SECTION 371.1651. Provider Eligibility

A person is subject to administrative actions or sanctions if the person:

(1) is suspended, terminated, or otherwise sanctioned by Medicare, Medicaid, another HHS program, CHIP, or any state or federally funded health care program;

(2) is affiliated with a person who has been suspended, terminated, or otherwise prohibited from participating in Medicare, Texas Medicaid, CHIP, or other HHS program;

(3) is a provider and any person with an ownership interest in the provider has been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or Title XXI program in the last ten years;

(4) is a person with an ownership or control interest in a provider or is an agent or managing employee of the provider and fails to:

(A) disclose or submit timely and accurate information, including fingerprints if required by federal or state rule, statute, regulation, or published policy; or

(B) cooperate with any and all screening methods required during the provider screening process under statute or regulation;

(5) is a provider, has an ownership or control interest in a provider, or is an agent or managing employee of a provider and fails to:

(A) submit timely and accurate information, including fingerprints if required by CMS or state rule; and

(B) cooperate with any and all screening methods required during the provider screening process as provided by statute, rule, or regulation;

(6) is a provider or person with an ownership interest in the provider and fails to timely submit sets of fingerprints during the provider screening process as required by rule, statute, or other regulation;

(7) fails to permit access to any and all provider locations for unannounced or announced on-site visits or inspections during the provider screening process as required by rule, statute, or other regulation;

(8) falsifies any information provided on a provider enrollment application;

(9) is a provider whose identity CMS or the OIG is unable to verify;

(10) has a criminal history that would result in denial of a provider enrollment application pursuant to rule;

(11) fails to disclose or omits any material fact on a provider enrollment application;

(12) fails to meet standards required for licensure or loses licensure, as finally determined by the licensing authority, when such licensure is required by state or federal law, administrative rule, provider agreement, or provider manual for participation in the Medicaid or other HHS program;

(13) fails to fully and accurately make any disclosure required by the Social Security Act §1124 or §1126;

(14) fails to identify or disclose in the provider screening process for any HHS program:

(A) all persons with a direct or indirect ownership or control interest, as defined by 42 C.F.R. §455.101;

(B) all information required to be disclosed in accordance with state administrative rule, 42 C.F.R. Part 1001, or other by statute, rule, or regulation;

(C) all agents or subcontractors of the provider:

(i) if the provider or a person with an ownership interest in the provider has an ownership interest in the agent or subcontractor; or

(ii) if the provider engages in a business transaction with the agent or subcontractor that meets the criteria specified by 42 C.F.R. §455.105;

(15) makes a false statement, misrepresentation or omission of a pertinent fact on, or fails to fully or correctly complete or execute a provider enrollment application, provider agreement or amendment, reinstatement request or any document requested as a prerequisite for Medicaid or other HHS program participation; or

(16) fails to timely correct, supplement, or update information on a provider enrollment application, provider agreement or amendment, reinstatement request, or any document requested as a prerequisite for continued Medicaid or other HHS program participation, including:

(A) change of mailing address;

(B) fax number;

(C) loss or forfeiture of corporate charter; or

(D) change in ownership.

Source Note: The provisions of this §371.1651 adopted to be effective October 14, 2012, 37 TexReg 7989; amended to be effective May 1, 2016, 41 TexReg 2941