Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.16 - Termination, Suspension or Exclusion of a Vendor's Eligibility to Participate in the Medical Assistance Program

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				The Department may terminate or suspend a vendor's eligibility to participate
				in the Medical Assistance Program, terminate or not renew a vendor's provider
				agreement, or exclude a person or entity from participation in the Medical
				Assistance Program, when it determines that, at any time:
1) The vendor is not complying with the
				Department's policy or rules, or with the terms and conditions prescribed by
				the Department in any vendor agreement developed as a result of negotiations
				with the vendor category, or with the covenants contained in certifications
				bearing the vendor's signature on claims submitted to the Department by the
				vendor, or with restrictions on participation imposed pursuant to Section
				140.32;
2) The vendor, person or entity is not
				properly licensed, certified, authorized or otherwise qualified, or the vendor
				person's or entity's professional license, certificate or other authorization
				has not been renewed or has been restricted, revoked, suspended or otherwise
				terminated as determined by the appropriate licensing, certifying or
				authorizing agency. The termination, suspension or exclusion shall be
				immediately effective;
3) The
				vendor violates records requirements as set forth in statute or Department
				rules, provider handbooks or policies.
A) The
				vendor has failed to keep or timely make available for inspection, audit or
				copying (including photocopying), after receiving a written request from the
				Department:
i) records required to be
				maintained by the Department or necessary to fully and completely disclose the
				extent of the services or supplies provided; or
ii) full and complete records required to be
				maintained by the Department regarding payments claimed for providing
				services.
B) This
				subsection (a)(3) does not require vendors to make available medical records of
				patients for whom services are not reimbursed under the Illinois Public Aid
				Code;
4) The vendor has
				failed to furnish any information requested by the Department regarding
				payments for providing goods or services, or has failed to furnish all
				information required by the Department in connection with the rendering of
				services or supplies to recipients of public assistance by the vendor or his or
				her agent, employer or employee;
5)
				The vendor has knowingly made, or caused to be made, any false statement or
				representation of a material fact in connection with the administration of the
				Medical Assistance Program. For purposes of this subsection (a)(5), statements
				or representations made "knowingly" shall include statements or representations
				made with actual knowledge that they were false as well as those statements
				made when the individual making the statement had knowledge of such facts or
				information as would cause one to be aware that the statements or
				representations were false when made;
6) The vendor has submitted claims for
				services or supplies that were not rendered or delivered by that
				vendor;
7) The vendor has furnished
				goods or services to a recipient that, when based upon competent medical
				judgment and evaluation, are determined to be:
A) in excess of needs;
B) harmful (for the purpose of this
				subsection (a)(7)(B), "harmful" goods or services cause actual harm as defined
				in Section
				140.13 or place an
				individual at risk of harm, or of adverse side effects, that outweigh the
				medical benefits sought); or
C) of
				grossly inferior quality;
8) The vendor knew or should have known that
				a person with management responsibility for a vendor, an officer or person
				owning (directly or indirectly) 5% or more of the shares of stock or other
				evidences of ownership in a corporate vendor, an investor in the vendor, a
				technical or other advisor of the vendor, an owner of a sole proprietorship
				that is a vendor, or a partner in a partnership that is a vendor was previously
				terminated, suspended, excluded or barred from participation in the Medical
				Assistance Program, or in another state or federal medical assistance or health
				care program;
9) The vendor has a
				delinquent debt owed to the Department;
10) The vendor engaged in practices
				prohibited by federal or State law or regulation.
A) The vendor, a person with management
				responsibility for a vendor, an officer or person owning (directly or
				indirectly) 5% or more of the shares of stock or other evidences of ownership
				in a corporate or limited liability company vendor, an owner of a sole
				proprietorship that is a vendor, or a partner in a partnership that is a
				vendor, either:
i) has engaged in practices
				prohibited by applicable federal or State law or regulation; or
ii) was a person with management
				responsibility for a vendor at the time that the vendor engaged in practices
				prohibited by applicable federal or State law or regulation; or
iii) was an officer, or person owning
				(directly or indirectly) 5% or more of the shares of stock or other evidences
				of ownership in a vendor at the time the vendor engaged in practices prohibited
				by applicable federal or State law or regulation; or
iv) was an owner of a sole proprietorship or
				partner of a partnership that was a vendor at the time the vendor engaged in
				practices prohibited by applicable federal or State law or
				regulation;
B) For
				purposes of this subsection (a)(10), "applicable federal or State law or
				regulation" includes, but is not limited to, licensing or certification
				standards contained in State or federal law or regulations related to the
				Medical Assistance Program, any other licensing standards as they relate to the
				vendor's practice or business or any federal or State laws or regulations
				related to the Medical Assistance Program;
C) For purposes of this subsection (a)(10),
				conviction or a plea of guilty to activities violative of applicable federal or
				State law or regulation shall be conclusive proof that those activities were
				engaged in;
11) The
				vendor, a person with management responsibility for a vendor, an officer or
				person owning (directly or indirectly) 5% or more of the shares of stock or
				other evidences of ownership in a corporate vendor, an owner of a sole
				proprietorship that is a vendor, or a partner in a partnership that is a vendor
				has been convicted in this or any other State, or in any Federal Court, of any
				offense not related to the Medical Assistance Program, if the offense
				constitutes grounds for disciplinary action under the licensing Act applicable
				to that individual or vendor;
12)
				The vendor, a person with management responsibility for a vendor, an officer or
				person owning (directly or indirectly) 5% or more of the shares of stock or
				other evidences of ownership in a corporate vendor, an owner of a sole
				proprietorship that is a vendor, or partner in a partnership that is a vendor
				has been convicted in this or any other state, or in any Federal Court, of:
A) murder;
B) a Class X felony under the Illinois
				Criminal Code of 1961;
C) sexual
				misconduct that may subject recipients to an undue risk of harm;
D) a criminal offense that may subject
				recipients to an undue risk of harm;
E) a crime of fraud or dishonesty;
F) a crime involving a controlled
				substance;
G) a misdemeanor
				relating to fraud, theft, embezzlement or breach of fiduciary responsibility;
				or
H) other financial misconduct
				related to a health care program.
13) The direct or indirect ownership of the
				terminated, suspended or excluded vendor (including the ownership of a vendor
				that is a sole proprietorship, a partner's interest in a vendor that is a
				partnership, or ownership of 5% or more of the shares of stock or other
				evidences of ownership in a corporate vendor) has been transferred by an
				individual to the individual's spouse, child, brother, sister, parent,
				grandparent, grandchild, uncle, aunt, niece, nephew, cousin or relative by
				marriage.