7 AAC 43.982. Restrictions on payments

(a) Upon notice to a provider, the department may place restrictions on the payment of claims submitted by the provider, including the necessity of the provider to obtain prior authorization of services or to submit to prepayment review of claims, if

(1) the department has reason to believe, based on reliable information or evidence, that the provider has violated its provider agreement or an applicable statute or regulation, and the department is reviewing, auditing, or investigating the provider's compliance with the requirements of 7 AAC 43.030 or other sections of this chapter; or

(2) a state professional licensing or certifying agency is investigating the provider for having committed fraud, abuse, professional misconduct, unprofessional conduct, or a violation of a statute or regulation.

(b) A restriction imposed under this section may continue until the department issues a notice of informal resolution under (d) of this section or until any related proceedings to impose sanctions against the provider under 7 AAC 43.950 - 7 AAC 43.985 are resolved.

(c) The department will not impose a restriction under this section until the provider receives written notice of the department's intent to do so. The notice will

(1) identify the restriction and state that it has been imposed on the payment of claims submitted by the provider;

(2) state that the restriction will continue until the department issues a written notice of informal resolution under (d) of this section or until any related proceedings to impose sanctions against the provider under 7 AAC 43.950 - 7 AAC 43.985 are resolved;

(3) specify, when appropriate, each type of medical assistance claim to which the restriction applies;

(4) specify, when appropriate, general allegations that justify the imposition of the restriction;

(5) state that the provider's failure to comply with the restriction imposed under this section may result in the imposition of sanctions under 7 AAC 43.950; and

(6) inform the provider of the right to submit written information and materials for consideration by the department in resolving the matter.

(d) The department will remove the restriction and issue a notice of informal resolution if it determines that a provider did not commit the violations alleged or that the violations do not merit the imposition of sanctions. If the provider is found to have committed violations, the department will

(1) include in the notice of informal resolution a description of each violation, specifying the statute or regulation found to have been violated; and

(2) refer the provider to written materials designed to help the provider avoid similar violations in the future.

History: Eff. 6/19/2004, Register 170

Authority: AS 47.05.010

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