Title: Section 504.5 - Denial of an application.
504.5 Denial of an application. (a) In determining whether to enter into a contract with an applicant, the department shall consider the following factors with respect to the applicant and any affiliated person:
(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 an applicant has entered into a plan of restitution of such overpayments, an application may not be denied based solely on this factor unless the 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) a pending 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 of having engaged in an unacceptable practice in the medical assistance program, another state's Medicaid program, the Medicare program or any other publicly funded program;
(10) a pending indictment for, or prior conviction of, any crime relating to the furnishing of or billing for medical care, services or supplies, or a determination of having engaged in an unacceptable practice in the medical assistance program;
(11) a prior finding by a licensing, certifying or professional standards board or agency of the violation of the standards or conditions relating to licensure or certification or as to the quality of services provided;
(12) any prior pattern or practices in furnishing medical care, services or supplies and any prior conduct under any private or publicly funded program or policy of insurance;
(13) any other factor having a direct bearing on the applicant's ability to provide high-quality medical care, services or supplies to recipients of medical assistance benefits, or to be fiscally responsible to the program for care, services or supplies to be furnished under the program including actions by persons affiliated with the applicant;
(14) any other factor which may affect the effective and efficient administration of the program, including, but not limited to, the current availability of medical care, services or supplies to recipients
(taking into account geographic location and reasonable travel time).
(b) If any application is denied, the applicant shall be given a written notice of the denial, stating the reason or reasons for the denial. The written notice of denial will be effective upon the date it is mailed to the applicant.
(c) Denial of an application shall preclude the applicant from submitting claims for payment under the medical assistance program either directly, or indirectly through any other person. Any claims submitted by such applicant or such other person and paid by the department shall constitute overpayments.
(d) If an application has been denied, the applicant may reapply only upon correction of the factors leading to its denial, or after two years if the factors relate to prior conduct of the applicant or an affiliated person.
(e)(1) If an application is denied, the applicant may appeal the denial by filing a written request for reconsideration with the department within 45 days of the date of the notice of denial. A timely request stays any action to terminate a provider currently participating in the medical assistance program pending the decision on reconsideration.
(2) The request for reconsideration must include all information which the applicant wishes to be considered in the reconsideration, including any documentation or arguments which would controvert the reason for the denial or disclose that the denial was based upon a mistake of fact.
(3) The department will review its determination to deny enrollment and issue a written determination after reconsideration within 60 days of receipt of the request. The determination after reconsideration may affirm, revoke or modify the denial and will be the final decision of the department.
VOLUME C (Title 18)