10A NCAC 22F .0603        PROVIDER LOCK-OUT

(a)  The Division may restrict the provider, through suspension or otherwise, from participating in the Medicaid program, provided that:

(1)           Before imposing any restrictions, the Division will give the provider notice and opportunity for review in accordance with procedures established by the Division.

(2)           The Division shows, before so restricting a provider, that in a significant number of proportion of cases, the provider has:

(A)          provided care, services, and items at a frequency or amount not medically necessary, as determined in accordance with utilization guidelines established by the Division; or

(B)          provided care, service, and items of a quality that does not meet professionally recognized standards of health care.

(3)           The Division will assure that recipients do not lose reasonable access to services of adequate quality as a result of such restrictions.

(4)           The Division will give general notice to the public of the restriction, its basis, and its duration.

(b)  Suspension or termination from participation of any provider shall preclude such provider from submitting claims for payment to the state agency.  No claims may be submitted by or through any clinic, group, corporation, or other association for any services or supplies provided by a person within such organization who has been suspended or terminated from participation in the Medicaid program, except for those services or supplies provided prior to the suspension or termination effective date.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. December 1, 1995.