1301.1 For purposes of this chapter, "exclusion" means that items or services furnished by a specific provider who has defrauded or abused the Medicaid Program shall not be reimbursed under Medicaid.

1301.2 The Director shall exclude a provider from Medicaid reimbursement if he or she has done any one (1) of the following:

1. (a) Knowingly and willfully made or caused to be made any false statement or misrepresentation of material fact in claiming, or in determining the right to, payment under Medicaid;
2. (b) Furnished or ordered services under Medicaid that are substantially in excess of the recipient's needs or that fail to meet professionally recognized standards for health care;
3. (c) Submitted or caused to be submitted to the Medicaid Program bills or requests for payment containing charges or costs that are substantially in excess of customary charges or costs; or
4. (d) Engaged in Medicaid Program abuse or fraud as defined in §1399 of this chapter.

1301.3 The activities in §1301.2 may be used as a basis to terminate a provider agreement under §1302 of this chapter.

1301.4 The Director may base his or her determination that services were excessive or of unacceptable quality on reports, including sanction reports, from any or all of the following sources:

1. (a) The Professional Standard Review Organization for the area served by the provider;

(b) District, State or local licensing or certification authorities;

(c) Peer review committee or fiscal agents or contractors;

(d) District, State or local professional societies; and

(e) Other sources deemed appropriate by the Director or Health Care Financing Administration (HCFA).

SOURCE: Final Rulemaking published at 31 DCR 3870 (August 3, 1984).