1. (a) NH medicaid providers and provider applicants shall meet the provider participation requirements contained in chapter He-W 500, as applicable, for providers of the type of services they will be providing, as well as requirements in this section.

2. (b) The following individuals and entities shall be subject to a risk determination:

   1. (1) NH medicaid provider applicants;
   2. (2) NH medicaid providers who are applying to enroll a new practice location(s);
   3. (3) NH medicaid providers who are re-enrolling; and
   4. (4) NH medicaid providers being revalidated in accordance with 42 CFR 455.414.
3. (c) Providers shall be categorized in one of 3 risk levels, limited, moderate, or high risk.
4. (d) For provider types that exist in both medicare and medicaid, the department shall assign the same risk category as medicare.
5. (e) Any new provider type not defined by medicare shall be assigned as moderate risk for one year. At one year, the department shall determine if the provider or provider type should remain at moderate risk or be moved to limited risk.

6. (f) Limited provider types shall be subject to all federally required database checks of those with a 5% or greater ownership and controlling interest, and managing directors of the provider, for each location, as defined under 42 CFR 455.101 and described in 42 CFR 102 and 42 CFR 104. Limited provider types include the following:

   1. (1) Physician or non-physician practitioners, including nurse practitioners, certified registered nurse anesthetists, occupational therapists, speech or language pathologists, and audiologists, and medical groups or clinics;
   2. (2) Ambulatory surgical centers (ASCs);
   3. (3) Competitive acquisition program/Part B vendors;
   4. (4) End-stage renal disease facilities (ESRDs);
   5. (5) Federally qualified health centers (FQHCs);
   6. (6) Histocompatibility laboratories;
   7. (7) Home infusion therapy suppliers;
   8. (8) Hospitals, including critical access hospitals (CAHs), Department of Veterans Affairs hospitals, and other federally-owned hospital facilities;
   9. (9) Health programs operated by an Indian Health Program, as defined in section 4(12) of the Indian Health Care Improvement Act, or an urban Indian organization, as defined in section 4(29) of the Indian Health Care Improvement Act, that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act;
   10. (10) Mammography screening centers;
   11. (11) Mass immunization roster billers;
   12. (12) Opioid treatment programs, if 42 CFR 424.67(b)(3)(ii) applies;
   13. (13) Organ procurement organizations (OPOs);
   14. (14) Pharmacies newly enrolling or revalidating via the CMS-855B application;
   15. (15) Radiation therapy centers (RTCs);
   16. (16) Religious non-medical health care institutions (RNHCIs); and
   17. (17) Rural health clinics (RHCs).

7. (g) Moderate risk providers are subject to the database checks described in (f) but also subject to a provider site visit. Moderate provider types include the following:

   1. (1) Ambulance service suppliers;
   2. (2) Community mental health centers (CMHCs);
   3. (3) Comprehensive outpatient rehabilitation facilities (CORFs);
   4. (4) Independent clinical laboratories (ICLs);
   5. (5) Independent diagnostic testing facilities (IDTFs);
   6. (6) Physical therapists enrolling as individuals or as group practices;
   7. (7) Portable x-ray suppliers (PXRSs);
   8. (8) Prospective, newly enrolling, and revalidating opioid treatment programs (OTP) that have been fully and continuously certified by the Substance Abuse and Mental Health Services Administration (SAHMSA) since October 23, 2018;
   9. (9) Revalidating durable medical equipment, prosthetic devices, prosthetics, orthotics, and supplies (DMEPOS) suppliers;
   10. (10) Revalidating home health agencies (HHAs);
   11. (11) Revalidating medicare diabetes prevention program (MDPP) suppliers;
   12. (12) Revalidating skilled nursing facilities (SNFs); and
   13. (13) Revalidating hospices.
8. (h) High risk providers are subject to (f) and (g) above, and a criminal background check including fingerprinting as described in (j) below.

9. (i) Individuals and entities in (f) and (g) above who meet either of the following criteria shall be determined to be high-risk providers or high-risk provider applicants:

   1. (1) The individual or entity, with the exception of those who are undergoing revalidation in accordance with 42 CFR 455.414, provides home health services, nursing facilities, or durable medical equipment services; or

   2. (2) The individual’s or entity’s risk level was adjusted to high by the department as required by 42 CFR 455.450(e)(1) because any of the following occurred:

      1. a. The department imposed a payment suspension on the individual or entity based on credible allegation of fraud, waste, or abuse;
      2. b. The individual or entity has an existing medicaid overpayment;
      3. c. The individual or entity was excluded from participation in a federally funded program by the office of inspector general or another state’s medicaid program within the 10 years preceding the date of application or date of revalidation; or
      4. d. In accordance with 42 CFR 455.450(e)(2), NH medicaid or the Centers for Medicare and Medicaid Services (CMS) in the previous 6 months lifted a temporary moratorium for the particular provider type and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider within 6 months from the date the moratorium was lifted.

10. (j) The following individuals and entities shall be subject to a state and federal criminal background check, including fingerprinting, in accordance with this section:

    1. (1) Persons with a direct or indirect ownership interest in a high-risk provider or high-risk provider applicant described in (i)(1) above; and
    2. (2) High-risk providers or high-risk provider applicants described in (i)(2) above.

11. (k) Those who meet the criteria in (h) above shall not be subject to an additional criminal background check, including fingerprinting, if, within the previous 36 months, they have undergone a criminal background check as required by:

    1. (1) A Medicare administrative contractor;
    2. (2) NH medicaid;
    3. (3) Any other state’s medicaid agency, and the department is able to access the information from the other state’s medicaid agency; or
    4. (4) Any other state’s children’s health insurance program (CHIP), and the department is able to access the information from the other state’s CHIP.

12. (l) Those who meet the criteria in (j) above, and who are not excluded in (k) above, shall be notified in writing of the following by the department:

    1. (1) That a state and federal criminal background check, including fingerprinting, is required;
    2. (2) Where the criminal background check, including fingerprinting, can be conducted as specified in (n)(1) below; and
    3. (3) The deadline by which the criminal background check, including fingerprinting, shall be conducted as specified in (m) below.
13. (m) The deadline for undergoing a criminal background check, including fingerprinting, shall be 30 days from the date of the notification in (l) above.

14. (n) Those who meet the criteria in (j) above, and who are not excluded in (k) above, shall undergo a state and federal criminal background check by:

    1. (1) Having a complete set of electronic fingerprints taken at any location maintained by the NH state police criminal records unit that has electronic fingerprinting capability, or by any other in or out of state law enforcement agency that conducts fingerprinting electronically; and
    2. (2) Completing and submitting to the location in (1) above a notarized department of safety’s Form DSSP 417, “New Hampshire Health and Human Services Criminal History Record Information Authorization, New Hampshire Medicaid Program” incorporated by reference in Saf-C 5703.10, Table 5700-1, which authorizes the release of the individual’s criminal history record, if any, to the department.

15. (o) Those who meet the criteria in (j) above shall be terminated from, or denied enrollment in, the NH medicaid program if:

    1. (1) The individual fails to get fingerprinted by the deadline in (m) above, as applicable; or

    2. (2) The results of the criminal background check indicate that the individual has been convicted of any of the following federal or state felony offenses within the 10 years preceding the date of application or date of revalidation of enrollment:

       1. a. Felony crimes against persons, such as murder, sexual assault, assault, interference with freedom, destruction of property, unauthorized entries, robbery and theft, fraud and corruption, and other similar crimes for which the individual was convicted, including guilty pleas;
       2. b. Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud, and other similar crimes for which the individual was convicted, including guilty pleas; or
       3. c. Any felony that placed the medicaid program or its recipients at immediate risk, such as a malpractice suit that resulted in a conviction of criminal neglect or misconduct.
16. (p) An individual or entity being terminated from, or denied enrollment in, the NH medicaid program in accordance with (o) above shall receive a written notice from the department of the denial or termination.

17. (q) The notice in (p) above shall contain:

    1. (1) The reason for, and legal basis of, the denial or termination; and
    2. (2) Information that an appeal of the denial or termination may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial or termination.
18. (r) Appeals of the results of the criminal background check shall be made in accordance with the department of safety rules at Saf-C 5703.12.

Source. #12023, INTERIM, eff 11-1-16, EXPIRES: 4-30-17; ss by #12166, eff 4-29-17; ss by 14415, eff 10-22-25, EXPIRES 10-22-35