Title 42
State Affairs and Government

Chapter 7.2
Office of Health and Human Services

§ 42-7.2-18.1. Professional responsibility — Criminal records check for high-risk providers.

(a) As a condition of enrollment and/or continued participation as a Medicaid provider, applicants to become and/or remain a provider shall be required to undergo criminal records checks including a national criminal records check supported by fingerprints by the level of screening based on risk of fraud, waste, or abuse as determined by the executive office of health and human services for that category of Medicaid provider.

(b) Establishment of risk categories.  The executive office of health and human services, in consultation with the department of attorney general, shall establish through regulation, risk categories for Medicaid providers and provider categories who pose an increased financial risk of fraud, waste, or abuse to the Medicaid/CHIP program, in accordance with 42 C.F.R. §§ 455.434 and 455.450.

(c) High-risk categories, as determined by the executive office of health and human services, may include:

(1) Newly enrolled home health agencies that have not been Medicare certified;

(2) Newly enrolled durable medical equipment providers;

(3) New or revalidating providers that have been categorized by the executive office of health and human services as high risk;

(4) New or revalidating providers with payment suspension histories;

(5) New or revalidating providers with office of inspector general exclusion histories;

(6) New or revalidating providers with qualified overpayment histories; and

(7) New or revalidating providers applying for enrollment post debarment or moratorium (Federal or State-based).

(d) Upon the state Medicaid agency determination that a provider or an applicant to become a provider, or a person with a five percent (5%) or more direct or indirect ownership interest in the provider, meets the executive office of health and human services’ criteria for criminal records checks as a “high” risk to the Medicaid program, the executive office of health and human services shall require that each such provider or applicant to become a provider undergo a national criminal records check supported by fingerprints.

(e) The executive office of health and human services shall require such a “high risk” Medicaid provider or applicant to become a provider, or any person with a five percent (5%) or more direct or indirect ownership interest in the provider, to submit to a national criminal records check supported by fingerprints within thirty (30) days upon request from the Centers for Medicare and Medicaid Services or the executive office of health and human services.

(f) The Medicaid providers requiring the national criminal records check shall apply to the department of attorney general bureau of criminal identification (BCI) to be fingerprinted. The fingerprints will subsequently be transmitted to the federal bureau of investigation for a national criminal records check. The results of the national criminal records check shall be made available to the applicant undergoing a records check and submitting fingerprints.

(g) Upon the discovery of any disqualifying information, as defined in § 42-7.2-18.2 and as in accordance with the regulations promulgated by the executive office of health and human services, the bureau of criminal identification of the department of the attorney general will inform the applicant, in writing, of the nature of the disqualifying information; and, without disclosing the nature of the disqualifying information, will notify the executive office of health and human services, in writing, that disqualifying information has been discovered.

(h) In those situations in which no disqualifying information has been found, the bureau of criminal identification of the department of the attorney general shall inform the applicant and the executive office of health and human services, in writing, of this fact.

(i) The applicant shall be responsible for the cost of conducting the national criminal records check through the bureau of criminal identification of the department of attorney general.