Individual Provider Enrollment (Exclusion/Sanction) Page

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You use the Exclusion/Sanction page to add or edit exclusion/sanction information for individual provider's enrollment application.

Exclusion / Sanction- Section 7 Fields

Field	Description
Subcontractor Relative Fields
1. Has any person who has ownership of, or a controlling interest in, the provider’s practice or business entity, or who is an agent, managing employee, contract employee, subcontractor, or employee of the provider’s practice or business entity, ever been convicted of a criminal offense related to Alaska’s Medical Assistance programs, the Medicaid program in another state or territory, the Medicare program, or any other federally funded health or social service program?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.
To add a new relative, click Add Name. Existing relatives, if any, are listed in a table. To edit, in the Name table, click the appropriate row. After changing or adding information, on the Name action bar, click Save.
Last Name	Last name of the relative related to owners of the subcontract.
First Name	First name of the relative related to owners of the subcontract.
MI	Middle initial of the relative related to owners of the subcontract.
Suffix	Suffix of the relative related to owners of the subcontract.
Relationship	Relationship of the person to the provider.
Type of Conviction	Type of conviction for the relative related to owners of the subcontract.
Conviction City	The city where the relative of the owners of the subcontract was convicted.
Conviction State	The state where the relative of the owners of the subcontract was convicted.
Date of Conviction	The date when the relative of the owners of the subcontract was convicted.
Program Type	Indicates the type of assistance program related to the conviction.
2. Have you or any member of your immediate family ever been convicted, assessed, debarred, or excluded from the Medicaid, Medicare, or Title XVIII, Title XIX, Title XX Social Security program or any other federal program due to fraud, obstruction of an investigation, or a controlled substance violation?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.
Last Name	Last name of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.
First Name	First name of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.
MI	Middle initial of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.
Suffix	Suffix of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.
Relationship	Relationship to the owner of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.
Type of Conviction	Type of conviction for the relative or owner.
Conviction City	The city of the conviction for the relative or owner.
Conviction State	The state of the conviction for the relative or owner.
Date of Conviction	The date of the conviction for the relative or owner.
Program Type	Indicates the type of assistance program related to the conviction.
Overpayment Fields To add a new overpayment, click Add Overpayment. Existing overpayments, if any, are listed in a table. To edit, in the Overpayment table, click the appropriate row. After changing or adding information, on the Overpayment action bar, click Save.
3. Do you, under any name or business identity, have any outstanding overpayments with any state or federal program?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.
Last Name	Last name of the owner or business identity that has outstanding overpayments with any state or federal program.
First Name	First name of the owner or business identity that has outstanding overpayments with any state or federal program.
MI	Middle initial of the owner or business identity that has outstanding overpayments with any state or federal program.
Suffix	Suffix of the owner or business identity that has outstanding overpayments with any state or federal program.
Overpayment Amount	The overpayment amount with the state or federal program.
Program Type	The type of state or federal program.
Disposition	The disposition of the state or federal program. The description of the settlement.
Attach additional information to Application	Select if you wish to attach additional information to the provider enrollment application.
Restitution Fields
4. Have you ever plead guilty, no contest or been sentenced for any felony crime and/or had a criminal fine or restitution order assessed or do you have a felony charge pending under Federal or State Law?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.
To add a new restitution, click Add Restitution. Existing overpayments, if any, are listed in a table. To edit, in the Restitution table, click the appropriate row. After changing or adding information, on the Restitution action bar, click Save.
Last Name	Last name of the owner who had a criminal fine or restitution order.
First Name	First name of the owner who had a criminal fine or restitution order.
MI	Middle initial of the owner who had a criminal fine or restitution order.
Suffix	Suffix of the owner who had a criminal fine or restitution order.
Conviction City	The city of the conviction for the owner.
Conviction State	The state of the conviction for the owner.
Type of Conviction	The type of conviction for the owner.
Date of Conviction	The date of the conviction for the owner.
Fine Amount	The criminal fine dollar amount.
Restitution Order Amount	The restitution order dollar amount.
Attach additional information to Application	Select if you wish to attach additional information to the provider enrollment application.
Add Sanction Fields
5. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been sanctioned by the Office of Inspector General (OIG), Medicare, Medicaid, or the Social Security Act, including a state Medicaid program?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.
To add a new sanction, click Add Sanction. Existing sanctions, if any, are listed in a table. To edit, in the Sanction table, click the appropriate row. After changing or adding information, on the Sanction action bar, click Save.
Last Name	Last name of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.
First Name	First name of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.
MI	Middle initial of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.
Suffix	Suffix of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.
Relationship	Relationship of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.
Type of Sanction	Type of sanction by the OIG, state, or other federal program.
Sanction City	The city where the sanction occurred.
Sanction State	The state where the sanction occurred.
Date of Sanction	The date when the sanction occurred.
Program Type	The type of state or federal program.
Attach additional information to Application	Select if you wish to attach additional information to the provider enrollment application.
6. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been denied malpractice insurance or ever voluntarily or involuntarily agreed to any limitations, restrictions, or conditions to your license, certification, or permit including any formal or informal Professional Board Disciplinary Action(s)?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.
Date of Occurrence	The date when the person was denied malpractice insurance or agreed to limitations, restrictions and conditions on a permit, license, or certification.
State Occurred	The state in which the person was denied malpractice insurance or agreed to limitations, restrictions and conditions on a permit, license, or certification.
Description	Description of the incident.
Attach additional information to Application	Select if you wish to attach additional information to the provider enrollment application.
Other Questions Fields The fields listed above for Question 6 are also displayed for the following questions (7, 8, 9) if Yes is selected.
7. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever had any Program Exclusions from any federally funded program?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.
8. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, been involved in any civil litigation whereby a judgment or settlement was entered into, or a Civil Monetary Penalty(s) was paid?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.
9. Do you or any of your employees, contract employees, or any person or entity with ownership of your business have any Judgment(s) or Pending actions under the False Claims Act?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit information.

Field

Description

Subcontractor Relative Fields

1. Has any person who has ownership of, or a controlling interest in, the provider’s practice or business entity, or who is an agent, managing employee, contract employee, subcontractor, or employee of the provider’s practice or business entity, ever been convicted of a criminal offense related to Alaska’s Medical Assistance programs, the Medicaid program in another state or territory, the Medicare program, or any other federally funded health or social service program?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.

To add a new relative, click Add Name. Existing relatives, if any, are listed in a table. To edit, in the Name table, click the appropriate row. After changing or adding information, on the Name action bar, click Save.

Last Name

Last name of the relative related to owners of the subcontract.

First Name

First name of the relative related to owners of the subcontract.

Middle initial of the relative related to owners of the subcontract.

Suffix

Suffix of the relative related to owners of the subcontract.

Relationship

Relationship of the person to the provider.

Type of Conviction

Type of conviction for the relative related to owners of the subcontract.

Conviction City

The city where the relative of the owners of the subcontract was convicted.

Conviction State

The state where the relative of the owners of the subcontract was convicted.

Date of Conviction

The date when the relative of the owners of the subcontract was convicted.

Program Type

Indicates the type of assistance program related to the conviction.

2. Have you or any member of your immediate family ever been convicted, assessed, debarred, or excluded from the Medicaid, Medicare, or Title XVIII, Title XIX, Title XX Social Security program or any other federal program due to fraud, obstruction of an investigation, or a controlled substance violation?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.

Last Name

Last name of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.

First Name

First name of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.

Middle initial of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.

Suffix

Suffix of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.

Relationship

Relationship to the owner of the person convicted, assessed, debarred or excluded from the Medicaid program or any other federal program.

Type of Conviction

Type of conviction for the relative or owner.

Conviction City

The city of the conviction for the relative or owner.

Conviction State

The state of the conviction for the relative or owner.

Date of Conviction

The date of the conviction for the relative or owner.

Program Type

Indicates the type of assistance program related to the conviction.

Overpayment Fields

To add a new overpayment, click Add Overpayment. Existing overpayments, if any, are listed in a table. To edit, in the Overpayment table, click the appropriate row. After changing or adding information, on the Overpayment action bar, click Save.

3. Do you, under any name or business identity, have any outstanding overpayments with any state or federal program?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.

Last Name

Last name of the owner or business identity that has outstanding overpayments with any state or federal program.

First Name

First name of the owner or business identity that has outstanding overpayments with any state or federal program.

Middle initial of the owner or business identity that has outstanding overpayments with any state or federal program.

Suffix

Suffix of the owner or business identity that has outstanding overpayments with any state or federal program.

Overpayment Amount

The overpayment amount with the state or federal program.

Program Type

The type of state or federal program.

Disposition

The disposition of the state or federal program. The description of the settlement.

Attach additional information to Application

Select if you wish to attach additional information to the provider enrollment application.

Restitution Fields

4. Have you ever plead guilty, no contest or been sentenced for any felony crime and/or had a criminal fine or restitution order assessed or do you have a felony charge pending under Federal or State Law?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.

To add a new restitution, click Add Restitution. Existing overpayments, if any, are listed in a table. To edit, in the Restitution table, click the appropriate row. After changing or adding information, on the Restitution action bar, click Save.

Last Name

Last name of the owner who had a criminal fine or restitution order.

First Name

First name of the owner who had a criminal fine or restitution order.

Middle initial of the owner who had a criminal fine or restitution order.

Suffix

Suffix of the owner who had a criminal fine or restitution order.

Conviction City

The city of the conviction for the owner.

Conviction State

The state of the conviction for the owner.

Type of Conviction

The type of conviction for the owner.

Date of Conviction

The date of the conviction for the owner.

Fine Amount

The criminal fine dollar amount.

Restitution Order Amount

The restitution order dollar amount.

Attach additional information to Application

Select if you wish to attach additional information to the provider enrollment application.

Add Sanction Fields

5. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been sanctioned by the Office of Inspector General (OIG), Medicare, Medicaid, or the Social Security Act, including a state Medicaid program?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.

To add a new sanction, click Add Sanction. Existing sanctions, if any, are listed in a table. To edit, in the Sanction table, click the appropriate row. After changing or adding information, on the Sanction action bar, click Save.

Last Name

Last name of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.

First Name

First name of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.

Middle initial of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.

Suffix

Suffix of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.

Relationship

Relationship of the person or entity with ownership in the business who has been sanctioned by the OIG, state, or other federal program.

Type of Sanction

Type of sanction by the OIG, state, or other federal program.

Sanction City

The city where the sanction occurred.

Sanction State

The state where the sanction occurred.

Date of Sanction

The date when the sanction occurred.

Program Type

The type of state or federal program.

Attach additional information to Application

Select if you wish to attach additional information to the provider enrollment application.

6. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been denied malpractice insurance or ever voluntarily or involuntarily agreed to any limitations, restrictions, or conditions to your license, certification, or permit including any formal or informal Professional Board Disciplinary Action(s)?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.

Date of Occurrence

The date when the person was denied malpractice insurance or agreed to limitations, restrictions and conditions on a permit, license, or certification.

State Occurred

The state in which the person was denied malpractice insurance or agreed to limitations, restrictions and conditions on a permit, license, or certification.

Description

Description of the incident.

Attach additional information to Application

Select if you wish to attach additional information to the provider enrollment application.

Other Questions Fields

The fields listed above for Question 6 are also displayed for the following questions (7, 8, 9) if Yes is selected.

7. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever had any Program Exclusions from any federally funded program?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.

8. Have you or any of your employees, contract employees, or any person or entity with ownership of your business, been involved in any civil litigation whereby a judgment or settlement was entered into, or a Civil Monetary Penalty(s) was paid?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.

9. Do you or any of your employees, contract employees, or any person or entity with ownership of your business have any Judgment(s) or Pending actions under the False Claims Act?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit information.