is an administrative action, not a sanction. A reinstatement
decision does not give rise to additional due process or notice
requirements.
(3) A determination
with respect to reinstatement is not subject to administrative or judicial
review.
(g) Scope and
effect of reinstatement.
(1) Reinstatement is
not effective unless the OIG approves the request and provides notice under
this section. Reinstatement is effective as provided in the notice. The
provider may apply for re-enrollment on or after the effective date of
reinstatement.
(2) An excluded
person may not be granted a contract or provider agreement in the Medicaid
program unless and until:
(A) reinstatement is
approved by the OIG;
(B) the
exclusion status is removed; and
(C) the person re-enrolls and is admitted as
a provider.
(3) If a
person circumvents or attempts to circumvent the reinstatement and reenrollment
requirements specified in subsections (a), (b), and (e) of this section and
receives or uses another Medicaid program provider number before being
reinstated, the person may be excluded without prior notice. The person may
also be subject to recoupment of all of the Medicaid provider payments made to
that provider number and imposition of administrative penalties.
(4) If a person submits claims or causes
claims to be submitted or payments to be made by the programs for items or
services furnished, ordered or prescribed, including administrative and
management services or salary, during the period of exclusion and before
reinstatement has been granted and re-enrollment completed, the OIG may deny
reinstatement on that basis. This section applies regardless of whether a
person has obtained a program provider number or equivalent, either as an
individual or as a member of a group, prior to being reinstated. The person is
subject to imposition of recoupment of any payments made and administrative
penalties.
