N.H. Admin. Code § He-W 520.06

Current through Register No. 36, September 5, 2024

Section He-W 520.06 - Provider Requirements

(a) NH medicaid providers and provider applicants shall meet the provider participation requirements contained in He-W 530 through He-W 577, as applicable, for providers of the type of services they will be providing, as well as requirements in He-W 520.06.

(b) The following individuals and entities shall be subject to a risk determination described in (c) below:

(1) NH medicaid providers enrolled as of November 1, 2016 who submitted their provider enrollment application to the department's fiscal agent on or after August 1, 2015 through October 31, 2016;

(2) NH medicaid provider applicants;

(3) NH medicaid providers who are applying to enroll a new practice location(s);

(4) NH medicaid providers who are re-enrolling; and

(5) NH medicaid providers being revalidated in accordance with 42 CFR 455.414.

(c) Individuals and entities in (b) above who meet either of the following criteria shall be determined to be high risk providers or high risk provider applicants:

(1) The individual or entity, with the exception of those who are undergoing revalidation in accordance with 42 CFR 455.414, provides home health services or durable medical equipment services; or

(2) The individual's or entity's risk level was adjusted to high by the department as required by 42 CFR 455.450(e) (1) because any of the following occurred:

a. The department imposed a payment suspension on the individual or entity based on credible allegation of fraud, waste, or abuse;

b. The individual or entity has an existing medicaid overpayment;

c. The individual or entity was excluded from participation in a federally funded program by the office of inspector general or another state's medicaid program within the 10 years preceding the date of application or date of revalidation; or

d. In accordance with 42 CFR 455.450(e) (2) , NH medicaid or the Centers for Medicare and Medicaid Services (CMS) in the previous 6 months lifted a temporary moratorium for the particular provider type and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider within 6 months from the date the moratorium was lifted.

(d) The following individuals and entities shall be subject to a state and federal criminal background check, including fingerprinting, in accordance with this section:

(1) Persons with a direct or indirect ownership interest in a high risk provider or high risk provider applicant described in (c) (1) above; and

(2) High risk providers or high risk provider applicants described in (c) (2) above.

(e) Those who meet the criteria in (d) above shall not be subject to an additional criminal background check, including fingerprinting, if, within the previous 36 months, they have undergone a criminal background check as required by:

(1) A Medicare administrative contractor;

(2) NH medicaid;

(3) Any other state's medicaid agency, and the department is able to access the information from the other state's medicaid agency; or

(4) Any other state's children's health insurance program (CHIP), and the department is able to access the information from the other state's CHIP.

(f) Those who meet the criteria in (d) above, and who are not excluded in (e) above, shall be notified in writing of the following by the department:

(1) That a state and federal criminal background check, including fingerprinting, is required;

(2) Where the criminal background check, including fingerprinting, can be conducted as specified in (h) (1) below; and

(3) The deadline by which the criminal background check, including fingerprinting, shall be conducted as specified in (g) below.

(g) The deadline for undergoing a criminal background check, including fingerprinting, shall be 30 days from the date of the notification in (f) above.

(h) Those who meet the criteria in (d) above, and who are not excluded in (e) above, shall undergo a state and federal criminal background check by:

(1) Having a complete set of electronic fingerprints taken at any location maintained by the NH state police criminal records unit that has electronic fingerprinting capability, or by any other in or out of state law enforcement agency that conducts fingerprinting electronically; and

(2) Completing and submitting to the location in (1) above a notarized Form DSSP 417, "New Hampshire Health and Human Services Criminal History Record Information Authorization," incorporated by reference in Saf-C 5703.10, Table 5700-1, which authorizes the release of the individual's criminal history record, if any, to the department.

(i) Those who meet the criteria in (d) above shall be terminated from, or denied enrollment in, the NH medicaid program if:

(1) The individual fails to get fingerprinted by the deadline in (g) above, as applicable; or

(2) The results of the criminal background check indicate that the individual has been convicted of any of the following federal or state felony offenses within the 10 years preceding the date of application or date of revalidation of enrollment:

a. Felony crimes against persons, such as murder, sexual assault, assault, interference with freedom, destruction of property, unauthorized entries, robbery and theft, fraud and corruption, and other similar crimes for which the individual was convicted, including guilty pleas;

b. Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud, and other similar crimes for which the individual was convicted, including guilty pleas; or

c. Any felony that placed the medicaid program or its recipients at immediate risk, such as a malpractice suit that results in a conviction of criminal neglect or misconduct.

(j) An individual or entity being terminated from, or denied enrollment in, the NH medicaid program in accordance with (i) above shall receive a written notice from the department of the denial or termination.

(k) The notice in (j) above shall contain:

(1) The reason for, and legal basis of, the denial or termination; and

(2) Information that an appeal of the denial or termination may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial or termination.

(l) Appeals of the results of the criminal background check shall be made in accordance with the department of safety rules at Saf-C 5703.12.

N.H. Admin. Code § He-W 520.06

Amended by Volume XXXVII Number 19, Filed May 11, 2017, Proposed by #12166, Effective 4/29/2017, Expires 4/29/2027.