10A N.C. Admin. Code 22F .0602 - ADMINISTRATIVE ACTIONS
(a) The following
types of administrative actions may be imposed in any particular order by the
Division in instances of program abuse by providers:
(1) warning letters for instances of abuse
that can be settled by issuing a warning to cease the specific abuse. The
letter shall state that any further violations shall result in administrative
or legal action initiated by the Division;
(2) suspension of a provider from further
participation in the Medicaid Program for a specified period of time, subject
to appeal rights under G.S. 150B, Article 3, provided that findings have been
made by the Divison that this action shall not deprive recipients of access to
reasonable service of adequate quality as set out in
42 C.F.R.
440.230,
440.260,
and
455.23,
which are adopted and incorporated by reference with subsequent changes or
amendments and available free of charge at https://www.ecfr.gov/;
(3) termination of a provider from further
participation in the Medicaid Program, subject to appeal rights under G.S.
150B, Article 3, provided that findings have been made by the Division that
this action shall not deprive recipients of access to reasonable services of
adequate quality as set out in
42 C.F.R.
440.230,
440.260,
and
455.23,
which are adopted and incorporated by reference with subsequent changes or
amendments and available free of charge at https://www.ecfr.gov;
(4) probation whereby a provider's
participation is monitored for a specified period of time not to exceed one
year, subject to appeal rights under G.S. 150B, Article 3. At the termination
of the probation period the Division shall conduct a follow-up review of the
provider's Medicaid practice to ensure compliance with all applicable laws,
regulations, and conditions of participation in Medicaid;
(5) negotiation of a financial settlement
with the provider;
(6) placing the
provider on prepayment review in accordance with
G.S.
108C-7; or
(7) establishing a monitoring program not to
exceed one year whereby the provider shall comply with pre-established
conditions of participation to allow review and evaluation of the provider's
Medicaid claims.
(b) The
following factors are illustrative of those to be considered in determining the
kind and extent of administrative actions to be imposed:
(1) seriousness of the offense;
(2) extent of violations found;
(3) history of prior violations;
(4) prior imposition of sanctions;
(5) length of time provider practiced
violations;
(6) provider
willingness to obey program rules;
(7) recommendations by the investigative
staff or Peer Review Committees; and
(8) effect on health care delivery in the
area.
(c) When the
Division has taken administrative action against a provider under Paragraphs
(a)(2), (a)(3), or (a)(4) of this Rule, the Division shall notify the licensing
board or other certifying group governing the sanctioned provider, federal and
state agencies, and departments of social services in the counties where
beneficiaries served by the provider reside of the findings made and the
sanctions imposed.
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