(a) The OIG uses a screening level of "Limited," "Moderate,"
or "High" risk, assigned in accordance with §352.9 of this title
(relating to Screening Levels) to determine the verifications and
further screening required under §371.1009 of this subchapter
(relating to Verifications Required for Each Screening Level).
(b) Case-by-case recommendation of screening levels.
For any enrollment application, the OIG may, in its sole discretion
and on a case-by-case basis, recommend that HHSC assign a higher or
lower screening level in accordance with §352.9(b) of this title
if the OIG determines in its discretion that the applicant may pose
an increased risk of committing fraud, waste, or abuse or may demonstrate
unfitness to provide or bill for medical assistance items or services.
The OIG may make such a recommendation after considering all circumstances,
including the applicant's criminal, regulatory, and administrative
sanction history, as well as the following, if applicable:
(1) The applicant or any person required to be disclosed
in the enrollment application is under a payment suspension based
on a credible allegation of fraud.
(2) The applicant or any person required to be disclosed
in the enrollment application has failed to repay any overpayments
incurred under Medicaid, CHIP, or other HHS programs.
(3) The applicant or any person required to be disclosed
in the enrollment application was excluded from participation in Medicaid,
CHIP, or other HHS program during the ten years before the date of
the enrollment application.
(4) The applicant is seeking enrollment as a provider
type that was subject to a state or federal temporary moratorium,
if the moratorium was lifted within six months before the date of
the enrollment application.
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