100185.5. (a) When a letter or order of denial of continued enrollment or suspension of any type or duration, based upon fraud or abuse, or a suspension of payments pursuant to Section 14107.11 of the Welfare and Institutions Code, is issued by the department to a provider, the director shall review the evidence supporting the denial of continued enrollment, suspension, or suspension of payments. If, in the opinion of the director, the evidence shows a pattern or practice of fraud, abuse, or willful misrepresentation that, if replicated in any other health care program administered by the department, could cause either fiscal loss to the state or harm to any participant, the director may deny continued enrollment, suspend, or suspend payments to, the provider with respect to those other health care programs. Any denial of continued enrollment, suspension, or suspension of payments may be for an indefinite or definite period of time, may be stayed for a period of time, and may be with or without conditions or probation.
(b) The director may deny the application of an applicant or provider to participate in any health care program administered by the department, when, based upon fraud or abuse, the applicant or provider has been denied continued enrollment in, or suspended from, any health care program administered by the department, or has had payments suspended in connection with the Medi-Cal program pursuant to Section 14107.11 of the Welfare and Institutions Code by the department, and remains ineligible to participate in the health care program from which the applicant or provider was denied continued enrollment, suspended, or had payments suspended.
(c) The director may deny any new or additional application of a provider to participate in any health care program administered by the department if utilization controls including, but not limited to, prior authorization or special claims review pursuant to Sections 51159, 51455, and 51460 of Title 22 of the California Code of Regulations have been imposed upon that provider by any health care program administered by the department. Applications shall not be denied based solely upon utilization controls imposed upon an entire class or category of providers to which that provider belongs.
(d) Notwithstanding any other law, any provider or applicant who has been denied continued enrollment in, or suspended from, or that has had payments suspended in connection with, any health care program administered by the department, or whose application to participate in a health care program administered by the department is denied, pursuant to this section, may appeal that action in accordance with Section 14043.65 of the Welfare and Institutions Code.
(e) For purposes of this section, the following definitions apply:
(1) “Abuse” has the same meaning as that term is defined in Section 14043.1 of the Welfare and Institutions Code.
(2) “Administered by the department” means administered by the State Department of Health Care Services or by its agents or contractors on behalf of the State Department of Health Care Services.
(3) “Applicant” means any person, individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that applies to the department for enrollment as a provider or participation as a provider in a health care program administered by the department.
(4) “Fraud” has the same meaning as that term is defined in Section 14043.1 of the Welfare and Institutions Code.
(5) “Provider” means any person, individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that provides services, goods, supplies, or merchandise, directly or indirectly, to a person enrolled in a health care program administered by the department.
(6) “Payment suspension” means the suspension of payments in accordance with Section 14107.11 of the Welfare and Institutions Code.
(f) For purposes of this section, “suspension” includes, but is not limited to, suspensions authorized under Article 1.3 (commencing with Section 14043) or Article 3 (commencing with Section 14123) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code.
(g) For purposes of this section, “health care program administered by the department” includes, but is not limited to, the Medi-Cal program.
(Amended by Stats. 2012, Ch. 797, Sec. 1. (SB 1529) Effective January 1, 2013.)