N.Y. Comp. Codes R. & Regs. tit. 9 § 9800.5

Current through Register Vol. 46, No. 45, November 2, 2024

Section 9800.5 - Denial of an application

(a) In determining whether to enter into a contract with a pharmacy-applicant, the following factors shall be grounds for denial of an application:

(1) any false representation or omission of any material fact in making the application;

(2) any previous or current suspension, exclusion or involuntary withdrawal from participation in the medical assistance program or the Medicaid program of any other state of the United States or from participation in any other governmental or private medical insurance program, including but not limited to Medicare, workers' compensation, physically handicapped children's program and rehabilitation services;

(3) the receipt of, but not having made restitution for, a Medicaid or Medicare overpayment, as determined to have been made pursuant to a final decision or determination of an agency having the powers to conduct the proceeding and after an adjudicatory proceeding in which no appeal is pending or after resolution of the proceeding by stipulation or agreement; however, if a pharmacy-applicant has entered into a plan of restitution of such overpayment, an application may not be denied based solely on this factor unless the pharmacy-applicant has defaulted in repayment;

(4) any false representation or omission of a material fact in making application in any state of the United States for any license, permit, certificate or registration related to a profession or business;

(5) any previous failure to correct deficiencies in the operation of a business or enterprise after having received written notice of the deficiencies from a State or Federal licensing or auditing agency;

(6) any failure to supply further information concerning the application after receiving a written request for such further information;

(7) the submission of an application which conceals an ownership or control interest of any person who would otherwise be ineligible to participate;

(8) an outstanding indictment for, or prior conviction of, any crime relating to the furnishing of, or billing for, medical care, services or supplies, or which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals;

(9) a prior finding by a licensing, certifying or professional standards board or agency of the violation of the standards or conditions relating to licensing or certification or as to the quality of services provided;

(10) the pharmacy-applicant's prior pattern or practices in furnishing medical care, services or supplies under any private or publicly funded program or policy of insurance; and

(11) any other factor having a direct bearing on the pharmacy-applicant's ability to provide high-quality pharmaceutical services to participants in the program, or to be fiscally responsible under the program, including actions by persons affiliated with the pharmacy-applicant.

(b) If any application is denied, the pharmacy-applicant shall be given a written notice of the denial, stating the reason or reasons for the denial, within three days of the determination to deny the application. The written notice of denial will be effective upon the date it is mailed to the pharmacy-applicant.

(c) The pharmacy-applicant may request a reconsideration of a denial by submitting a written request for a reconsideration to the executive director within 30 days of the date of the denial. The request shall include all arguments and documentation which the pharmacy-applicant wishes to be considered in its behalf. A written determination of acceptance or denial of the application shall be issued by the executive director within 60 days of receipt of the request for reconsideration, stating the basis for the determination and the reasons for affirming or reversing the initial determination.

(d) If an application has been denied, the pharmacy-applicant may reapply only upon correction of the factors leading to its denial, or after one year if the factors relate to prior conduct of the pharmacy-applicant or an affiliated person.

(e) Denial of an application shall preclude the pharmacy-applicant from submitting claims for payment under the program either directly, or indirectly through any other person. Any claims submitted by such pharmacy-applicant or such other person and paid by the contractor shall constitute overpayments.

N.Y. Comp. Codes R. & Regs. Tit. 9 § 9800.5