SMD Letter - Medicare/Medicaid Sanction-Reinstatement Report (HCFA Pub. 69) is a vital resource (5/16/00)  
May 16, 2000  
Dear State Medicaid Director:  
As we work together to curtail improper payments by State Medicaid agencies and the 
improper assignment of provider numbers to excluded providers, we wish to remind States 
that the Medicare/ Medicaid Sanction-Reinstatement Report (HCFA Pub. 69) is a vital 
resource for ascertaining and verifying whether a provider is excluded.  
The HHS Office of the Inspector General (OIG) excludes individuals and entities from 
participating in Federal health care programs under various provisions of the Social Security Act 
(the Act) including, inter alia sections 1128, 1128A, 1156, and 1892 of the Act. When an exclusion 
is imposed, Medicare, Medicaid, and all other Federal health care program (as defined in section 
1128B(f) of the Act) payments are prohibited for any items or services, including management and 
administrative services, (other than an emergency item or service not provided in a hospital 
emergency room) furnished, ordered, or prescribed by an excluded party. Payment is prohibited to 
any business or facility (e.g., hospital) for items or services provided, ordered, or prescribed by an 
excluded party. Also, payment is prohibited to any managed care organization (MCO) which 
contracts with an excluded party.  
As you know, an individual or entity may be excluded from receiving Medicare and Medicaid 
funds if that person or organization has been suspended or excluded from participation, or 
otherwise sanctioned under any Federal program, or a State health care program, for reasons 
bearing on professional competence, professional performance, or financial integrity.  
The OIG has recently discovered a number of instances where States have paid excluded providers 
and, consequently, States have received Federal payments under Medicaid for services provided 
by these excluded providers. OIG and HCFA are concerned that some States may not be using 
HCFA Pub. 69, published monthly by HCFA, to check for excluded providers. If left unchecked, 
States may inadvertently assign provider numbers to excluded providers because information 
about a provider's exclusion status is either not required on the Medicaid provider application or 
because a provider's exclusion may go undetected when they move from another State. In most 
instances, HCFA Pub. 69 would enable States to avoid this problem.  
This information is necessary to ensure that provider enrollment determinations are correct 
and that surveillance and utilization review activities are effective. At the same time, since 
HCFA Pub. 69  
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Sanction-Reinstatement Report (HCFA Pub. 69) is a vital resource (5/16/00)  
contains sensitive data, users need to be aware that the information is confidential, and should be 
treated with the utmost care to ensure that it is used only for its intended purposes by the intended 
recipient and his or her authorized personnel.   Each month, HCFA's Office of Issuances (OI) transmits HCFA Pub. 69 electronically to all HCFA 
regional offices, contractors, and State Medicaid agencies. Hard copies are mailed four to six weeks 
later.  
Through the Medicaid Fraud and Abuse Control Technical Advisory Group, we have attempted to 
ensure that every appropriate official in your State you want to receive this publication does so. If 
you are not receiving HCFA Pub. 69 and wish to receive the electronic and/or hard copy, please 
contact Seth Price at (410) 786-5264 or Bridgett Wilhite at (410) 786-5248 of HCFA's OI.  
In addition to HCFA's monthly listing, States can also access the OIG sanction webpage at 
www.dhhs. gov/progorg/oig. However, please keep in mind that the OIG sanction list does not 
include Social Security numbers and therefore, it may be more productive for States to use 
HCFA Pub. 69.  
Sections 1903(d)(2)(A) and 1903(i)(2) of the Act authorize HCFA to make adjustments or to 
make no payment to States with respect to any amount expended for items or services (other than 
an emergency item or service not provided in a hospital emergency room) furnished "under the 
plan by any individual or entity during any period when the individual or entity is excluded from 
participation under title V, XVIII, or XX of the Act or under [title XIX] pursuant to section 1128, 
1128A, 1156 or 1842(j)(2) ...," (Section 1903(i)(2)). HCFA Pub. 69 contains the exclusion 
information that will enable States to know which providers should not be receiving payments.  
Please remember that reinstatement to program participation is not automatic. An excluded 
individual or entity must apply to the OIG to be reinstated. Only after the OIG determines 
eligibility for reinstatement in accordance with regulations can an excluded provider be granted 
reinstatement. States have no authority to reinstate providers until they receive official notification 
from the OIG, or the stay of exclusion for health education assistance loan cases.  
If you have any questions regarding excluded providers or sanctions information, please contact 
Rhonda Hall at (404) 562-7175 or Paul Miner at (410) 786-5937.  
We want to continue working with you to ensure that all who are eligible for Medicaid receive 
the care they need and to ensure that Medicaid funds are spent appropriately.  
Sincerely,  
/s/  
Timothy M. 
Westmoreland 
Director  
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Sanction-Reinstatement Report (HCFA Pub. 69) is a vital resource (5/16/00)   cc: All HCFA Regional Administrators All HCFA Associate Regional Administrators - Division of 
Medicaid and State Operations Lee Partridge - Director, Health Policy Unit, American Public 
Human Services Association Joy Wilson - Director, Health Committee, National Conference of 
State Legislatures Matt Salo - Director of Health Legislation, National Governors' Association  
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