Form CMS-10398 #5 CMS-10398 #5 Payment Suspension Screen Shots

State			Number of Full Suspensions
Date of Report			Number of Partial Suspensions
Reporting Period			Number of Referrals to Law Enforcement
State Contact
		Name
		Title
		Office, Group, or Division
		Address 1
		Address 2
		City
		State
		Zip Code
		Telephone
		Email

State

Date of Report

Nature of Credible Allegation(s) of Fraud

 Billing Fraud  Other

Basis for Suspension Instructions: Select the most appropriate option(s). The total number associated with each option selected should equal the number of provider payment suspensions imposed.

Total Number of Payment Suspensions

1.  Upcode/Overcharge Medicaid program for services rendered 2.  Billing for services not rendered or performed 3.  Billing for medically unnecessary services 4.  Billing for Drugs: a.  unlicensed or unapproved drugs b.  brand-name drugs when generic drugs are prescribed c.  Short-filling prescriptions, but charging as if the full amount of the medication was dispensed 5.  Unbundling – Using multiple billing codes instead of a single billing code in order to increase the reimbursement amount 6.  Billing for services using stolen, deceased, or otherwise inappropriate provider and/or beneficiary identification number 7.  Billing for unlicensed or excluded providers 8.  Other

Total Number

Number of Payment Suspensions Resolved Number of Active Payment Suspensions

State
Date of Report
Total Dollar Amount of All Payments Suspended
Number of Provider Appeals of Payment Suspensions
Number of Payment Suspensions Lifted as a Result of Provider Appeals and Total Dollar Amount Associated with the Payment Suspensions that were Lifted as a Result of the Provider Appeals Reported Above
Of all payment suspensions, were any providers terminated and/or excluded as a result of referral to law enforcement?	 Yes  No
If yes, how many providers?

State
Date of Report
Good Cause Exercised (State exercised good cause to not suspend payments or partially suspend payments to providers)	 Yes  No (do not complete the rem  No (If no, do not answer the remainder of the questions) If Yes, Number of cases with no payment suspension implemented
	Number of existing payment suspensions discontinued Number of suspensions changed from full suspension to partial suspensions
Nature of Good Cause Exercised	1.  Law enforcement 2.  Suspension removed or partially imposed based upon submission of written evidence by the provider 3.  Recipient access to items or services would be jeopardized, i.e., Individual or entity is sole community physician or sole source of essential specialized services, or serves a large number of recipients within a HRSA-designated medically underserved area 4.  Law enforcement declines to certify that a matter continues to be under investigation 5.  State determines that suspension is not in the best interests of the Medicaid program 6.  Credible allegation of fraud focuses only on a specific type of claim or arises from a specific business unit of a provider and partial suspension ensures that potentially fraudulent claims were not continuing to be paid 7.  State determines that suspension in part is in the best interests of the Medicaid program. 8.  Other available remedies

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