| (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.
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