Mont. Admin. R. 37.85.512 - NOTICE OF ADVERSE ACTION
(1) As
provided in this rule, the department must notify a provider of any adverse
action it will take when the department has determined that the provider has
engaged in fraud, improper billing, waste, abuse, has received payment to which
the provider is not entitled, or where the department has verified a credible
allegation of fraud, as that term is defined at ARM
37.5.304. The notice must address
all of the following:
(a) a description of
the fraud, allegation, improper billing, waste, abuse, or
overpayments;
(b) the dollar value
of any overpayment;
(c) the adverse
action to be taken or sanction to be imposed by the department;
(d) explanation of any actions required of
the provider; and
(e) the
provider's right to submit written evidence for consideration by the
department, an administrative review, and fair hearing.
(2) The department is not required to notify
a provider pursuant to (1) until after the department has determined that
fraud, a credible allegation of fraud, improper billing, waste, abuse, or an
overpayment has occurred. The department is not required to notify the provider
when the department merely suspects or has information which suggests that
fraud, abuse or an overpayment has occurred or when the department has not
determined to take a particular adverse action in response to the fraud, abuse,
or overpayment.
(3) Subject to the
provisions of (4) and (5), and excepting suspensions of payment under ARM
37.85.513(3), the
department must notify the provider as required in this rule within 45 days
after the department has determined that fraud, improper billing, waste, abuse,
or an overpayment has occurred. The department's failure to notify a provider
as required by this rule is not a defense to recovery of the overpayment or
imposition of the sanction, but the department may be required to provide a new
notice in compliance with this rule.
(4) This rule shall not be construed to
require that the department investigate, complete an investigation, make a
determination or take any other action regarding a potential fraud, abuse or
overpayment within any particular time.
(5) While this rule does not require the
department to act within any particular time, if any governmental agency or
entity is conducting an investigation of a provider, the department shall not
in any event be required to notify the provider of a violation or overpayment
until the investigation is concluded and enforcement proceedings, if any, have
been completed, if in the sole discretion of the department or the governmental
agency or entity conducting the investigation, earlier notification would
interfere with or jeopardize the investigation, recovery of an overpayment or
imposition of a sanction.
Notes
53-2-201, 53-6-111, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA;
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