Txoj Cai Tswjfwm Ntiag Tug & Kev Tswj Xyuas Kev Siv
Rov qab mus rau Qhov Chaw Tshawb Fawb Hauv Tsev
Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (Department) muaj txoj cai nyob rau hauv Txoj Cai Welfare thiab Institutions Code los txiav txim rau kev tswj hwm thiab kev tswj xyuas kev siv ntawm Medi-Cal cov kws kho mob. Qee qhov piv txwv ntawm kev rau txim thiab kev siv cov kev tswj xyuas muaj xws li hauv qab no:
Kev Them Nyiaj Ib ntus
Kev ncua kev them nyiaj ib ntus suav nrog kev txiav nyiaj rov qab rau cov ntawv thov xa tuaj. Thaum cov kws kho mob raug muab tso rau qhov kev ncua sij hawm them nyiaj ib ntus, lawv tuaj yeem them nqi ntxiv rau qhov kev pab cuam Medi-Cal rau cov kev pab cuam. Cov nyiaj them rov qab uas lawv thov raug txiav tawm thiab muab tso rau hauv ib qho nyiaj tshwj xeeb tuav, tos qhov tshwm sim ntawm kev tshawb nrhiav.
Thaum tau txais kev lees paub txog kev dag ntxias raws li tau hais hauv subdivision (d) thiab qhov kev tshawb nrhiav tseem tab tom nyob hauv Medi-Cal qhov kev pab cuam tawm tsam tus kws kho mob raws li tau teev tseg hauv Tshooj 14043.1, lossis pib qhov kev ncua raws li Tshooj 14123, tus kws kho mob yuav tsum tau muab tso rau ib ntus raws li kev them nyiaj tsis raug txiav txim siab, tshwj tsis yog kev txiav txim siab zoo. kev them nyiaj lossis ncua lawv tsuas yog hauv ib feem.
(Kev Noj Qab Haus Huv thiab Institutions Code, Tshooj 14107.11 thiab Welfare and Institutions Code Section 24005 [FPACT]; 42 CFR Section 455.23).
Kev ncua ib ntus
A temporary suspension allows the Department to temporarily suspend a provider from the Medi-Cal Program. Providers placed on temporary suspension are not entitled to reimbursement for any services provided to Medi-Cal beneficiaries.
Yog tias pom tias tus kws kho mob tab tom tshawb xyuas los ntawm lub tuam tsev lossis ib lub xeev, hauv zos, lossis tseemfwv qib siab tswj hwm txoj cai lij choj rau kev dag lossis kev tsim txom, tus kws kho mob yuav raug ncua ib ntus los ntawm Medi-Cal qhov kev pab cuam, uas yuav tsum suav nrog kev tsis ua haujlwm ib ntus ntawm tus kws kho mob tus lej, suav nrog txhua qhov chaw nyob ua lag luam siv los ntawm tus kws kho mob kom tau txais cov nyiaj them rov qab los ntawm Medi-Cal.
(Kev Noj Qab Haus Huv thiab Lub Tsev Haujlwm Txoj Cai Tshooj 14043.36 (a))
Cov txheej txheem / Kev Cai Tshuaj Txhaum Cai (P / DCL)
The Department may limit, for 18 months or less, the American Medical Association’s Current Procedural Terminology Fourth Edition (CPT‐4) codes, the National Drug Codes (NDC), the Healthcare Common Procedure Coding System (HCPCS) codes, or codes established under Title II of the Health Insurance Portability & Accountability Act of 1996 (42 U.S.C. Sec. 1320d et seq.) for which any provider may bill, or for which reimbursement to any person or entity may be made by, the Medi‐Cal program or other health care programs administered by the Department if either of the following conditions exist:
(1) Lub Tsev Haujlwm txiav txim siab, los ntawm kev tshuaj xyuas lossis lwm yam kev tshawb nrhiav, tias cov kev pabcuam ntau dhau lossis kev them nqi, lossis kev tsim txom, tau tshwm sim, uas yuav suav nrog Lub Tsev Haujlwm nrhiav pom lossis txiav txim siab tias qhov kev thov raug xa rov qab los ntawm Medi-Cal qhov kev pabcuam rau kev kuaj ntshav qabzib, electromyography, lossis cov txheej txheem, kuaj, kuaj, lossis lwm yam kev pabcuam khomob uas Lub Tsev Haujlwm tau teev tseg lossis tsis muaj cov ntaub ntawv sau tseg, tab sis tsis muaj qee yam kev pabcuam. tus neeg lossis lub koomhaum xa daim ntawv thov nyiaj rov qab tsis muaj, daim ntawv pov thawj lossis daim ntawv pov thawj xav tau los ntawm Tshooj 14170.11.
(2) Lub Tsev Haujlwm Saib Xyuas Kev Khomob hauv California lossis lwm lub chaw tso cai lossis lub tsev hais plaub uas muaj peev xwm txwv tsis pub tus neeg muaj cai siv tshuaj lossis ua haujlwm khomob, thiab qhov txwv txwv tsis pub tus neeg muaj ntawv tso cai ua cov kev pabcuam uas tuaj yeem them rov qab los ntawm Medi-Cal program lossis lwm yam kev pabcuam khomob uas tswj hwm los ntawm Lub Tsev Haujlwm.
(Welfare and Institutions Code, section 14044 (a)(1), 22 California Code of Regulations (CCR) Sections 51481, 51485, 54209).
Kev nplua nyiaj pej xeem (CMP)
Ib tus neeg muab kev pabcuam lossis tus neeg uas nthuav tawm lossis ua rau muaj kev thov rau kev pabcuam rau tus tub ceev xwm, tus neeg ua haujlwm, lossis tus neeg sawv cev ntawm lub xeev, lossis ntawm Lub Tsev Haujlwm lossis lub koomhaum uas tau hais tseg hauv lub xeev txoj cai lij choj, uas Tus Thawj Coj txiav txim siab yog rau kev khomob lossis lwm yam khoom lossis kev pabcuam uas tus neeg paub lossis muaj laj thawj paub; (a) tsis tau muab raws li tau thov, lossis (b) kev them nyiaj uas yuav tsis ua raws li qhov kev zov me nyuam hauv cov xwm txheej hauv qab no:
(1) when the person or provider has been suspended from participation in the program, or (2) when the Department determines that the services or items claimed are substantially in excess of the needs of individuals or are of a quality that fails to meet professionally recognized standards of health care, or (3) when the Department determines that a person has demonstrated a pattern of abusive overbilling of the program, or (4) when the Department determines that a person has intentionally or negligently made a false statement or representation on any request for payment submitted to the Medi‐Cal program; or (c) is submitted in violation of an agreement between the person and the state, shall be subject in addition to any other penalties that may be prescribed by law, to a civil money penalty of not more than three times the amount claimed for each item or service. For continuing intentional violations, a civil money penalty of not more than three times the amount claimed for each item or service may be imposed for each day the violation continues.
Tus thawj coj yuav tsum txiav txim siab los soj ntsuam cov nyiaj nplua rau pej xeem thiab yuav tsum muaj lub luag haujlwm rau kev sau cov nqi nplua.
(2) Kev nplua nyiaj pej xeem tej zaum yuav raug nplua nyob rau hauv cov xwm txheej hauv qab no:
(A) Yog tias tus kws kho mob nthuav tawm lossis ua rau muaj kev thov rau kev them nyiaj los ntawm Medi-Cal qhov kev pab cuam uas yog:
(i) Kev them nqi tsis raug, thiab yog rau ib qho kev pabcuam lossis cov khoom uas tus kws khomob tau txais ob lossis ntau daim ntawv ceeb toom ntawm kev xa nqi tsis raug, tus kws khomob tuaj yeem, ntxiv rau lwm yam kev nplua uas yuav raug txiav txim los ntawm txoj cai lij choj, raug nplua nyiaj pej xeem ntawm ib puas duas las ($ 100) ib daim ntawv thov, lossis txog li ob npaug ntawm tus nqi tsis raug thov rau txhua yam khoom lossis kev pabcuam, qhov twg los xij.
(ii) Rau ib qho kev pabcuam lossis yam khoom uas Lub Tsev Haujlwm tau thov tus nqi them rau kev siv los xam Medi-Cal cov nyiaj rov qab los yog hauv kev suav thiab muab Medi-Cal cov nqi them rov qab, cov ntawv tshaj tawm cov nqi cuam tshuam rau cov lus thov raug suav tsis raug, thiab tus kws kho mob tau txais ob lossis ntau tshaj ceeb toom ntawm cov ntaub ntawv tsis raug nqi ntxiv rau lwm tus, xws li substantiation. Cov kev nplua uas yuav raug txiav txim los ntawm txoj cai lij choj, yuav raug nplua nyiaj pej xeem ntawm ib puas duas las ($ 100) rau ib qho kev hloov kho los ntawm Lub Tsev Haujlwm rau cov nqi xa los ntawm tus kws kho mob, lossis txog li ob npaug ntawm tus nqi tsis raug thov rau txhua yam khoom lossis kev pabcuam, qhov twg ntau dua.
(B) Yog tias tus kws kho mob nthuav tawm lossis ua rau muaj kev thov rau kev them nyiaj los ntawm Medi-Cal qhov kev pab cuam uas yog:
(i) Kev them nqi tsis raug, thiab yog rau cov kev pabcuam lossis cov khoom uas tus kws khomob tau txais peb lossis ntau tshaj daim ntawv ceeb toom ntawm kev xa nqi tsis raug, lossis tau raug ntsuas raug nplua raws li nqe lus (A), tus kws khomob yuav, ntxiv rau lwm yam kev nplua uas yuav raug txiav txim los ntawm txoj cai lij choj, yuav raug nplua nyiaj rau pej xeem ntawm ib txhiab daus las ($ 1,000) rau ib qho kev thov, los yog ntau tshaj li peb qhov kev thov ntau dua.
(ii) Rau ib qho kev pabcuam lossis yam khoom uas Lub Tsev Haujlwm tau thov tus nqi them rau kev siv hauv kev suav nyiaj Medi-Cal rov qab los yog hauv kev suav thiab muab Medi-Cal cov nqi them rov qab, thiab cov ntawv tshaj tawm cov nqi cuam tshuam rau cov lus thov raug suav tsis raug, thiab tus kws kho mob tau txais peb lossis ntau tshaj cov lus ceeb toom ntawm cov ntaub ntawv tsis tsim nyog suav nrog suav nrog cov nqi nplua raws li kev nplua lossis kev nplua raws li tus nqi qis. subparagraph (A), tus kws kho mob tuaj yeem, ntxiv rau lwm yam kev nplua uas yuav tau sau tseg los ntawm txoj cai lij choj, raug nplua nyiaj pej xeem ntawm ib txhiab daus las ($ 1,000) rau ib qho kev hloov kho los ntawm Lub Tsev Haujlwm rau cov nqi xa los ntawm tus muab kev pabcuam, lossis peb npaug ntawm tus nqi thov rau txhua yam khoom lossis kev pabcuam, qhov twg ntau dua.
(Txoj Cai Kev Noj Qab Haus Huv thiab Tsev Kawm Ntawv, ntu 14123.2, 14123.25 (c), 22 California Code of Regulations (CCR) Section 51485.1).