Provider Interventions and Sanctions are utilized when OMS determines that a PCP acts or fails to act according to requirements set forth in Supplement 5, the Addendum to the Provider Agreement or violates any of the requirements of section 1932 and 1905(t) of the Act and implementing regulations. Interventions and sanctions listed are specific to the services covered within this SPA, PCCM (case-management) services.
Interventions are considered an informal process to seek program compliance for PCPs that OMS determines are out of compliance. Utilization of these processes does not restrict the State’s ability to initiate sanctions. Informal interventions may consist but are not limited to the following:
The OMS determination to impose a sanction may be based on findings from onsite survey, enrollee or other complaints, or any other source when OMS determines that a PCP acts or fails to act according to requirements set forth in Supplement 5, the Addendum to the Provider Agreement or violates any of the requirements of section 1932 and 1905(t) of the Act and implementing regulations. Sanctions under this SPA are limited to the following:
OMS has the authority to terminate a PCP agreement and enroll that provider’s enrollees with another PCP or provide their Medicaid benefits through other options included in the State plan. This sanction may be applied if the State determines that PCP has failed to carry out the substantive terms of its agreement (Addendum to the Provider Agreement), requirements set forth in the Managed Care Provider Manual or has failed to meet applicable requirements in sections 1932 and 1905(t) of the Act.
Before terminating the PCP agreement, OMS must provide the PCP predetermination hearing. OMS must:
The State utilizes a number of interventions other than denial of services not covered through this SPA to enforce compliance with beneficiary requirements listed in Supplement 4. Beneficiary interventions include the following: