Individual Provider Enrollment (Exclusion/Sanction) Page

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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, Assessment, or Exclusion from Federal Program Fields
1. Have you or any member of your immediate family ever been convicted, assessed, or excluded from the Medicare, Medicaid, or State Health Insurance Program,or any federal program due to fraud, obstruction of an investigation, or a controlled substance violation?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit your conviction information.
To add a new conviction, click Add Conviction. Existing convictions, if any, are listed in a table. To edit, in the Conviction table, click the appropriate row. After changing or adding information, on the Add Family/Household Information action bar, click Save.
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.
Suffix	Suffix of the person convicted, assessed or excluded from the Medicaid program.
Relationship	Relationship of the person convicted to the provider.
Overpayment Fields
2. Do you under any name or business identity have any outstanding overpayments with any federal or state program?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit the federal or state programs.
To add a new federal program, click Add Federal Program. Existing overpayments, if any, are listed in a table. To edit, in the Federal Program table, click the appropriate row. After changing or adding information, on the Federal Program action bar, click Save.
Federal Program Name	Name of the federal Medicaid program you currently have an outstanding overpayment with.
Last Name or Business Name	Last name of the person who or the name of the business that 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.
Suffix	Suffix of the person who has the outstanding overpayment.
Felony Conviction Fields
3. Have you ever been convicted of a felony under Federal or State Law?	Select Yes or No to indicate your answer. If you select Yes, you must provide appropriate documentation about the situation and enter the date of the conviction.
Date of Occurrence	Date the conviction occurred. Format: MM/DD/YYYY, or click the calendar to select.
Adverse Legal Action Fields Please indicate for each item below whether you have ever had any of the following adverse legal actions imposed or pending by Medicaid or any federal agency or program. Check the appropriate item and indicate the date when the adverse legal action was imposed. Important: Please attach copy(s) of adverse legal action notification(s).
4. Administrative Sanction(s)?	Select Yes or No to indicate if you have had any administrative sanctions. If you select Yes, then an additional field is displayed for you to add the date of occurrence.
Date of Occurrence	Date the event occurred. Format: MM/DD/YYYY, or click the calendar to select. Note: The Date of Occurrence field appears after each additional question if Yes is selected.
5. Professional Board Disciplinary Action(s)?	Select Yes or No to indicate if you have had any professional board disciplinary actions.
6. Program Exclusion(s)?	Select Yes or No to indicate if you have had any program exclusions.
7. Suspension of Payment(s)?	Select Yes or No to indicate if you have had any suspension of payments.
8. Civil Monetary Penalty(s)?	Select Yes or No to indicate if you have had any civil monetary penalties.
9. Assessment(s)?	Select Yes or No to indicate if you have had any assessments.
10. Program Debarment(s)?	Select Yes or No to indicate if you have had any program debarments.
11. Criminal Fine(s)?	Select Yes or No to indicate if you have had any criminal fines.
12. Restitution Order(s)?	Select Yes or No to indicate if you have had any restitution orders.
13. Pending Civil Judgment(s)?	Select Yes or No to indicate if you have had any pending civil judgments.
14. Pending Criminal Judgments	Select Yes or No to indicate if you have had any pending criminal judgments.
15. Judgment(s) Pending under the False Claims Act?	Select Yes or No to indicate if you have had any judgments pending under the False Claims Act.

Field

Description

Conviction, Assessment, or Exclusion from Federal Program Fields

1. Have you or any member of your immediate family ever been convicted, assessed, or excluded from the Medicare, Medicaid, or State Health Insurance Program,or any federal program due to fraud, obstruction of an investigation, or a controlled substance violation?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit your conviction information.

To add a new conviction, click Add Conviction. Existing convictions, if any, are listed in a table. To edit, in the Conviction table, click the appropriate row. After changing or adding information, on the Add Family/Household Information action bar, click Save.

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.

Suffix

Suffix of the person convicted, assessed or excluded from the Medicaid program.

Relationship

Relationship of the person convicted to the provider.

Overpayment Fields

2. Do you under any name or business identity have any outstanding overpayments with any federal or state program?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit the federal or state programs.

To add a new federal program, click Add Federal Program. Existing overpayments, if any, are listed in a table. To edit, in the Federal Program table, click the appropriate row. After changing or adding information, on the Federal Program action bar, click Save.

Federal Program Name

Name of the federal Medicaid program you currently have an outstanding overpayment with.

Last Name or Business Name

Last name of the person who or the name of the business that has the outstanding overpayment.

First Name

First name of the person who has the outstanding overpayment.

Middle initial of the person who has the outstanding overpayment.

Suffix

Suffix of the person who has the outstanding overpayment.

Felony Conviction Fields

3. Have you ever been convicted of a felony under Federal or State Law?

Select Yes or No to indicate your answer.

If you select Yes, you must provide appropriate documentation about the situation and enter the date of the conviction.

Date of Occurrence

Date the conviction occurred.

Format: MM/DD/YYYY, or click the calendar to select.

Adverse Legal Action Fields

Please indicate for each item below whether you have ever had any of the following adverse legal actions imposed or pending by Medicaid or any federal agency or program. Check the appropriate item and indicate the date when the adverse legal action was imposed.

Important: Please attach copy(s) of adverse legal action notification(s).

4. Administrative Sanction(s)?

Select Yes or No to indicate if you have had any administrative sanctions.

If you select Yes, then an additional field is displayed for you to add the date of occurrence.

Date of Occurrence

Date the event occurred.

Format: MM/DD/YYYY, or click the calendar to select.

Note: The Date of Occurrence field appears after each additional question if Yes is selected.

5. Professional Board Disciplinary Action(s)?

Select Yes or No to indicate if you have had any professional board disciplinary actions.

6. Program Exclusion(s)?

Select Yes or No to indicate if you have had any program exclusions.

7. Suspension of Payment(s)?

Select Yes or No to indicate if you have had any suspension of payments.

8. Civil Monetary Penalty(s)?

Select Yes or No to indicate if you have had any civil monetary penalties.

9. Assessment(s)?

Select Yes or No to indicate if you have had any assessments.

10. Program Debarment(s)?

Select Yes or No to indicate if you have had any program debarments.

11. Criminal Fine(s)?

Select Yes or No to indicate if you have had any criminal fines.

12. Restitution Order(s)?

Select Yes or No to indicate if you have had any restitution orders.

13. Pending Civil Judgment(s)?

Select Yes or No to indicate if you have had any pending civil judgments.

14. Pending Criminal Judgments

Select Yes or No to indicate if you have had any pending criminal judgments.

15. Judgment(s) Pending under the False Claims Act?

Select Yes or No to indicate if you have had any judgments pending under the False Claims Act.