Penalties for Non-Compliance. At the discretion of EOHHS, Contractor may be subject to monetary penalties if the encounter denial rate exceeds two percent (2%). EOHHS may assess the following penalties against the Contractor: • Civil monetary penalties in the amount of one-hundred thousand dollars ($100,000), not to exceed one-percent (1%) of the Contractor’s capitation, to be assessed each month that Contractor submits encounter data, including the encounter data of their subcontractor, for which the denial rate exceeds two percent (2%). • Appointment of temporary management for the Contractor as contained in and accordance with 42 CFR 438.706. • Granting members, the right to terminate enrollment with the Contractor without cause and notifying the affected members of their right to disenroll from the Contractor. • Suspension of new enrollment, including default enrollment, after notice of the effective date of a sanction against the Contractor. • Suspension of payment for members enrolled after the effective date of the sanction and until CMS or EOHHS is satisfied that the reason for the sanction no longer exists and is not likely to recur.
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