Sanction or suspension

In accordance with state and federal law, Priority Health pays sanctioned providers only for emergent and urgent services.

Lists and databases referenced

The Office of the Inspector General (OIG) at the US Department of Health & Human Services maintains a sanction list that identifies individuals found guilty of fraudulent billing, misrepresentation of credentials, and other infractions. Priority Health checks the sanction list each time it is issued.

In addition, Priority Health does not pay for items or services furnished, ordered or prescribed by any provider listed or identified on any of the following lists and databases:

  • 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)
  • The U.S. Department of Treasury, Office of Foreign Assets Control Specially Designated Nationals (SDN) list
  • Any individual state provider exclusion or sanction list
  • Any database including, but not limited to, state Office of Medicaid Inspector exclusion lists
  • The sanction/suspension process

The Priority Health Chief Medical Officer is responsible for initiating any corrective action/sanction process in which the infraction or conduct could adversely affect the health or welfare of members. The recommendation is forwarded to the Priority Health Adverse Action Committee (PAAC).

The sanctioned provider with a Medicare contract has an opportunity to appeal. All providers have received, in the initial credentialing packet, a Priority Health policy and procedure regarding the appeal process. For a copy of the appeal process, refer to your credentialing packet or contact your Provider Performance Specialist.