37.85.512    NOTICE OF ADVERSE ACTION

(1) As provided in this rule, the department must notify a provider of any adverse action it will take when the department has determined that the provider has engaged in fraud, improper billing, waste, abuse, has received payment to which the provider is not entitled, or where the department has verified a credible allegation of fraud, as that term is defined at ARM 37.5.304. The notice must address all of the following:

(a) a description of the fraud, allegation, improper billing, waste, abuse, or overpayments;

(b) the dollar value of any overpayment;

(c) the adverse action to be taken or sanction to be imposed by the department;

(d) explanation of any actions required of the provider; and

(e) the provider's right to submit written evidence for consideration by the department, an administrative review, and fair hearing.

(2) The department is not required to notify a provider pursuant to (1) until after the department has determined that fraud, a credible allegation of fraud, improper billing, waste, abuse, or an overpayment has occurred. The department is not required to notify the provider when the department merely suspects or has information which suggests that fraud, abuse or an overpayment has occurred or when the department has not determined to take a particular adverse action in response to the fraud, abuse, or overpayment.

(3) Subject to the provisions of (4) and (5), and excepting suspensions of payment under ARM 37.85.513(3), the department must notify the provider as required in this rule within 45 days after the department has determined that fraud, improper billing, waste, abuse, or an overpayment has occurred. The department's failure to notify a provider as required by this rule is not a defense to recovery of the overpayment or imposition of the sanction, but the department may be required to provide a new notice in compliance with this rule.

(4) This rule shall not be construed to require that the department investigate, complete an investigation, make a determination or take any other action regarding a potential fraud, abuse or overpayment within any particular time.

(5) While this rule does not require the department to act within any particular time, if any governmental agency or entity is conducting an investigation of a provider, the department shall not in any event be required to notify the provider of a violation or overpayment until the investigation is concluded and enforcement proceedings, if any, have been completed, if in the sole discretion of the department or the governmental agency or entity conducting the investigation, earlier notification would interfere with or jeopardize the investigation, recovery of an overpayment or imposition of a sanction.

History: 53-2-201, 53-6-111, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 1980 MAR p. 1619, Eff. 6/13/80; AMD, 1997 MAR p. 474, Eff. 3/11/97; TRANS, from SRS, 2000 MAR p. 479; AMD, 2011 MAR p. 2823, Eff. 12/23/11.