Title: Section 515.5 - Sanctions; effect.

515.5 Sanctions; effect. (a) No payments will be made to or on behalf of any person for the medical care, services or supplies furnished by or under the supervision of the person during a period of exclusion or in violation of any condition of participation in the program. In the case of a hospital, nursing home or home health care provider, the department may continue payments for up to 30 days after the date of exclusion for clients admitted prior to the exclusion or whose plan of care was implemented prior to the exclusion.

(b) No payment will be made for medical care, services or supplies ordered or prescribed by any person while that person is excluded, nor for any medical care, services or supplies ordered or prescribed in violation of any condition of participation in the program. The department may pay the first claim(s) submitted by or on behalf of a dispensing provider for care, services or supplies ordered or prescribed by an excluded person after the date of exclusion and notify the dispensing provider of the exclusion. The department may not pay for any care, services or supplies ordered or prescribed by an excluded person more than 20 days after the date of a notice of an exclusion to a dispensing provider.

(c) A person who is excluded from the program cannot be involved in any activity relating to furnishing medical care, services or supplies to recipients of medical assistance for which claims are submitted to the program, or relating to claiming or receiving payment for medical care, services or supplies during the period.

(d) Providers reimbursed on a cost-related basis may not claim as allowable costs any amounts paid or credited to any person who is excluded from the program or who is in violation of any condition of participation in the program.

(e) Providers reimbursed on a fee-for-services basis may not submit any claim and cannot be reimbursed for any medical care, services or supplies furnished by any person who is excluded from the program or which are furnished in violation of any condition of participation in the program.

 

Volume

VOLUME C (Title 18)

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