Title 42—Public Health--Volume 1
PART 1001—PROGRAM INTEGRITY—MEDICARE AND STATE HEALTH CARE PROGRAMS
§ 1001.3001   Timing and method of request for reinstatement.
(a)(1) Except as provided in paragraph (a)(2) of this section or in § 1001.501(b)(2), § 1001.501(c), or § 1001.601(b)(4), an excluded individual or entity (other than those excluded in accordance with §§ 1001.1001 and 1001.1501) may submit a written request for reinstatement to the OIG only after the date specified in the notice of exclusion. Obtaining a program provider number or equivalent does not reinstate eligibility.
(2) An entity excluded under § 1001.1001 may apply for reinstatement prior to the date specified in the notice of exclusion by submitting a written request for reinstatement that includes documentation demonstrating that the standards set forth in § 1001.3002(c) have been met.
(b) Upon receipt of a written request, the OIG will require the requestor to furnish specific information and authorization to obtain information from private health insurers, peer review bodies, probation officers, professional associates, investigative agencies and such others as may be necessary to determine whether reinstatement should be granted.
(c) Failure to furnish the required information or authorization will result in the continuation of the exclusion.
(d) If a period of exclusion is reduced on appeal (regardless of whether further appeal is pending), the individual or entity may request reinstatement once the reduced exclusion period expires.
§ 1001.3002   Basis for reinstatement.
(a) The OIG will authorize reinstatement if it determines that—
(1) The period of exclusion has expired;
(2) There are reasonable assurances that the types of actions that formed the basis for the original exclusion have not recurred and will not recur; and
(3) There is no additional basis under sections 1128(a) or (b) or 1128A of the Act for continuation of the exclusion.
(b) In making the reinstatement determination described in paragraph (a) of this section, the OIG will consider—
(1) Conduct of the individual or entity occurring prior to the date of the notice of exclusion, if not known to the OIG at the time of the exclusion;
(2) Conduct of the individual or entity after the date of the notice of exclusion;
(3) Whether all fines and all debts due and owing (including overpayments) to any Federal, State, or local government that relate to Medicare, Medicaid, and all other Federal health care programs have been paid or satisfactory arrangements have been made to fulfill obligations;
(4) Whether CMS has determined that the individual or entity complies with, or has made satisfactory arrangements to fulfill, all the applicable conditions of participation or supplier conditions for coverage under the statutes and regulations;
(5) Whether the individual or entity has, during the period of exclusion, submitted claims, or caused claims to be submitted or payment to be made by any Federal health care program, for items or services the excluded party furnished, ordered, or prescribed, including health care administrative services. This section applies regardless of whether an individual or entity has obtained a program provider number or equivalent, either as an individual or as a member of a group, prior to being reinstated; and
(c) If the OIG determines that the criteria in paragraphs (a)(2) and (3) of this section have been met, an entity excluded in accordance with § 1001.1001 will be reinstated upon a determination by the OIG that the individual whose conviction, exclusion, or civil money penalty was the basis for the entity's exclusion—
(1) Has properly reduced his or her ownership or control interest in the entity below 5 percent;
(2) Is no longer an officer, director, agent or managing employee of the entity; or
(3) Has been reinstated in accordance with paragraph (a) of this section or § 1001.3005.
(d) Reinstatement will not be effective until the OIG grants the request and provides notice under § 1001.3003(a) of this part. Reinstatement will be effective as provided in the notice.
(e) A determination with respect to reinstatement is not appealable or reviewable except as provided in § 1001.3004.
(f) An ALJ may not require reinstatement of an individual or entity in accordance with this chapter.
§ 1001.3003   Approval of request for reinstatement.
(a) If the OIG grants a request for reinstatement, the OIG will—
(1) Give written notice to the excluded individual or entity specifying the date of reinstatement;
(2) Notify CMS of the date of the individual's or entity's reinstatement;
(3) Notify appropriate Federal and State agencies that administer health care programs that the individual or entity has been reinstated into all Federal health care programs; and
(4) To the extent applicable, give notice to others that were originally notified of the exclusion.
(b) A determination by the OIG to reinstate an individual or entity has no effect if a Federal health care program has imposed a longer period of exclusion under its own authorities.
§ 1001.3004   Denial of request for reinstatement.
(a) If a request for reinstatement is denied, OIG will give written notice to the requesting individual or entity. Within 30 days of the date on the notice, the excluded individual or entity may submit:
(1) Documentary evidence and written argument against the continued exclusion,
(2) A written request to present written evidence and oral argument to an OIG official, or
(3) Both documentary evidence and a written request.
(b) After evaluating any additional evidence submitted by the excluded individual or entity (or at the end of the 30-day period, if none is submitted), the OIG will send written notice either confirming the denial, and indicating that a subsequent request for reinstatement will not be considered until at least one year after the date of denial, or approving the request consistent with the procedures set forth in § 1001.3003(a).
(c) The decision to deny reinstatement will not be subject to administrative or judicial review.
§ 1001.3005   Withdrawal of exclusion for reversed or vacated decisions.
(a) An exclusion will be withdrawn and an individual or entity will be reinstated into Medicare, Medicaid, and other Federal health care programs retroactive to the effective date of the exclusion when such exclusion is based on—
(1) A conviction that is reversed or vacated on appeal;
(2) An action by another agency, such as a State agency or licensing board, that is reversed or vacated on appeal; or
(3) An OIG exclusion action that is reversed or vacated at any stage of an individual's or entity's administrative appeal process.
(b) If an individual or entity is reinstated in accordance with paragraph (a) of this section, CMS and other Federal health care programs will make payment for services covered under such program that were furnished or performed during the period of exclusion.
(c) The OIG will give notice of a reinstatement under this section in accordance with § 1001.3003(a).
(d) An action taken by the OIG under this section will not require any other Federal health care program to reinstate the individual or entity if such program has imposed an exclusion under its own authority.
(e) If an action which results in the retroactive reinstatement of an individual or entity is subsequently overturned, the OIG may reimpose the exclusion for the initial period of time, less the period of time that was served prior to the reinstatement of the individual or entity.