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(1) Where the department has notified a provider of a violation, sanction, or an overpayment pursuant to ARM 37.85.512 the department may withhold payments on pending and subsequently received claims in an amount reasonably calculated to approximate the amounts in question or may suspend all payments pending the outcome of a departmental or law enforcement investigation.

(2) Where the department intends to withhold or suspend payments not regarding a credible allegation of fraud, as that term is defined at ARM 37.5.304, it shall notify the provider in writing at least ten days prior to commencement of withholding and shall include a statement of the provider's right to request an informal reconsideration of such decision as provided in ARM 37.5.305. This rule does not require that an informal reconsideration or any hearing be conducted prior to the withholding or suspension of payments.

(3) Where the department suspends payments based on a credible allegation of fraud in accordance with 42 CFR 455.23, the department may suspend payments without first notifying the provider.

(a) The department must send notice of its suspension of payments within the following timeframes:

(i) five days of taking such action unless requested in writing by a law enforcement agency to temporarily withhold such notice;

(ii) thirty days if requested by law enforcement in writing to delay sending such notice, which request for delay may be renewed in writing up to twice and in no event exceed 90 days.

(b) In addition to the noticing requirements of ARM 37.85.512(1), the notice must state that the suspension is in accordance with 42 CFR 455.23 and is for a temporary period and cite the circumstances under which the withholding will be terminated. Suspension of payment will not continue after either of the following:

(i) the agency or the prosecuting authorities determine that there is insufficient evidence of fraud or willful misrepresentation by the provider; or

(ii) legal proceedings related to the provider's alleged fraud are completed.

(4) Where the department has terminated or suspended a provider, the provider shall be eligible to bill for covered services for the period covered by the suspension or termination if an appeal is decided in the provider's favor.

History: 53-2-201, 52-2-211, 53-6-111, 53-6-113, MCA; IMP, 52-2-112, 53-2-201, 53-6-111, MCA; NEW, 1980 MAR p. 1619, Eff. 6/13/80; AMD, 1984 MAR p. 1639, Eff. 11/16/84; TRANS & AMD, from SRS, 2000 MAR p. 1653, Eff. 6/30/00; AMD, 2011 MAR p. 2823, Eff. 12/23/11.

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