Mont. Admin. R. 37.85.513 - SUSPENSION OR WITHHOLDING OF PAYMENTS
(1)
Where the department has notified a provider of a violation, sanction, or an
overpayment pursuant to ARM
37.85.512 the department may
withhold payments on pending and subsequently received claims in an amount
reasonably calculated to approximate the amounts in question or may suspend all
payments pending the outcome of a departmental or law enforcement
investigation.
(2) Where the
department intends to withhold or suspend payments not regarding a credible
allegation of fraud, as that term is defined at ARM
37.5.304, it shall notify the
provider in writing at least ten days prior to commencement of withholding and
shall include a statement of the provider's right to request an informal
reconsideration of such decision as provided in ARM
37.5.305. This rule does not
require that an informal reconsideration or any hearing be conducted prior to
the withholding or suspension of payments.
(3) Where the department suspends payments
based on a credible allegation of fraud in accordance with
42 CFR
455.23, the department may suspend payments
without first notifying the provider.
(a) The
department must send notice of its suspension of payments within the following
timeframes:
(i) five days of taking such
action unless requested in writing by a law enforcement agency to temporarily
withhold such notice;
(ii) thirty
days if requested by law enforcement in writing to delay sending such notice,
which request for delay may be renewed in writing up to twice and in no event
exceed 90 days.
(b) In
addition to the noticing requirements of ARM
37.85.512(1), the
notice must state that the suspension is in accordance with
42 CFR
455.23 and is for a temporary period and cite
the circumstances under which the withholding will be terminated. Suspension of
payment will not continue after either of the following:
(i) the agency or the prosecuting authorities
determine that there is insufficient evidence of fraud or willful
misrepresentation by the provider; or
(ii) legal proceedings related to the
provider's alleged fraud are completed.
(4) Where the department has terminated or
suspended a provider, the provider shall be eligible to bill for covered
services for the period covered by the suspension or termination if an appeal
is decided in the provider's favor.
Notes
53-2-201, 52-2-211, 53-6-111, 53-6-113, MCA; IMP, 52-2-112, 53-2-201, 53-6-111, MCA;
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