Utah Admin. Code R414-22-3 - Grounds for Excluding Providers

(1) Upon learning of the crime, misdemeanor or misconduct, the department shall exclude a prospective Medicaid provider who:

(a) has a current suspension from DOPL or another state's equivalent agency for sexual misconduct with a child, minor, or non-consenting adult under Title 76, Utah Criminal Code; or

(b) is serving any term, completing any associated probation or parole, or still making complete court-imposed restitution for a felony conviction that involves the following:

(i) a sexual crime;

(ii) a controlled substance;

(iii) health care fraud; or

(c) the provider is serving any term, completing any associated probation or parole, or still making complete court-imposed restitution for a misdemeanor conviction that involves a controlled substance.

(2) Upon learning of the crime, misdemeanor or misconduct, the department shall terminate a current Medicaid provider for any violation stated in Subsection (1).

(3) If a prospective or current Medicaid provider has a current restriction or probation on their license from DOPL or another state's equivalent agency to treat only a certain age group or gender, or DOPL requires another medical professional to supervise and restrict the provider's activity, then the department will require the provider to submit the same documentation to the department that the provider is required to submit to DOPL or another state's equivalent agency to demonstrate compliance with the restriction. Failure to submit the required documentation to the department is a basis for suspension or termination of enrollment with Medicaid.

(4) Subject to approval of the Provider Sanction Committee, the department may enroll a provider who has served any term, completed any associated probation or parole, or made complete court-imposed restitution for an earlier felony conviction involving:

(a) a sexual crime;

(b) a controlled substance; or

(c) health care fraud.

(5) Subject to approval of the Provider Sanction Committee, the department may enroll a provider or allow a provider to remain in the Medicaid program if the provider has a previous restriction, suspension, or probation from DOPL for sexual misconduct with a child, minor, or non-consenting adult under Title 76, Utah Criminal Code.

(6) Subject to approval of the Provider Sanction Committee, the department may allow a provider to remain in the Medicaid program if OIG has recommended the program consider termination of the provider.

(7) The Provider Sanction Committee may consider the need to maintain member access to services when making a determination related to convictions or sanctions described in Subsection R414-22-3(4), (5), or (6).

(8) The Provider Sanction Committee may use any grounds described in Section R414-22-4 to exclude providers from Medicaid.

(9) The department may exclude a prospective Medicaid provider who has a current suspension from DOPL or another state's equivalent agency.

(10) The Provider Sanction Committee may exclude a prospective provider for significant misconduct or substantial evidence of misconduct that creates a substantial risk of harm to the Medicaid program.

(11) If after review, the Provider Sanction Committee finds there is earlier misconduct outlined in Section R414-22-3 or Section R414-22-4, the committee retains discretionary authority to not renew a provider agreement, to not reinstate a provider agreement, and to not enroll a provider until the provider has completed the requirements deemed necessary by the committee.

Notes

Utah Admin. Code R414-22-3

Amended by Utah State Bulletin Number 2020-05, effective 2/4/2020 Amended by Utah State Bulletin Number 2024-03, effective 1/22/2024