SECTION 317:30-3-19.4. Application fee, provider screening, and applicants subject to a fingerprint-based criminal background check

  Pursuant to Subpart E of Part 455 of Title 42 of the Code of Federal Regulations (C.F.R.), an enrolling or re-enrolling SoonerCare provider must meet the screening requirements described in this rule and pay an application fee if required in the appendix to this rule. See Appendix A at the end of this chapter.

(1)   Application fees. The amount of the application fee is the amount established by the Center for Medicare and Medicaid Services (CMS) in accordance with 42 United States Code § 1395cc (j)(2)(C)(i), adjusted for inflation.

(A)   Per 42 C.F.R. § 455.460, the application fee shall not apply to the following providers:

(i)   Individual physician or non-physician practitioners;

(ii)   Providers who have enrolled or re-enrolled in Medicare, and have met the provider screening requirements and paid an application fee to CMS or its designee; and

(iii)   Providers who have enrolled or re-enrolled in another state's Medicaid or CHIP program, and have met the provider screening requirements and paid an application fee to the State Medicaid Agency or its designee.

(iv)   A provider must submit documentation to support any claim that it meets the exemption(s) described in paragraph (1)(A)(ii) and/or (1)(A)(iii) of this rule.

(B)   The application fee will not be refunded if:

(i)   Enrollment or re-enrollment is denied as a result of failure to meet the provider screening requirements described in this rule; or

(ii)   Enrollment or re-enrollment is denied based on the results of the provider screening.

(2)   Risk categories. Federal law requires the OHCA to screen all providers based on a categorical risk level of "limited," "moderate," or "high." If more than one risk level applies to a provider, the highest level of screening is required.

(A)   Limited-risk screens include:

(i)   Verification that the provider meets any applicable federal regulations, or state requirements for the provider type;

(ii)   License verification, including state licensure verification in states other than Oklahoma; and

(iii)   Database checks, including, but not limited to, those required by 42 C.F.R. § 455.436.

(B)   Moderate-risk screens include:

(i)   All limited-risk screening requirements; and

(ii)   Pre- and post-enrollment site visits by OHCA Provider Enrollment staff to confirm the accuracy of the provider's application and to determine compliance with federal and state enrollment requirements.

(iii)   Enrolled providers must permit the CMS, its agents, its designated contractors, or OHCA to conduct unannounced on-site inspections of any and all provider locations.

(C)   High-risk screens include:

(i)   All limited-risk screening requirements;

(ii)   All moderate-risk screening requirements; and

(iii)   A fingerprint-based criminal background check of the provider, or of any person with a five percent (5%) or more direct or indirect ownership interest in the provider.

(3)   OHCA's risk categories. OHCA has adopted the same risk categories as have been established for Medicare providers in 42 C.F.R. § 424.518. For certain Medicaid providers that are not recognized under Medicare, risk categories have been set forth in OHCA's "Appendix A. Risk Levels for Providers," using criteria similar to that used for Medicare providers, in determining the risk of fraud, waste and abuse.

(4)   Changes in risk categories. In accordance with 42 C.F.R. § 455.450(e), limited- and moderate-risk providers are moved to the high-risk category whenever:

(A)   OHCA imposes a payment suspension on a provider based on a credible allegation of fraud, waste or abuse;

(B)   The provider has an existing Medicaid overpayment;

(C)   The provider has been excluded by the Office of the Inspector General for the Department of Health and Human Services or any other state's Medicaid program within the previous ten (10) years; or

(D)   OHCA or CMS lifted a temporary moratorium for the particular provider type in the previous six (6) months and a provider that was prevented from enrolling based on the moratorium applies for enrollment within six (6) months from the date the moratorium was lifted.

(5)   Fingerprint-based criminal background check. Any applicant subject to a fingerprint-based criminal background check as provided in subsection (2)(C)(iii) of this rule, shall be denied enrollment if he/she has a felonious criminal conviction and may be denied enrollment for a misdemeanor criminal conviction relating, but not limited, to:

(A)   The provision of services under Medicare, Medicaid, or any other Federal or State health care program;

(B)   Homicide, murder, or non-negligent manslaughter;

(C)   Aggravated assault;

(D)   Kidnapping;

(E)   Robbery;

(F)   Abuse, neglect, or exploitation of a child or vulnerable adult;

(G)   Human trafficking;

(H)   Negligence and/or abuse of a patient;

(I)   Forcible rape and/or sexual assault;

(J)   Terrorism;

(K)   Embezzlement, fraud, theft, breach of fiduciary duty, or other financial misconduct; and/or

(L)   Controlled substances, provided the conviction was entered within the preceding ten-year period.

(6)   The appropriate screening based on screening risk level must be given to all service locations of an enrolled provider. Providers must disclose all service locations at time of enrollment and notify the agency of changes or additional service locations.

(7)   In accordance with 42 C.F.R. § 455.452, the OHCA reserves the right to conduct additional screenings and background checks as is determined necessary.

(8)   Any OHCA decision denying an application for contract enrollment based on the applicant's criminal history pursuant to Oklahoma Administrative Code 317:30-3-19.4 shall be a final agency decision that is not administratively appealable. However, nothing in this section shall preclude an applicant whose criminal conviction has been overturned on final appeal, and for whom no other appeals are pending or may be brought, from reapplying for enrollment.

[Source: Added at 34 Ok Reg 617, eff 9-1-17; Amended at 36 Ok Reg 858, eff 9-1-19]