California Health and Safety Code

§ 100185.5

HSC § 100185.5 Effective Jan 1, 2013Div. 101 · Part 1 · Ch. 2 · Art. 1

Statute text

(a)When a letter or order of denial of continued enrollment or suspension of any type or duration, based upon fraud or abuse, or a suspension of payments pursuant to Section 14107.11 of the Welfare and Institutions Code, is issued by the department to a provider, the director shall review the evidence supporting the denial of continued enrollment, suspension, or suspension of payments. If, in the opinion of the director, the evidence shows a pattern or practice of fraud, abuse, or willful misrepresentation that, if replicated in any other health care program administered by the department, could cause either fiscal loss to the state or harm to any participant, the director may deny continued enrollment, suspend, or suspend payments to, the provider with respect to those other health care programs. Any denial of continued enrollment, suspension, or suspension of payments may be for an indefinite or definite period of time, may be stayed for a period of time, and may be with or without conditions or probation.

(b)The director may deny the application of an applicant or provider to participate in any health care program administered by the department, when, based upon fraud or abuse, the applicant or provider has been denied continued enrollment in, or suspended from, any health care program administered by the department, or has had payments suspended in connection with the Medi-Cal program pursuant to Section 14107.11 of the Welfare and Institutions Code by the department, and remains ineligible to participate in the health care program from which the applicant or provider was denied continued enrollment, suspended, or had payments suspended.

(c)The director may deny any new or additional application of a provider to participate in any health care program administered by the department if utilization controls including, but not limited to, prior authorization or special claims review pursuant to Sections 51159, 51455, and 51460 of Title 22 of the California Code of Regulations have been imposed upon that provider by any health care program administered by the department. Applications shall not be denied based solely upon utilization controls imposed upon an entire class or category of providers to which that provider belongs.

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Legislative history

Amended by Stats. 2012, Ch. 797, Sec. 1. (SB 1529) Effective January 1, 2013.