N.J. Admin. Code § 10:84-2.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:84-2.2 - Withholding of provider payments

(a) In accordance with the Commissioner of Human Services' delegated authority in 30:1-12b., and the authority vested in the Director of DFD in 30:1-9 and 30:4B-1 and 2, when the Division receives reliable evidence of theft, fraud, willful misrepresentation, or tampering with records by a provider, the Division shall withhold program payments, in whole or part, upon approval of the Division Director or Assistant Division Director or their designee.

(b) "Reliable evidence," as used in this section, shall include, but is not limited to, the following:

1. Receipt of information from a Division unit or from another executive branch department or agency, or from a law enforcement, investigatory, or prosecutorial agency that indicates theft, fraud, willful misrepresentation, or tampering with records has occurred or is occurring; or

2. Information from any other local, county, state, or Federal agency indicating theft, fraud, willful misrepresentation, or tampering with records has occurred or is occurring.

(c) Withholding may be total or partial, and if partial, may be predicated upon specific claims, bills, or invoices, electronic or otherwise, or actions of providers or clients, or other factors as determined by DFD.

(d) The Division shall send notice of the withholding to the affected provider or entity within five days of taking such action, if practicable. It shall set forth the general allegations as to the nature of the withholding action, but need not disclose specific information concerning any ongoing civil or criminal investigation. The notice shall state the following:

1. Payment is being withheld in accordance with this section;

2. Withholding is for a period not to exceed six months initially, until a review by DFD determines whether it is warranted for an additional period. If the Division determines there is insufficient evidence of theft, fraud, willful misrepresentation, or tampering of records, and legal proceedings have been completed, withholding shall be terminated;

3. If appropriate under the circumstances, the claims, bills, invoices, and providers or clients the withholding affects;

4. The right of the provider or entity to submit written evidence for consideration by DFD;

5. The provider's or entity's right to submit to DFD, within 20 days of their receipt of the withholding notice, a request for an administrative hearing. Upon receipt of such request, DFD shall schedule a hearing according to the Administrative Procedure Act, 52:14B-1 et seq., and 52:14F-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.

6. DFD shall make corrective payments to the provider or entity retroactive to the date the incorrect action was taken by DFD, when the administrative hearing is favorable to the provider or entity, or a review by DFD prior to the administrative hearing is favorable to the provider or entity.

N.J. Admin. Code § 10:84-2.2