S.C. Code Regs. § § 126-403

Current through Register Vol. 48, No. 10, October 25, 2024

Section 126-403 - Grounds for Sanction

The grounds for sanctioning providers shall include, but not be limited to, the following:

A. Presenting or causing to be presented for payment any false or fraudulent claim for services or merchandise.

B. Submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled, including charges in excess of the fee schedule or usual and customary charges.

C. Submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements.

D. Failure to disclose or make available to the Single State Agency or its authorized agent records of services provided to Medicaid beneficiaries and records of payment made therefore.

E. Continuing a course of conduct deemed abusive of the Medicaid Program after receiving written notice from the Single State Agency that said conduct must cease, provided that the written notice shall specify the practices deemed abusive.

F. Breach of the terms of the Medicaid provider agreement or failure to comply with the terms of provider certification on the Medicaid claim form.

G. Over-utilizing the Medicaid Program by including, furnishing, or otherwise causing a beneficiary to receive service(s) or merchandise not otherwise required by the beneficiary.

H. Rebating or accepting a fee or portion of a fee or charge for a beneficiary referral.

I. Submission of a false or fraudulent application for provider status.

J. Conviction against a provider for a criminal offense related to his or her involvement in the Medicaid or Medicare Program.

K. Failure to meet standards required by State or Federal law for Medicaid participation (i.e., failed to meet the licensing requirements constituting minimum qualification).

L. Exclusion from Medicare because of fraudulent or abusive practices (i.e., terminated or suspended from participation in the Medicare Program under 42 CFR, Part 1001.)

M. Failure to correct deficiencies in provider operations after receiving written notice of these deficiencies from the Single State Agency.

N. Failure to repay or make arrangements for the repayment of identified overpayments or otherwise erroneous payments.

O. Termination for cause under Medicare or under the Medicaid or CHIP program of any other State [ 42 CFR § 455.416 and Section 6501 of the Affordable Care Act]

S.C. Code Regs. § 126-403

Replaced and amended by State Register Volume 42, Issue No. 05, eff. 5/25/2018.