South Carolina Code of Regulations › Chapter 126 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › Article 4 - PROGRAM EVALUATION › Subarticle 1 - ADMINISTRATIVE SANCTIONS AGAINST MEDICAID PROVIDERS › Section 126-400 - Definitions

Current through Register Vol. 48, No. 6, June 28, 2024
A. Provider - means
				an individual, firm, corporation, association or institution which is
				providing, or has been approved to provide, medical assistance to a beneficiary
				pursuant to the State Medical Assistance Plan and in accord with Title XIX of
				the Social Security Act of 1932, as amended.
B. Person - any natural person, company,
				firm, association, partnership, corporation or other legal entity.
C. Practitioner - means a physician or other
				health care professional licensed under State law to practice his or her
				profession.
D. Educational
				Intervention - means a visit to a provider by a staff member to explain
				Medicaid Program policies and procedures. This includes instructions on correct
				billing procedures. Educational intervention may also take the form of a
				telephone call or letter to a provider calling his or her attention to a
				particular problem in Program administration or billing practices.
E. Abuse - provider practices that are
				inconsistent with sound fiscal, business, or medical practices, and result in
				an unnecessary cost to the Medicaid Program, or in reimbursement for services
				that are not medically necessary or that fail to meet professionally recognized
				standards for health care.
F. Fraud
				- an intentional deception or misrepresentation made by a person with the
				knowledge that the deception could result in some unauthorized benefit to
				himself or some other person. It includes any act that constitutes fraud under
				applicable Federal or State law. [
				42
				CFR §
										455.2 ].
G. Conviction or convicted - means a judgment
				or conviction after trial, or the entry of a plea of guilty or a plea of no
				contest (nolo contendere) in a federal, state or local court, regardless of
				whether an appeal from that judgment is pending.
H. Exclusion - means that a health care
				provider, either an individual practitioner or facility, organization,
				institution, business, or other type of entity, cannot receive Medicaid payment
				for any health care services rendered. [
				42
				CFR §
										455.2 ].
I. Suspension of Payment - means that upon
				determination by the Department that there is a credible allegation of fraud
				against a specified provider for which an investigation is pending under the
				Medicaid program, all payments pending at the time of determination and all
				payments for items or services furnished by the specified provider will be
				retained by the Department until resolution of the investigation, unless the
				Department determines that good cause to not suspend or to only suspend in part
				exists, as set forth in
				42 CFR §
										455.23(e) and §
									455.23(f)
				respectively. [§ 455.23].
J.
				Termination - occurs when the Medicare program, a State Medicaid program, or
				Children's Health Insurance Program (CHIP) has taken an action to revoke a
				provider's billing privileges, a provider has exhausted all applicable appeal
				rights or the timeline for appeal has expired, and there is no expectation on
				the part of a provider or supplier or the Medicare program, State Medicaid
				program, or CHIP that the revocation is temporary. The requirement for
				termination based upon a termination in another program applies in cases where
				providers, suppliers, or eligible professionals were terminated or had their
				billing privileges revoked for cause which may include reasons based on fraud,
				integrity, or quality. [Section 6501 of the Affordable Care Act amended section
				1902(a)(39) of the Social Security Act (the Act) and requires State Medicaid
				agencies to terminate the participation of any individual or entity if such
				individual or entity is terminated under Medicare or under the Medicaid program
				or CHIP of any other state].
K.
				Suspension - means that items or services furnished by a specified provider who
				has been convicted of a program-related offense in a Federal, State, or local
				court will not be reimbursed under Medicaid. [
				42
				CFR §
										455.2 ].