Group Provider Enrollment (Exclusions/Sanctions) Page

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You use the Exclusions/Sanctions page for Group Provider Enrollment to add or edit a group provider's exclusion/sanction information to the enrollment application.

Exclusion/Sanction- Section 7 Fields

Field	Description
Subcontractor Relative Fields
1. Are any of the named owners related to owners of the subcontractor as spouse, parent, child, sibling or household member?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit relative information.
To add a new relative, click Add Name. Existing relatives, if any, are listed in a table. To edit, in the Name table, click the appropriate row. After changing or adding information, on the Name action bar, click Save.
Last Name	Last name of the relative related to owners of the subcontract.
First Name	First name of the relative related to owners of the subcontract.
MI	Middle initial of the relative related to owners of the subcontract.
Relationship	Relationship of the person to the provider.
Chain Fields
2. Is the group chain affiliated?	Select Yes or No to indicate your answer. If you select Yes, then additional fields will display for you to add or update your group chain information.
To add a new chain, click Add Chain. Existing chains, if any, are listed in a table. To edit, in the Chain table, click the appropriate row in the table. After changing or adding information, on the Chain action bar, click Save.
Business Name	Official business name of the provider group.
EIN	Organization's employer identification number.
Address	Physical street address of the provider group.
City	City where the specific provider group is located.
State	State where the specific provider group is located.
Zip	Zip code and extension where the specific provider group is located.
Phone Number	Phone number where the specific provider group is located.
Management Company Field
3. Is the group operated by a management company or leased in whole or part by another organization?	Select Yes or No to indicate your answer.
Conviction, Assessment, or Exclusion from Federal Program Fields
4. Are there any individuals or organizations having a direct or indirect ownership or controlling interest of 5% or more in the group that have been convicted of a criminal offense related to involvement of such individuals, or organization in any of the programs established by DHS?	Select Yes or No to indicate your answer.
5. Are there any directors, officers, agents, or managing employees of the group that have ever been convicted of a criminal offense related to their involvement in such programs established by DHS?	Select Yes or No to indicate your answer.
6. Has any family or household member or any person who has ownership or controlling interest in the group, ever been convicted, assessed, or excluded from any State or Federal programs 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 relative information.
To add a new relative, click Add Name. Existing relatives, if any, are listed in a table. To edit, in the Name table, click the appropriate row. After changing or adding information, on the Name action bar, click Save.
Last Name	Last name of the person convicted, assessed or excluded from the Medicaid program or any other federal program.
First Name	First name of the person convicted, assessed or excluded from the Medicaid program or any other federal program.
MI	Middle initial of the person convicted, assessed or excluded from the Medicaid program or any other federal program.
Relationship	Relationship of the person convicted to the provider.
Overpayment Fields
7. Does the applicant under any name or business identity, have any outstanding overpayments with any state or federal programs?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or update your relative information.
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 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
Felony Conviction Field
8. Has the applicant 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 submit appropriate documentation pertaining to the situation
Date Of Occurrence	Date the event 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).
9. 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.
10. Professional Board Disciplinary Action(s)?	Select Yes or No to indicate if you have had any professional board disciplinary actions.
11. Program Exclusions?	Select Yes or No to indicate if you have had any program exclusions.
12. Suspension of Payments?	Select Yes or No to indicate if you have had any payments suspended.
13. Civil Monetary Penalty(s)?	Select Yes or No to indicate if you have had any civil monetary penalties.
14. Assessment(s)?	Select Yes or No to indicate if you have had any assessments.
15. Program Debarment(s)?	Select Yes or No to indicate if you have had any program debarments.
16. Criminal Fine(s)?	Select Yes or No to indicate if you have had any criminal fines.
17. Restitution Order(s)?	Select Yes or No to indicate if you have had any restitution orders.
18. Pending Civil Judgment(s)?	Select Yes or No to indicate if you have had any pending civil judgments.
19. Pending Criminal Judgment(s)?	Select Yes or No to indicate if you have had any pending criminal judgments.
20. 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

Subcontractor Relative Fields

1. Are any of the named owners related to owners of the subcontractor as spouse, parent, child, sibling or household member?

Select Yes or No to indicate your answer.

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

To add a new relative, click Add Name. Existing relatives, if any, are listed in a table. To edit, in the Name table, click the appropriate row. After changing or adding information, on the Name action bar, click Save.

Last Name

Last name of the relative related to owners of the subcontract.

First Name

First name of the relative related to owners of the subcontract.

Middle initial of the relative related to owners of the subcontract.

Relationship

Relationship of the person to the provider.

Chain Fields

2. Is the group chain affiliated?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields will display for you to add or update your group chain information.

To add a new chain, click Add Chain. Existing chains, if any, are listed in a table. To edit, in the Chain table, click the appropriate row in the table. After changing or adding information, on the Chain action bar, click Save.

Business Name

Official business name of the provider group.

EIN

Organization's employer identification number.

Address

Physical street address of the provider group.

City

City where the specific provider group is located.

State

State where the specific provider group is located.

Zip

Zip code and extension where the specific provider group is located.

Phone Number

Phone number where the specific provider group is located.

Management Company Field

3. Is the group operated by a management company or leased in whole or part by another organization?

Select Yes or No to indicate your answer.

Conviction, Assessment, or Exclusion from Federal Program Fields

4. Are there any individuals or organizations having a direct or indirect ownership or controlling interest of 5% or more in the group that have been convicted of a criminal offense related to involvement of such individuals, or organization in any of the programs established by DHS?

Select Yes or No to indicate your answer.

5. Are there any directors, officers, agents, or managing employees of the group that have ever been convicted of a criminal offense related to their involvement in such programs established by DHS?

Select Yes or No to indicate your answer.

6. Has any family or household member or any person who has ownership or controlling interest in the group, ever been convicted, assessed, or excluded from any State or Federal programs 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 relative information.

Last Name

Last name of the person convicted, assessed or excluded from the Medicaid program or any other federal program.

First Name

First name of the person convicted, assessed or excluded from the Medicaid program or any other federal program.

Middle initial of the person convicted, assessed or excluded from the Medicaid program or any other federal program.

Relationship

Relationship of the person convicted to the provider.

Overpayment Fields

7. Does the applicant under any name or business identity, have any outstanding overpayments with any state or federal programs?

Select Yes or No to indicate your answer.

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

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 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

Felony Conviction Field

8. Has the applicant 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 submit appropriate documentation pertaining to the situation

Date Of Occurrence

Date the event 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).

9. 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.

10. Professional Board Disciplinary Action(s)?

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

11. Program Exclusions?

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

12. Suspension of Payments?

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

13. Civil Monetary Penalty(s)?

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

14. Assessment(s)?

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

15. Program Debarment(s)?

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

16. Criminal Fine(s)?

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

17. Restitution Order(s)?

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

18. Pending Civil Judgment(s)?

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

19. Pending Criminal Judgment(s)?

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

20. 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.