210 R.I. Code R. 210-RICR-20-00-1.7

Current through December 3, 2024

Section 210-RICR-20-00-1.7 - Provider Eligibility - Eligibility Criteria

A. To be eligible to participate in the Rhode Island Medicaid program as any provider type, a provider must:

1. Be fully licensed, certified, registered, and/or credentialed, where required by the State, as an active practitioner by the agency or board overseeing the specific provider type;

2. Be registered with appropriate state and federal agencies to prescribe controlled substances, for any provider type that is legally authorized to write prescriptions for medications;

3. Never have been the subject of and/or never have had common parties in interest with any provider subject to any disciplinary action, sanction, or other limitation or restriction of any nature imposed with or without the consent of the provider, by any state or federal agency, or board, including the Rhode Island Medicaid program or another state's Medicaid program;

4. Never have purchased or otherwise obtained its practice or business entity from any provider suspended or terminated from participation in the Rhode Island Medicaid program due to violations of applicable laws, rules, or regulations; or from a provider that is currently subject to a withholding of Medicaid payments for a credible allegation of fraud or who terminates or has its Medicaid participation terminated while subject to such a withholding of Medicaid payments;

5. Cooperate with the Rhode Island Medicaid program during any application, revalidation of enrollment, or other review process, such as permitting, facilitating site visits, and submitting fingerprints, as determined by EOHHS;

6. Not be subject to a moratorium on enrollment imposed in accordance with 42 C.F.R. § 455.470 (2021); and

7. Not have any evidence of a disqualifying conviction that is revealed during a national criminal records check or otherwise revealed during EOHHS' provider risk screening process.

B. A provider who does not meet the requirements of this section may, at EOHHS' sole discretion, participate in the Rhode Island Medicaid program only if, in the judgment of EOHHS, such participation:

1. Would not threaten the health, welfare, or safety of members; and

2. Would not compromise the integrity of the Rhode Island Medicaid program.

C. A provider who does not meet the requirements of this section is entitled to a hearing on the issue of eligibility pursuant to the State's Administrative Procedures Act, as found at R.I. Gen. Laws Chapter 42-35, as amended, and in conformance with Part 10-05-2 of this Title, Appeals Process and Procedures for EOHHS Agencies and Programs.

210 R.I. Code R. 210-RICR-20-00-1.7

Amended effective 3/17/2022
Amended effective 7/17/2023
Amended effective 3/17/2024