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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care : 2.2 Provider Enrollment and Responsibilities : 2.2.4 Excluded Entities and Providers

The Code of Federal Regulations (CFR) section 1003.102(a)(2) states that civil monetary penalties may be imposed against managed care entities (MCEs) that employ or enter into contracts with excluded individuals or entities to provide items or services to Medicaid clients. No Medicaid payments can be made to an MCE for any items or services directed or prescribed by an excluded physician or other authorized person if the MCE either knew or should have known of the exclusion. This prohibition applies even when the Medicaid payment itself is made to another provider, practitioner, or supplier that is not excluded.

Texas Medicaid & Healthcare Partnership
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