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California Law (Last Updated: March 4, 2014) |
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Welfare and Institutions Code - WIC |
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Division 9. PUBLIC SOCIAL SERVICES |
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Part 3. AID AND MEDICAL ASSISTANCE |
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Chapter 7. Basic Health Care |
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ARTICLE 1.3. Provider Enrollment, Application, and Participation |
Section 14043.38.
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(a) Provider types are designated as "limited," "moderate," or "high" categorical risk by the federal government in Section 424.518 o. The department shall, at minimum, utilize the federal regulations in determining a provider's or applicant's categorical risk.
(b) If the department designates a provider as a "high" categorical risk, the department shall conduct a criminal background check and shall require submission of a set of fingerprints in accordance with Section 13000 of the Penal Code. If fingerprints are required, providers and any person with a 5-percent direct or indirect ownership interest in the provider shall be required to submit fingerprints in a manner determined by the department within 30 days of the request.
(c) In accordance with Section 455.450 o, the department shall designate a provider as a "high" categorical risk if any of the following occur:
(1) The department imposes a payment suspension based on a credible allegation of fraud, waste, or abuse.
(2) The provider has an existing Medicaid overpayment based on fraud, waste, or abuse.
(3) The provider has been excluded by the federal Office of the Inspector General or another state's Medicaid program within the previous 10 years.
(4) The federal Centers for Medicare and Medicaid Services lifted a temporary moratorium within the previous six months for the particular provider type submitting the application, the applicant would have been prevented from enrolling based on that previous moratorium, and the applicant applies for enrollment as a provider at any time within six months from the date the moratorium was lifted.
(d) (1) This section shall become operative on the effective date of the state plan amendment necessary to implement this section, as stated in the declaration executed by the director pursuant to paragraph (2).
(2) Upon approval of the state plan amendment necessary to implement this section under Sections 424.518, 455.434, and 455.450 o, the director shall execute a declaration, to be retained by the director and posted on the department's Internet Web site, that states that this approval has been obtained and the effective date of the state plan amendment. The department shall transmit a copy of the declaration to the Legislature.