SECTION 371.1007. Screening Levels

(a) The OIG uses a screening level of "Limited," "Moderate," or "High" risk, assigned in accordance with §352.9 of this title (relating to Screening Levels) to determine the verifications and further screening required under §371.1009 of this subchapter (relating to Verifications Required for Each Screening Level).

(b) Case-by-case recommendation of screening levels. For any enrollment application, the OIG may, in its sole discretion and on a case-by-case basis, recommend that HHSC assign a higher or lower screening level in accordance with §352.9(b) of this title if the OIG determines in its discretion that the applicant may pose an increased risk of committing fraud, waste, or abuse or may demonstrate unfitness to provide or bill for medical assistance items or services. The OIG may make such a recommendation after considering all circumstances, including the applicant's criminal, regulatory, and administrative sanction history, as well as the following, if applicable:

(1) The applicant or any person required to be disclosed in the enrollment application is under a payment suspension based on a credible allegation of fraud.

(2) The applicant or any person required to be disclosed in the enrollment application has failed to repay any overpayments incurred under Medicaid, CHIP, or other HHS programs.

(3) The applicant or any person required to be disclosed in the enrollment application was excluded from participation in Medicaid, CHIP, or other HHS program during the ten years before the date of the enrollment application.

(4) The applicant is seeking enrollment as a provider type that was subject to a state or federal temporary moratorium, if the moratorium was lifted within six months before the date of the enrollment application.

Source Note: The provisions of this §371.1007 adopted to be effective December 31, 2012, 37 TexReg 10189; amended to be effective May 1, 2016, 41 TexReg 2941