Common use of Prohibitions on Payments for Excluded Providers Clause in Contracts

Prohibitions on Payments for Excluded Providers. (A) In accordance with Section 1903(i)(2)(A) of the Social Security Act, the Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished: (1) under the Health Plan by any individual or entity during any period when the individual or entity is excluded from participation under Title V, XVII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act; (2) at the medical direction or prescription of a physician, during the period when such physician is excluded from participation under Title V, XVII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act and when the person furnishing such item or service knew or had reason to know of the exclusion (after a reasonable time period after reasonable notice has been furnished to the person); or (3) by any individual or entity to whom the Department has failed to suspend payments during any period when there is a pending allegation of fraud against the individual or entity, unless the Department determines there is good cause not to suspend such payments.

Prohibitions on Payments for Excluded Providers. (A) In accordance with Section 1903(i)(2)(A) of the Social Security Act, the Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished: (1) under the Health Plan by any individual or entity during any period when the individual or entity is excluded from participation under Title V, XVIIXVIII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act; (2) at the medical direction or prescription of a physician, during the period when such physician is excluded from participation under Title V, XVII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act and when the person furnishing such item or service knew or had reason to know of the exclusion (after a reasonable time period after reasonable notice has been furnished to the person); or (3) by any individual or entity to whom the Department has failed to suspend payments during any period when there is a pending allegation of fraud against the individual or entity, unless the Department determines there is good cause not to suspend such payments.

Prohibitions on Payments for Excluded Providers. (A) In accordance with Section 1903(i)(2)(A1903(i)(2) of the Social Security Act, the Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished: (1) under Under the Health Contractor’s Integrated Care Plan by any individual or entity during any period when the individual or entity is excluded from participation under Title V, XVIIXVIII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act; (2) at At the medical direction or prescription of a physician, during the period when such physician is excluded from participation under Title V, XVIIXVIII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act and when the person furnishing such item or service knew or had reason to know of the exclusion (after a reasonable time period after reasonable notice has been furnished to the person); or (3) by By any individual or entity to whom the Department has failed to suspend payments during any period when there is a pending allegation of fraud against the individual or entity, unless the Department determines there is good cause not to suspend such payments.

Prohibitions on Payments for Excluded Providers. (A) In accordance with Section 1903(i)(2)(A1903(i)(2) of the Social Security Act, the Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished: (1) under the Health Plan by any individual or entity during any period when the individual or entity is excluded from participation under Title V, XVIIXVIII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act; (2) at the medical direction or prescription of a physician, during the period when such physician is excluded from participation under Title V, XVII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act and when the person furnishing such item or service knew or had reason to know of the exclusion (after a reasonable time period after reasonable notice has been furnished to the person); or (3) by any individual or entity to whom the Department has failed to suspend payments during any period when there is a pending allegation of fraud against the individual or entity, unless the Department determines there is good cause not to suspend such payments.

Prohibitions on Payments for Excluded Providers. (A) In accordance with Section 1903(i)(2)(A1903(i)(2) of the Social Security Act, the Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished: (1) under the Contractor’s Health Plan by any individual or entity during any period when the individual or entity is excluded Excluded from participation under Title V, XVIIXVIII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act; (2) at the medical direction or prescription of a physician, during the period when such physician is excluded Excluded from participation under Title V, XVIIXVIII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act and when the person furnishing such item or service knew or had reason to know of the exclusion Exclusion (after a reasonable time period after reasonable notice has been furnished to the person); or (3) by any individual or entity to whom the Department has failed to suspend payments during any period when there is a pending allegation of fraud Fraud against the individual or entity, unless the Department determines there is good cause not to suspend such payments.

Prohibitions on Payments for Excluded Providers. (A) In accordance with Section 1903(i)(2)(A1903(i)(2) of the Social Security Act, the Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished: (1) under the Contractor’s Health Plan by any individual or entity during any period when the individual or entity is excluded from participation under Title V, XVIIXVIII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act; (2) at the medical direction or prescription of a physician, during the period when such physician is excluded from participation under Title V, XVIIXVIII, or XX of the Social Security Act pursuant to Sections 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act and when the person furnishing such item or service knew or had reason to know of the exclusion (after a reasonable time period after reasonable notice has been furnished to the person); or (3) by any individual or entity to whom the Department has failed to suspend payments during any period when there is a pending allegation of fraud against the individual or entity, unless the Department determines there is good cause not to suspend such payments.