Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012 Page: 8,008
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(8) has been excluded from participation in Medicare or
any other federal health care programs.
(b) OIG may exclude a person without sending prior notice of
intent to exclude in the following circumstances:
(1) OIG determines that the person is or may be placing the
health and/or safety of persons receiving services under a HHS program
at risk;
(2) a person fails:
(A) to grant immediate access to OIG or to a Requesting
Agency upon reasonable request;
(B) to allow OIG or a Requesting Agency to conduct
any duties that are necessary to the performance of their official func-
tions; or
(C) to provide to OIG or a Requesting Agency as re-
quested copies or originals of any records, documents, or other items,
as determined necessary by OIG or the Requesting Agency;
(3) the person engages in acts that violate 42 CFR
1001.1401 (hospital's failure to comply with corrective action plan
required by the Centers for Medicare and Medicaid Services);
(4) the person engages in acts that violate 42 CFR
1001.1501 (default on health education loan or scholarship obliga-
tions);
(5) the person engages in acts that violate 42 CFR
1001.901 (false or improper claims);
(6) the person engages in acts that violate 42 CFR
1001.951 (fraud and kickbacks and other prohibited activities);
(7) the person engages in acts that violate 42 CFR
1001.1601 (violations of the limitations on physician charges);
(8) the person engages in acts that violate 42 CFR
1001.1701 (billing for services of assistant at surgery during cataract
operations); or
(9) the person has been excluded from the Medicaid pro-
gram and obtains a new provider number without first completing the
reinstatement and re-enrollment process as required by 371.1719 of
this division (relating to Recoupment of Overpayments Identified by
Audit).
(c) Notice.
(1) Except as provided in subsection (b) of this section,
OIG will issue a notice of intent to exclude when it proposes to exclude
any person on permissive grounds. The notice of intent to exclude will
include:
(A) the basis for the potential exclusion;
(B) the potential effect of the exclusion; and
(C) whether OIG also proposes to cancel any agreement
held by the person to be excluded.
(2) When OIG makes a final determination to exclude the
person or when the exclusion is based upon the grounds enumerated in
subsection (b) of this section, OIG issues a final notice of exclusion,
which will state:
(A) a description of the final exclusion;
(B) the basis of the final exclusion;
(C) the effect of the final exclusion;
(D) the duration of the final exclusion;(E) the earliest date on which OIG will consider a re-
quest for reinstatement;
(F) the requirements and procedures for reinstatement;
(G) whether OIG will also cancel any agreement held
by the person to be excluded; and
(H) a statement of the person's right to request a formal
administrative appeal hearing regarding the exclusion.
(d) Due process.
(1) A person may request an informal review in accordance
with 371.1613 of this subchapter (relating to Informal Review) after
receipt of a notice of intent to exclude. OIG must receive the written
request for the informal review no later than the thirtieth (30th) calen-
dar day after the date the person receives the notice. A request for an
informal review does not expand the time allowed to the provider to
request an administrative hearing.
(2) Within 30 days of receipt of the notice of intent to ex-
clude, the person receiving the notice may submit to OIG, any doc-
umentary evidence or written argument regarding whether exclusion
is warranted and any related issues to be considered during the infor-
mal review. Submission of documentary evidence or written argument,
however, is no guarantee that OIG will not ultimately exclude the per-
son.
(3) A person may request an administrative appeal hearing
in accordance with 371.1615 of this subchapter (relating to Appeals)
after receipt of a final notice of exclusion. OIG must receive the written
request for an appeal no later than the 15th calendar day after the date
the person receives final notice.
(4) If both an informal review and an administrative hear-
ing are requested after a final notice of exclusion, OIG may elect, in
its sole discretion, to conduct an informal review. The administra-
tive hearing and all pertinent discovery, prehearing conferences, and
all other issues and activities regarding the administrative hearing will
be abated until all informal review discussions have concluded without
settlement or resolution of the issues.
(e) Scope and effect of exclusion.
(1) The period of exclusion begins on the effective date.
An exclusion becomes effective on the following:
(A) the date reflected on the final notice of exclusion if
the exclusion is based on a health or safety risk as described in subsec-
tion (b)(1) of this section;
(B) the date of the original request for records if the ex-
clusion is based on failure to provide access as described in subsection
(b)(2) of this section;
(C) unless otherwise provided, 30 days after the per-
son's receipt of the final notice of exclusion if the provider does not
timely file a written request for an appeal that satisfies the requirements
of 371.1615 of this subchapter; or
(D) if the person timely filed a written request for ap-
peal, the date the hearing officer or administrative law judge upholds
the decision to exclude; however, if the administrative law judge up-
holds an exclusion based upon subsection (b)(1) of this section, the
effective date will be made retroactive to the date of the final notice,
and if the judge upholds an exclusion based upon subsection (b)(2) of
this section, the effective date will be made retroactive to the date of
the original request for records.
(2) An exclusion remains in effect for the period indicated
in the final notice of exclusion. The person is not eligible to apply for37 TexReg 8008 October 5, 2012 Texas Register
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Texas. Secretary of State. Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012, periodical, October 5, 2012; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth288982/m1/193/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.