Exclusions: Sanction, suspension, debarment

Priority Health doesn't pay for items or services furnished, ordered or prescribed by any provider listed or identified on any of the following lists and databases. There's a limited exception to this payment prohibition for the provision of certain emergency items or services not provided in a hospital emergency room. See 42 CFR 1001.1901(c).
Priority Health adopted the State and Federal exclusion requirements in place for Medicare, Medicaid and the Federal Employees Health Benefit Program (FEHBP). This means Priority Health won't pay services furnished, ordered or prescribed by any provider listed on a State or Federal sanction/exclusion, debarment list/database. This applies to all Priority Health products including commercial and individual.

Lists and databases referenced 

  • The U.S. Department of Health & Human Services, Office of Inspector General List of Excluded Individuals and Entities (LEIE)
  • The System for Award Management (SAM)
  • All individual state published exclusion lists
  • CMS preclusion list
  • FEHBP debar list
  • Summary suspensions

Priority Health screens all providers initially upon credentialing or claim payment in addition to monthly screening. If a provider is identified on one of the exclusion lists, the case will be reviewed and presented to the Priority Health Adverse Action Committee (PAAC). Actions taken include:

  • Termination of contract aligned with exclusion date, if applicable
  • Recovery of claims paid after exclusion date, if applicable
  • Updating Priority Health systems to reflect exclusion status to prevent claims payment after exclusion date. If a provider is on multiple lists, the earliest exclusion date will apply
  • Notification to impacted members if a provider is listed on the CMS preclusion or FEHB debarment list

The sanctioned provider with a Medicare contract has an opportunity to appeal the termination process. All providers have access to the credentialing policies within our Provider Manual including the appeal process. For a copy of the policy, refer to the Provider Manual.

Exclusion References

  • Section 1128, 1156, 1902, 1862 of the Social Security Act (SSA)
  • 42 CFR 422.503, 422.752, 423.504, 1001.1901
  • 42 CFR§455.101
  • 422.222 – 422.224
  • 5 U.S.C. § 8902
  • 5 CFR Subpart J
  • OPM’s Guidelines for Implementation of FEHBP Debarment and Suspension Orders