Individual Billing Provider Enrollment (Exclusion/Sanction) Page

You use the Exclusion/Sanction page to add or edit exclusion/sanction information for individual provider's enrollment application.

Exclusion/Sanction- Section 7 Fields

Field Description

Conviction Information Fields

1. Has any person who has ownership of, or a controlling interest in, the provider's practice or business entity, or who is an agent, managing employee, contract employee, subcontractor, or employee of the provider's practice or business entity, ever been convicted of a criminal offense related to the New Hampshire's Medical Assistance programs, the Medicaid program in another state or territory, the Medicare program, or any other federally funded health or social service program?

Select Yes or No to indicate the provider's answer.

If you select Yes, then additional fields are displayed for you to add or edit the provider's conviction information.
To add a new conviction information, click Add Conviction Information. To edit, in the Conviction Information table, click the appropriate row.
Last Name Last name of the person convicted, assessed or excluded from the Medicaid program.
First Name First name of the person convicted, assessed or excluded from the Medicaid program.
Middle Initial Middle name of the person convicted, assessed or excluded from the Medicaid program.
Relationship Relationship of the person convicted to the provider.
Type of Conviction Type of conviction implied.
Date of Conviction Date on which the person was convicted, assessed or excluded from the Medicaid program.
Conviction City City in which the person was convicted, assessed or excluded from the Medicaid program.
Conviction State State in which the person was convicted, assessed or excluded from the Medicaid program.
Program Type The program type of the conviction.
2. Have you or any member of your immediate family ever been convicted, assessed, debarred, or excluded from the Medicaid, Medicare, or Title XVIII, Title XIX, Title XX Social Security program or any other federal program due to fraud, obstruction of an investigation, or controlled substance violation?

Select Yes or No to indicate the provider's answer.

If you select Yes, additional fields are displayed for you to complete.
To add a new conviction record, click Add Conviction Information. To edit, in the Conviction Information table, click the appropriate row.
Last Name Last name of the relative related to the provider.
First Name First name of the relative related to the provider.
MI Middle initial of the relative related to the provider.
Relationship Relationship of the person to the provider.
Type of Conviction Type of conviction implied.
Date of Conviction Date on which the person was convicted for fraud, obstruction of an investigation, or controlled substance violation.
Conviction City City in which the person was convicted for fraud, obstruction of an investigation, or controlled substance violation.
Conviction State State in which the person was convicted for fraud, obstruction of an investigation, or controlled substance violation.
Program Type The program type of the conviction.
Overpayment Fields
3. Do you, under any name or business identity, have any outstanding overpayments with any state or federal program?

Select Yes or No to indicate the provider's answer.

If you select Yes, then additional fields are displayed for you to add or edit the overpayment information.
To add a new overpayment record, click Add Overpayment Information. To edit, in the Overpayment Information table, click the appropriate row. After changing or adding information, on the Overpayment Information panel action bar, click Save.
Last Name Last name of the person who has the outstanding overpayment.
First Name First name of the person who has the outstanding overpayment.
MI Middle initial of the person who has the outstanding overpayment.
Overpayment Amount The total amount of outstanding overpayment.
Program Type The program type of overpayment.
Restitution Information Fields
4. Have you ever plead guilty, no contest or been sentenced for any felony crime and/or had a criminal fine or restitution order assessed or do you have a felony charge pending under Federal or State Law?

Select Yes or No to indicate the provider's answer.

If you select Yes, then additional fields are displayed.
To add a new restitution record, click Add Restitution Information. To edit, in the Restitution Information table, click the appropriate row.
Last Name Last name of the person with felony charge pending under Federal or State law.
First Name First name of the person with felony charge pending under Federal or State law.
MI Middle name of the person with felony charge pending under Federal or State law.
Type of Conviction Type of conviction implied.
Date of Conviction Date on which the person was convicted of felony charge.
Conviction City City in which the person was convicted of felony charge.
Conviction State State in which the person was convicted of felony charge.
Program Type The program type of the felony charge.
Sanction Information Fields
5. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been sanctioned by the Office of Inspector General (OIG), Medicare, Medicaid, or the Social Security Act, including a state Medicaid program?

Select Yes or No to indicate the provider's answer.

If you select Yes, then additional fields are displayed.
To add a new sanction information, click Add Sanction Information. To edit, in the Sanction Information table, click the appropriate row.
Last Name Last name of the person who has been sanctioned.
First Name First name of the person who has been sanctioned.
MI Middle initial of the person who has been sanctioned.
Relationship Relationship of the person to the provider.
Type of Sanction The type of sanction issued.
Date of Sanction Date on which the person was sanctioned.
Sanction City City in which the person was sanctioned.
Sanction State State in which the person was sanctioned.
Program Type The program type of the sanction.
Detailed Information Fields
6. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been denied malpractice insurance or ever voluntarily or involuntarily agreed to any limitations, restrictions, or conditions to your license, certification, or permit including any formal or informal Professional Board Disciplinary Action(s)?

Select Yes or No to indicate the provider's answer.

If you select Yes, then additional fields are displayed.
To add detailed information, click Add Detailed Information. To edit, in the Detailed Information table, click the appropriate row.
Last Name Last name of the person convicted for formal or informal Professional Board Disciplinary Actions.
First Name First name of the person convicted for formal or informal Professional Board Disciplinary Actions.
MI Middle initial of the person convicted for formal or informal Professional Board Disciplinary Actions.
Relationship Relationship of the person convicted to the provider.
Date of Occurrence Date on which the person was convicted.
State Occurred State in which the person was conviction.
Description Description about the conviction, if any.
Exclusion Information Fields
7. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever had any Program Exclusions from any federally funded program? Select Yes or No. If you select Yes, then additional fields are displayed.
To add exclusion information, click Add Exclusion Information. To edit, in the Exclusion Information table, click the appropriate row.
Last Name Last name of the person who had program exclusions from the federally funded program.
First Name First name of the person who had program exclusions from the federally funded program.
MI Middle initial of the person who had program exclusions from the federally funded program.
Relationship Relationship of the person convicted to the provider.
Date of Occurrence Date on which the person was excluded.
State Occurred State in which the person was excluded.
Description Description about the exclusion, if any.
Litigation Information Fields
8. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, been involved in any civil litigation whereby a judgment or settlement was entered into, or a Civil Monetary Penalty(s) was paid? Select Yes or No. If you select Yes, then additional fields are displayed.
To add a new litigation information, click Add Litigation Information. To edit, in the Litigation Information table, click the appropriate row.
Last Name Last name of the person who was involved in civil litigation.
First Name First name of the person who was involved in civil litigation.
MI Middle name of the person who was involved in civil litigation.
Relationship Relationship of the person convicted to the provider.
Date of Occurrence Date on which the person was convicted.
State Occurred State in which the person was convicted.
Description Description about the conviction, if any.
Pending Action Information Fields
9. Do you or any of your employees, contract employees, or any person or entity with ownership of your business have any judgments(s) or Pending Actions under the False Claims Act? Select Yes or No. If you select Yes, then additional fields are displayed.
To add a pending action record, click Add Pending Actions. To edit the pending action information, click the appropriate row.
Last Name Last name of the person who was involved in any Judgment(s) or Pending Actions under the False Claims Act.
First Name First name of the person who was involved in any Judgment(s) or Pending Actions under the False Claims Act.
MI Middle name of the person who was involved in any Judgment(s) or Pending Actions under the False Claims Act.
Relationship Relationship of the person involved to the provider.
Date of Occurrence Date on which the person was involved.
State Occurred State in which the person was involved.
Description Description about the involvement, if any.
Payment Suspension Fields
10. Have you, under any name or business identity, ever had suspended payment by any state or federal program? Select Yes or No. If you select Yes, then additional fields are displayed.
To add a new payment suspension, click Add Payment Suspension. To edit, in the Payment Suspension table, click the appropriate row.
Last Name Last name of the person who was involved in payment suspension by the state or federal program.
First Name First name of the person who was involved in payment suspension by the state or federal program.
MI Middle name of the person who was involved in payment suspension by the state or federal program.
Suspension Amount The suspension amount paid by the person.
Program Type The program type of payment suspension.
Disposition The disposition of the payment suspension.