HAR §17-1736-33. Providers' right to review

(a) A provider may request an administrative hearing following the department's administrative decision to do any one of the following: (1) Withhold, terminate, or suspend a provider's certification to participate in the medical assistance program; (2) Withhold payment of claims as a result of audit or investigation; (3) Recover money claimed to have been overpaid to the provider by medicaid; or (4) Impose remedies established in section 17- 1736-40 for nursing facilities that do not meet the requirements of participation. (b) Any notice of intent to do any of the actions specified in subsection (a) shall be sent to the provider by certified mail. The provider shall have thirty days from the date that notification is mailed to request in writing an administrative hearing. There shall be no required format for the provider's written request for an administrative hearing, though the provider must clearly state that the provider requests an administrative hearing. At the time the provider requests an administrative hearing, the provider shall include with the request all documents and written evidence that the provider wishes to be considered at the hearing. Where a provider makes a timely request for an administrative hearing, the provider shall not be terminated or suspended until the hearing has been held and a decision has been rendered. (c) DHS may suspend or terminate a provider from the medicaid program for one or more of the following reasons: (1) Failure by the provider to maintain with DHS a signed agreement identifying the terms and conditions under which the provider may participate in the Hawaii medical assistance program; (2) Refusal or failure by the provider to make available at the provider's place of business UNOFFICIAL 1736-18 or at an appropriate location, either during normal business hours, or at the mutual convenience of the parties, immediate access to all records and all diagnostic devices required to be maintained by section 346- 40(b), HRS; (3) Refusal or failure by a provider without reasonable justification to keep those adequate written records necessary to disclose fully the type and extent of health care, service,s or supplies provided to medicaid recipients as provided by section 346-40(a) and (c), HRS; (4) Revocation or suspension of the provider's license, certification, authorization, or permit to practice or provide service in the provider's health care specialty by a state or federal government, court, or agency; (5) Failure to maintain a current and valid license, certification, or permit to practice the provider's profession; (6) A criminal complaint against the provider, indictment by grand jury, or information about or conviction of the provider by a state or federal court for an offense involving the provider's participation in the medicaid program. A criminal complaint against the provider, indictment, or information may remain the basis for a suspension or termination by the department even though the complaint, information, or indictment results in acquittal; (7) Any fraud against the medicaid program or abuse of health care services as defined in this section; (8) A determination by a peer review organization that the provider has failed to provide adequate quality services to medicaid recipients as judged against accepted medical community standards in Hawaii; (9) Any intentional failure to repay overpayments made by the medicaid program to the provider; or (10) Any effort by the provider to interfere with, hinder, or stop an investigation by any state or federal agency into fraud or abuse in the medicaid program. UNOFFICIAL 1736-19 (d) During the period of time from the notice of suspension or termination until the department orders a decision after administrative hearing, payment on any claims of the provider requesting review shall, at the med-QUEST administrator's discretion, be withheld pending the hearing officer's final determination. If the administrative hearing officer upholds suspension or termination, decides that the contested claim shall not be paid, or renders a decision denying the provider's appeal, then the provider claims for which payment was withheld shall not be paid. If, after the administrative hearing, the hearing officer overturns a provider's suspension or termination, decides that any contested claims shall be paid, or renders a favorable decision on the provider's appeal, then the provider claims for which payment was withheld shall be paid. (e) A provider may request an administrative hearing only after an administrative decision by the department is made against that provider. There shall be no right of hearing for class actions on the part of other providers and there shall be no right to administrative hearing for the purpose of obtaining advisory opinions. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R §431.10) (Imp: HRS §§346-14, 346-40; 42 C.F.R. §§431.10, 455.13)