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RULE §371.1717Reinstatement

(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 §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.

Source Note: The provisions of this §371.1717 adopted to be effective October 14, 2012, 37 TexReg 7989; amended to be effective April 15, 2014, 39 TexReg 2833; amended to be effective May 1, 2016, 41 TexReg 2941

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