Provider Payment Suspension Sample Clauses

Provider Payment Suspension. The MCO is required to cooperate with the Department when payment suspensions are imposed for the Medicaid provider by the Department. When Department sends notice that payments to a provider have been suspended, the MCO must also suspend payments to the provider within one (1) business day if such provider is in the MCO network and receives payments. When such notice is received from the Department by the MCO, the MCO must respond to the notice within three (3) business days and inform the Department of whether the MCO has implemented the suspension. The MCO must also report all of the following information to the Department monthly: name of the suspended MCO provider, date the suspension was imposed, date the suspension was discontinued, reason for discontinuing the suspension, amount of payments held, and, if applicable, the good cause rationale for not suspending payment (for example, the provider is not enrolled in the MCO’s network) or imposing a partial payment suspension. MCOs shall include in their monthly report those providers that the MCO was notified of by BMS. Reports shall also include the amount withheld from providers on a cumulative basis. If the MCO does not suspend payments to the provider, the Department may impose contractual remedies. The Department is responsible for evaluating allegations of fraud and imposing payment suspensions, when appropriate, for those MCO providers who are a part of the State fee-for- service network. The MCO is responsible for initiating payment suspensions based on the credible allegation of fraud for its in-network providers who are not a part the State fee-for- service network. For payment suspensions initiated by the MCO, the MCO must comply with all requirements of 42 CFR 455.23. The MCO report the following information to the Department within one (1) business day after suspension: the nature of the suspected fraud, basis for the suspension, date the suspension was imposed, date the suspension was discontinued, reason for discontinuing the suspension, outcome of any appeals, the amount of payments held, and, if applicable, the good cause rationale for imposing a partial payment suspension.