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(1) Sanctions may be imposed by the department against a provider of medical assistance, provided under ARM Title 37, chapters 40, 80, 82, 83, 85, 86, 88, for any one or more of the following reasons:

(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 under the rules of the department.

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

(d) Failure to maintain and retain records required by the rules of the department.

(e) Failure to disclose or make available required records to the department, its authorized agent or other legally authorized persons, organizations, or governmental entities.

(f) Failure to provide and maintain services to Medicaid recipients at a quality that is within accepted medical community standards as adjudged by a body of peers.

(g) Engaging in a course of conduct or performing an act which the department's rules or the decision of the applicable professional peer review committee, or licensing board, have determined to be improper or abusive of the Montana Medicaid program; or continuing such conduct following notification that the conduct should cease.

(h) Breach of the terms of the provider contract or failure to comply with the terms of the provider certification on medical assistance claim forms or the failure to comply with requirements imposed by the rules of the department.

(i) Over-utilizing the Montana Medicaid program by inducing, or otherwise causing a recipient to receive services or goods not medically necessary.

(j) Rebating or accepting a fee or portion of a fee or charge for a Medicaid patient referral.

(k) Violating any provision of the state Medicaid law, Title 53, chapter 6, MCA or any rule promulgated pursuant thereto, or violating any provision of Title XIX of the Social Security Act or any regulation promulgated pursuant thereto.

(l) Submission of a false or fraudulent application for provider status.

(m) Violations of any statutes, regulations or code of ethics governing the conduct of occupations or professions or regulated industries.

(n) Conviction of a criminal offense relating to medical assistance programs administered by the department or provided under contract with the state; or conviction for negligent practice resulting in death or injury to patients.

(o) Failure to meet requirements of state or federal law for participation (e.g. licensure).

(p) Exclusion from the Medicare program (Title XVIII of the Social Security Act) because of fraudulent or abusive practices.

(q) Charging Medicaid recipients for amounts over and above the amounts paid by the department for services rendered, except as specifically allowed under ARM 37.83.825 and 37.83.826.

(r) Refusal to execute a new provider agreement when requested to do so.

(s) Failure to correct deficiencies as defined by the ARM or federal regulation after receiving written notice of these deficiencies from the department, or the federal Department of Health and Human Services. The standards set forth at 42 CFR Part 442, Part 483 and Part 488, updated through February 2004, which identify deficiencies for providers of intermediate care facilities for the mentally retarded, skilled nursing and nursing facility services, are incorporated by reference. A copy of 42 CFR Part 442, Part 483 and Part 488, updated through February 2004, are available from the Department of Public Health and Human Services, Quality Assurance Division, 2401 Colonial Drive, P.O. Box 202653, Helena, MT 59620-2953.

(t) Formal reprimand or censure by an association of the provider's peers for unethical practices.

(u) Suspension or termination from participation in another government medical program including but not limited to workers' compensation, crippled children's services, rehabilitation services and Medicare.

(v) Filing of criminal indictment, information or complaint for fraudulent billing practices or negligent practice resulting in death or injury to the provider's patients.

(w) Civil judgement for fraudulent billing practices or negligent practice resulting in death or injury to the provider's patients.

(x) Failure to repay or make acceptable arrangements for the repayment of identified overpayments or otherwise erroneous payments.

(y) Threatening, intimidating or harassing patients or their relatives in an attempt to influence reimbursement rates or affect the outcome of disputes between the provider and the department.

(z) Submitting claims for reimbursement of costs or services which the provider knows or has reason to know are not reimbursable.

History: 53-2-201, 53-2-803, 53-4-111, 53-6-111, 53-6-113, MCA; IMP, 53-2-306, 53-2-801, 53-2-803, 53-4-112, 53-6-111, 53-6-131, MCA; NEW, 1980 MAR p. 1619, Eff. 6/13/80; AMD, 1984 MAR p. 1639, Eff. 11/16/84; AMD, 1986 MAR p. 1321, Eff. 8/1/86; AMD, 1987 MAR p. 2164, Eff. 11/28/87; AMD, 1989 MAR p. 835, Eff. 6/30/89; TRANS, from SRS, 2000 MAR p. 479; AMD, 2004 MAR p. 736, Eff. 4/9/04.

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