Common use of Ineligible Organizations Clause in Contracts

Ineligible Organizations. Upon obtaining information or receiving information from the Department or from another verifiable source, the HMO must exclude from participation in the HMO all organizations that could be included in any of the categories defined in a, 1), a) through e) of this section (references to the Act in this section refer to the Social Security Act). a. Entities that could be excluded under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the entity, or a person who has direct or indirect ownership or control interest of 5% or more in the entity has: 1) Been convicted of the following crimes: a) Program related crimes, i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid (Section 1128(a)(1) of the Act). b) Patient abuse, i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care (Section 1128(a)(2) of the Act). c) Fraud, i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government (Section 1128(b)(1) of the Act). d) Obstruction of an investigation, i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections a), b), or c) (Section 1128(b)(2) of the Act). e) Offenses relating to controlled substances, i.e., conviction of a state or federal crime relating to the manufacture, distribution, prescription or dispensing of a controlled substance (Section 1128(b)(3) of the Act). 2) Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order. 3) Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations, agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (Section 1128(b)(8)(B)(ii) of the Act.) b. Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection 1. A substantial contractual relationship is defined as any contractual relationship which provides for one or more of the following services: 1) The administration, management, or provision of medical services. 2) The establishment of policies pertaining to the administration, management, or provision of medical services. 3) The provision of operational support for the administration, management, or provision of medical services. c. Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision (directly or indirectly) of health care, utilization review, medical social work or administrative services. For the services listed, the HMO must refrain from contracting with any entity that employs, contracts with, or contracts through an entity that has been excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. The HMO attests by signing this Contract, that it excludes from participation in the HMO all organizations that could be included in any of the above categories.

Ineligible Organizations. Upon obtaining information or receiving information from the Department or from another verifiable source, the HMO must exclude from participation in the HMO all organizations that could be included in any of the categories defined in a, 1), a) through e) of this section (references to the Act in this section refer to the Social Security Act). a. Entities that could be excluded under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the entity, or a person who has direct or indirect ownership or control interest of 5% or more in the entity has: 1) Been convicted of the following crimes: a) Program related crimes, crimes (i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid Medicaid). (Section 1128(a)(1) of the Act.). b) Patient abuse, abuse (i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care care). (Section 1128(a)(2) of the Act.). c) Fraud, Fraud (i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government government). (Section 1128(b)(1) of the Act.). d) Obstruction of an investigation, investigation (i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections a), b), or c) ). (Section 1128(b)(2) of the Act.). e) Offenses relating to controlled substances, substances (i.e., conviction of a state or federal crime relating to the manufacture, distribution, prescription or dispensing of a controlled substance substance. (Section 1128(b)(3) of the Act.). 2) Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order. 3) Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations, agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (Section 1128(b)(8)(B)(ii) of the Act.) b. Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection Subsection 1. A substantial contractual relationship is defined as any contractual relationship which provides for one or more of the following services: 1) The administration, management, or provision of medical services. 2) The establishment of policies pertaining to the administration, management, or provision of medical services. 3) The provision of operational support for the administration, management, or provision of medical services. c. Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision (directly or indirectly) of health care, utilization review, medical social work or administrative services. For the services listed, the HMO must refrain from contracting with any entity that employs, contracts with, or contracts through an entity that has been excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. The HMO attests by signing this Contract, that it excludes from participation in the HMO all organizations that could be included in any of the above categories.

Ineligible Organizations. Upon obtaining information or receiving information from the Department or from another verifiable source, the HMO must exclude from participation in the HMO all organizations that could be included in any of the categories defined in a, 1), a) through e) of this section (references to the Act in this section refer to the Social Security Act). a. Entities that could be excluded under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the entity, or a person who has direct or indirect ownership ownerships or control interest of 5% or more in the entity has: 1) Been convicted of the following crimes: a) : • Program related crimes, crimes (i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid Medicaid). (Section 1128(a)(1) of the Act). b) • Patient abuse, abuse (i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care care). (Section 1128(a)(2) of the Act). c) Fraud, • Fraud (i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government government). (Section 1128(b)(1) of the Act). d) • Obstruction of an investigation, investigation (i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections Subsections a), b), or c) ). (Section 1128(b)(2) of the Act). e) • Offenses relating to controlled substances, substances (i.e., conviction of a state or federal crime relating to the manufacture, distribution, prescription or dispensing of a controlled substance substance. (Section 1128(b)(3) of the Act.). 2) Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order. 3) Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations, agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (Section 1128(b)(8)(B)(ii) of the Act.) b. Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection Subsection 1. A substantial contractual relationship is defined as any contractual relationship which provides for one or more of the following services: 1) The administration, management, or provision of medical services. 2) The establishment of policies pertaining to the administration, management, or provision of medical services. 3) The provision of operational support for the administration, management, or provision of medical services. c. Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision (directly or indirectly) of health care, utilization review, medical social work or administrative services. For the services listed, the HMO must refrain from contracting with any entity that employs, contracts with, or contracts through an entity that has been debarred or excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. The HMO attests by signing this Contract, that it excludes from participation in the HMO all organizations that could be included in any of the above categories.

Ineligible Organizations. Upon obtaining information or receiving information from the Department or from another verifiable source, source the HMO County must exclude from participation in the HMO County’s Managed Care Program all organizations that which could be included in any of the categories defined in a, 1), a) 1 through e3) of this section (references to the Act in this section refer to the Social Security Act).): a. 1. Entities that could be excluded under Which Could Be Excluded Under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the entity, or a person who has direct or indirect ownership or control interest of 5% or more in the entity has: 1) a. Been convicted of the following crimes: a1) Program related crimes, (i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid (see Section 1128(a)(1) of the Act).); b2) Patient abuse, abuse (i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care (see Section 1128(a)(2) of the Act).); c3) Fraud, (i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary judiciary responsibility, or other financial misconduct in connection with the delivery of health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government (see Section 1128(b)(1) of the Act).); d4) Obstruction of an investigation, (i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections a), b), or c) c (see Section 1128(b)(2) of the Act).); or e5) Offenses relating to controlled substances, (i.e., conviction of a state or federal crime relating to the manufacture, distribution, and prescription or dispensing of a controlled substance (see Section 1128(b)(3) of the Act)). 2) b. Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above above) from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-non- procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines guideline implementing such order. 3) c. Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations, agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (See Section 1128(b)(8)(B)(ii) of the Act.) b. 2. Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection GG. 1. A substantial contractual relationship is defined as any contractual relationship which provides for one or more of the following services: 1) a. The administration, management, or provision of medical services.; 2) b. The establishment of policies pertaining to the administration, management, or provision of medical services.; or 3) c. The provision of operational support for the administration, management, or provision of medical services. c. 3. Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision Provision (directly or indirectly) of health care, utilization reviewUtilization Review, medical social work or administrative services. For the services listed, the HMO County must refrain exclude from contracting with any entity that which employs, contracts with, or contracts through an entity that which has been excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. 4. CCF agree to disclose the following information to the State: a. The name and address of any individual or corporation with an ownership or controlling interest. The HMO address must include the primary business location and PO Box address. b. In the case of an individual include the date of birth and social security number. c. In the case of a corporation include the tax identification number. d. Identify whether the person or corporation with a controlling interest is related to another person with a controlling interest such as a spouse, parent, child or sibling or whether the person has a 5% or more controlling interest in the entity. e. Also CCF must disclose the name, address, DOB, SSN of any managing employee of the entity. f. Disclosures are due upon submission of the provider application, upon execution of the Managed Care contract, upon re-certification of the Managed Care Organization, within 35 days of any change in ownership. g. Sanctions for failure to provide disclosures will result in not participating in the Federal financial participation. The County attests by signing this Contract, that it excludes from participation in the HMO County all organizations that which could be included in any of the above categories. 5. If the State learns that the County has a prohibited relationship with a person or entity that is debarred, suspended, or excluded from participation in federal healthcare programs, the State: a. Must notify the Secretary of the noncompliance. b. May continue an existing agreement with the County unless the Secretary directs otherwise. c. May not renew or extend the existing agreement with the County unless the Secretary provides to the State and to Congress a written statement describing compelling reasons that exist for renewing or extending the agreement.

Ineligible Organizations. Upon obtaining information or receiving information from the Department or from another verifiable source, the HMO must exclude from participation in the HMO all organizations that could be included in any of the categories defined in a, 1), a) through e) of this section (references to the Act in this section refer to the Social Security Act). a. Entities that could be excluded under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the entity, or a person who has direct or indirect ownership ownerships or control interest of 5% or more in the entity has: 1) Been convicted of the following crimes: a) i. Program related crimes, crimes (i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid Medicaid). (Section 1128(a)(1) of the Act.). b) ii. Patient abuse, abuse (i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care care). (Section 1128(a)(2) of the Act.). c) Fraud, iii. Fraud (i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government government). (Section 1128(b)(1) of the Act.). d) iv. Obstruction of an investigation, investigation (i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections Subsections a), b), or c) ). (Section 1128(b)(2) of the Act.). e) v. Offenses relating to controlled substances, substances (i.e., conviction of a state or federal crime relating to the manufacture, distribution, prescription or dispensing of a controlled substance substance. (Section 1128(b)(3) of the Act.). 2) Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order. 3) Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations, agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (Section 1128(b)(8)(B)(ii) of the Act.) b. Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection Subsection 1. A substantial contractual relationship is defined as any contractual relationship which provides for one or more of the following services: 1) The administration, management, or provision of medical services. 2) The establishment of policies pertaining to the administration, management, or provision of medical services. 3) The provision of operational support for the administration, management, or provision of medical services. c. Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision (directly or indirectly) of health care, utilization review, medical social work or administrative services. For the services listed, the HMO must refrain from contracting with any entity that employs, contracts with, or contracts through an entity that has been excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. The HMO attests by signing this Contract, that it excludes from participation in the HMO all organizations that could be included in any of the above categories.

Ineligible Organizations. Upon obtaining information or receiving information from the Department or from another verifiable source, the HMO must exclude from participation in the HMO all organizations that could be included in any of the categories defined in a, 1), a) through e) of this section (references to the Act in this section refer to the Social Security Act). a. Entities that could be excluded under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the entity, or a person who has direct or indirect ownership or control interest of 5% or more in the entity has: 1) Been convicted of the following crimes: a) Program related crimes, crimes (i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid Medicaid). (Section 1128(a)(1) of the Act.). b) Patient abuse, abuse (i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care care). (Section 1128(a)(2) of the Act.). c) Fraud, Fraud (i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government government). (Section 1128(b)(1) of the Act.). d) Obstruction of an investigation, investigation (i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections Subsections a), b), or c) ). (Section 1128(b)(2) of the Act.). e) Offenses relating to controlled substances, substances (i.e., conviction of a state or federal crime relating to the manufacture, distribution, prescription or dispensing of a controlled substance substance. (Section 1128(b)(3) of the Act.). 2) Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order. 3) Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations, agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (Section 1128(b)(8)(B)(ii) of the Act.) b. Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection Subsection 1. A substantial contractual relationship is defined as any contractual relationship which provides for one or more of the following services: 1) The administration, management, or provision of medical services. 2) The establishment of policies pertaining to the administration, management, or provision of medical services. 3) The provision of operational support for the administration, management, or provision of medical services. c. Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision (directly or indirectly) of health care, utilization review, medical social work or administrative services. For the services listed, the HMO must refrain from contracting with any entity that employs, contracts with, or contracts through an entity that has been excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. The HMO attests by signing this Contract, that it excludes from participation in the HMO all organizations that could be included in any of the above categories.

Ineligible Organizations. Upon obtaining information or receiving information from the Department or from another verifiable source, the HMO must exclude from participation in the HMO all organizations that could be included in any of the categories defined in a, 1), a) through e) of this section (references to the Act in this section refer to the Social Security Act). a. Entities that could be excluded under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the entity, or a person who has direct or indirect ownership or control interest of 5% or more in the entity has: 1) Been convicted of the following crimes: a) Program related crimes, crimes (i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid (Section 1128(a)(1) of the Act). b) Patient abuse, abuse (i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care (Section 1128(a)(2) of the Act).. HMO Contract for February 1, 2006 - December 31, 2007 c) Fraud, Fraud (i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government (Section 1128(b)(1) of the Act). d) Obstruction of an investigation, investigation (i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections a), b), or c) (Section 1128(b)(2) of the Act). e) Offenses relating to controlled substances, substances (i.e., conviction of a state or federal crime relating to the manufacture, distribution, prescription or dispensing of a controlled substance (Section 1128(b)(3) of the Act). 2) Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order. 3) Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations, agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (Section 1128(b)(8)(B)(ii) of the Act.) b. Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection 1. A substantial contractual relationship is defined as any contractual relationship which provides for one or more of the following services: 1) The administration, management, or provision of medical services.. HMO Contract for February 1, 2006 - December 31, 2007 2) The establishment of policies pertaining to the administration, management, or provision of medical services. 3) The provision of operational support for the administration, management, or provision of medical services. c. Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision (directly or indirectly) of health care, utilization review, medical social work or administrative services. For the services listed, the HMO must refrain from contracting with any entity that employs, contracts with, or contracts through an entity that has been excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. The HMO attests by signing this Contract, that it excludes from participation in the HMO all organizations that could be included in any of the above categories.