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BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 1 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
Policy
In order to comply with 42 CFR 438.610, Bay-Arenac Behavioral Health Authority (BABHA) to
the best of its knowledge and belief will not have any of the following relationships with an
individual who is debarred, suspended or otherwise excluded from participating in Federal health
care programs:
1) Excluded individuals will not be a director, officer, or partner of the BABHA;
2) Excluded individuals will not have a beneficial ownership of five percent or more of
BABHA’s equity, if any; and
3) Excluded individuals will not have an employment, consulting, or other arrangement with
BABHA for the provision of items or services that are significant and material to
BABHA’s obligations under its contract with the State of Michigan.
BABHA to the best of its knowledge and belief, will not have any of the aforementioned
relationships with an individual who is an affiliate as defined in the Federal Acquisition
Regulations, of an individual or entity, nor has a controlling interest in any entity, that has been
so debarred, suspended or otherwise excluded from participating in procurement activities under
applicable Federal Acquisition Regulations, or non-procurement activities under the regulations
issued under Executive Order No. 12549.
BABHA will comply with the federal regulations to obtain, maintain, disclose, and furnish
required information about ownership and control interests, business transactions, and criminal
convictions as specified in 42 C.F.R. §455.104-106. In addition, BABHA will ensure that any
and all contracts, agreements, purchase orders, or leases to obtain space, supplies, equipment or
services provided under the Medicaid agreement will require compliance with 42 C.F.R.
§455.104-106.
Purpose
This policy and procedure defines a process to ensure BABHA directors, officers, employees,
BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 2 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
licensed independent practitioners, contracted service providers and suppliers, lessors,
consultants and Community Mental Health Service Programs (CMHSPs) operating under Local
Area Service Subcontracting Agreements (LSSAs), and any individuals with a beneficial
ownership of five percent or more of such individuals and entities, are not suspended by or
excluded from participation in, or under sanction by, any Federal or State health care program, or
debarred from participating in any Federal Executive Branch procurement or non-procurement
program.
Furthermore, this policy and procedure defines a process to ensure BABHA directors, officers,
employees, licensed independent practitioners, contracted service providers and suppliers,
lessors, consultants and CMHSP's, and any individuals with a beneficial ownership of five
percent or more of such individuals and entities, have not within a three-year period preceding
their engagement with BABHA been convicted of or had a civil judgment rendered against them
for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public (federal, state or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statement or receiving stolen
property; and are not presently indicted or otherwise criminally or civilly charged by a
government entity (federal, state or local) with commission of any of these offenses, and; have
not within a three year period preceding their engagement with BABHA had one or more public
transactions (federal, state or local) terminated for cause or default.
Applicability
All BABH Staff
Selected BABH Staff, as follows:
All Contracted Providers: Policy Only Policy and Procedure
Selected Contracted Providers, as follows:
Policy Only Policy and Procedure
BABH’s Affiliates: Policy Only Policy and Procedure
Other: Board Members, Consultants Policy Only Policy and Procedure
BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 3 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
Definition
1. Affiliate: As defined in Federal Acquisition Regulations, business concerns, organizations,
or individuals are affiliates of each other if, directly or indirectly, (1) either one controls or
has the power to control the other, or (2) a third party controls or has the power to control
both. Indicia of control include, but are not limited to, interlocking management or
ownership, identity of interest among family members, shared facilities and equipment,
common use of employees, or a business entity organized following the debarment,
suspension, or proposed debarment of a contractor which has the same or similar
management, ownership, or principal employees as the contractor that was debarred,
suspended, or proposed for debarment.
2. Debarment: Individuals or entities not allowed to receive contracts or conduct business with
the Federal government due to a conviction or civil judgment for commission of a fraud or
criminal offense in connection with obtaining, attempting to obtain or performing a public
contract or subcontract, violation of Federal or State antitrust statutes, commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, tax evasion, or receiving stolen property, or commission of any other offense
indicating a lack of business integrity or business honesty that seriously and directly affects
the present responsibility of a government contractor or sub-contractor.
3. Excluded: Individuals or entities that have been excluded from participating, but not
reinstated, in the Medicare, Medicaid, or any other Federal health care programs. Bases for
exclusion include convictions for program-related fraud and patient abuse, licensing board
actions and default on Health Education Assistance loans.
4. Engagement: An employment arrangement or contract, term of appointment, service
contract, service agreement, purchase order, lease, LSSA, or a consulting agreement with
BABHA, for the provision of items and services that are significant and material to BABHA's
obligations under its contract(s) with the Michigan Department of Community Health
(MDCH).
5. Ownership or Control Interest: An individual is considered to have an “ownership” or
“control interest” in an entity if it has direct or indirect ownership of 5 percent or more, or is
a managing employee (e.g., a general manager, business manager, administrator, or director)
BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 4 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
who exercises operational or managerial control over the entity, or who directly or indirectly
conducts the day-to-day operations of the entity as defined in section 1126(b) of the Act and
under 42 CFR section 1001.1001(a)(1).
Procedure
1. Prior to entering into an employment arrangement or contract, term of appointment, service
contract, service agreement, purchase order, lease, LSSA, or a consulting agreement, for the
provision of items and services that are significant and material to BABHA's obligations
under its contract(s) with the MDCH, BABHA will require the applicant to disclose in
writing:
a. Whether the individual or entity:
i. Is currently or has previously been excluded, debarred, or suspended from
participation in, or sanctioned by, any Federal or State health care program, or
has been debarred from any procurement activities under applicable Federal
Acquisition Regulations, or non-procurement activities under regulations
issued pursuant to Executive Order No. 12549;
ii. Is an affiliate, as defined in the Federal Acquisition Regulations, of an
individual or entity, and or has a controlling interest in an entity that has been
so excluded, suspended, debarred, or sanctioned;
iii. Has within a three-year period preceding their engagement by BABHA been
convicted of or had a civil judgment rendered against them for commission of
fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public (federal, state or local) transaction or contract under a
public transaction; violation of federal or state antitrust statutes or commission
of embezzlement, theft, forgery, bribery, falsification or destruction of records,
making false statement or receiving stolen property, or is presently indicted or
otherwise criminally or civilly charged by a government entity (federal, state
or local) with commission of any of these offenses; and
BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 5 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
iv. Have not within a three year period preceding their engagement with BABHA
had one or more public transactions (federal, state or local) terminated for
cause or default.
b. If an entity, information about individuals with an ownership or control interest in the
entity, including any additional ownership or control interest for those individuals in
other entities, as well as identifying when any of the individuals with ownership or
control interest have spousal, parent-child or sibling relationships with each other (see
related Ownership Disclosure form).
2. BABHA will ensure that the applicant knows that one of the terms of engagement requires
immediate disclosure in writing to the Chief Executive Officer (CEO) of BABHA or if the
CEO is the applicant, to the Chair of the BABHA Board of Directors, of any proposed or
actual suspension, exclusion, sanction, or debarment from any health care program funded in
whole or in part by the Federal or State government (including Medicare and Medicaid), or
any debarment from procurement activities under applicable Federal Acquisition Regulations,
or non-procurement activities under the regulations issued pursuant to executive Order No.
12549, or any criminal conviction that may lead to such suspension, exclusion, sanction or
debarment.
3. Prior to entering into an engagement, the BABHA Human Resources or Contract
Management Department will:
a. Review on-line, via the Internet, the Office of Inspector General’s (OIG) List of
Excluded Individuals/Entities and the General Services Administration’s (GSA) List
of Parties Excluded from Federal Procurement and Non-Procurement Programs to
ensure that the individual or entity, and any individuals with a beneficial ownership or
control interest in such an entity, are not included on either of those lists nor are they
an affiliate, as defined in the Federal Acquisition Regulations, of any one on the
GSA’s List, and document the results; and
b. Perform a criminal background check to ensure that the individual or entity, and any
individuals with a beneficial ownership or control interest in such an entity, have not
been charged with or convicted of a criminal offense relating to Medicare, Medicaid,
or other Federal or State health care program, or any other crime involving the
delivery of a health care item or service, and document the results.
BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 6 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
4. BABHA's Human Resources or Contract Management Department will conduct and
document subsequent checks of the OIG’s List of Excluded Individuals/Entities and the
GSA's List of Parties Excluded from Federal Procurement and Non-Procurement Programs,
at the following frequencies:
a. For employees who are providing clinical services, monthly; for all other employees,
at least annually;
b. For the CEO, Chief Financial Officer, Director of Clinical Operations and Medical
Director, of BABHA and the CMHSP's operating under LSSA's, monthly;
c. For members of the BABHA Board of Directors, with renewal of term of
appointment;
d. For contracted LIP's, monthly;
e. For contracted primary behavioral health care service providers, contracted ancillary
behavioral health care service providers (e.g. nursing, durable medical equipment,
etc.), and any individuals with a beneficial ownership or control interest in such
entities, monthly; and
f. For other contracted service providers, suppliers, lessors and consultants providing
items and services that are significant and material to BABHA's obligations under its
contract(s) with the MDCH (i.e., the provision of Federal and State funded health care
services), with the renewal of the contract or agreement, or at least on an annual basis.
5. BABHA will require, and verify through audit, that the CMHSP's, contracted primary
behavioral health care service providers, and contracted ancillary behavioral health care
service providers to have internal procedures/processes in place that require:
a. The entity to perform and document periodic checks of the OIG’s List of Excluded
Individuals/Entities and the GSA's List of Parties Excluded from Federal Procurement
and Non-Procurement Programs, to ensure individuals and entities, and those with
ownership or control interest in such entities, are not included on the lists nor are
they an affiliate, as defined in the Federal Acquisition Regulations, of an individual or
entity on such lists. At least quarterly review is recommended for those individuals
and entities who, based upon the nature of their work, would have the greatest
potential for debarment or exclusion from Medicare or Medicaid.
BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 7 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
b. The immediate disclosure of any proposed or actual suspension, exclusion, sanction,
or debarment from any health care program funded in whole or in part by the Federal
or State government (including Medicare and Medicaid), or any debarment from
procurement activities under applicable Federal Acquisition Regulations, or non-
procurement activities under the regulations issued pursuant to executive Order No.
12549, or any criminal conviction that may lead to such suspension, exclusion,
sanction or debarment.
6. Any matches or potential matches of an individual or entity against one of the government
databases as identified by the BABHA Human Resources or Contract Management
Departments will be treated as confidential and will be addressed as follows:
a. Any matches will be immediately reported to the CEO and the Corporate Compliance
Officer; and
b. The Corporate Compliance Officer, after consultation with the appropriate personnel
(e.g., Human Resources, Contract Management, and/or the CEO) will coordinate a
thorough internal investigation to determine if there is a true match against the
governmental listings. If, through those measures, it is still uncertain whether there is
a match, an inquiry will be sent to the OIG or other appropriate agency for
confirmation.
7. Any confirmed criminal offense or exclusion/sanction from a Federal or State health care
program will be treated as confidential and the following actions will be taken:
a. When BABHA becomes aware that an individual or entity, or any individual with a
beneficial ownership of five percent or more of such individuals and entities, has been
proposed for exclusion, suspension, or sanction during their engagement, BABHA
will take actions consistent with personnel policies and procedures, or the terms of the
contract or agreement;
b. BABHA will notify the Division of Program Development, Consultation and
Contracts, Mental Health and Substance Abuse Administration of the MDCH of
relevant disclosures , confirmed matches from checks of OIG and GSA lists, or
administrative actions that could lead to exclusion, debarment or suspension, by and
of individuals and entities engaged with BABHA; and
BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 8 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
c. The BABHA Corporate Compliance Officer will, after discussion with the CEO, and
legal counsel as appropriate, coordinate an investigation into the need for repayment
or further disclosure.
Attachments
N/A
Related Forms
1. Attestation of Non-Debarment from Participation in Federal Acquisition Programs,
including Medicare and Medicaid
2. BABH Employee Attestation Regarding Prohibited Affiliations and/or Exclusion,
Conviction or Debarment
3. Exhibit C - Disclosure by Provider - Information on Ownership and Control
Related Materials
N/A
BAY-ARENAC BEHAVIORAL HEALTH
POLICIES AND PROCEDURES MANUAL
Chapter: 13 Corporate Compliance
Section: 2 Administrative & Operational Practices
Topic: 11 Prohibited Affiliations and/or Exclusion or Conviction
Supersedes Date: Approval Date:
Page: 9 of 9 Pol: 9-16-04 Pol: 9-16-10
Proc: 4-23-08, 11-29-06, Proc: 9-16-10 _____________________________
9-16-04 Board Chairperson Signature
____________________________
Chief Executive Officer Signature
Note: Unless this document has an original signature, this copy is uncontrolled and valid on this date only:
2/9/2011. For Controlled copy, view shared directory
G:\\Isimage01\BACMH_users\bacmh_group\Agency\Agency_Manual.
DO NOT WRITE IN SHADED AREA ABOVE
References/Legal Authority
1. 42 CFR § 438.610
2. 42 CFR § 455.104-106
3. 42 CFR § 1001.1001
4. 45 CFR § 76
5. Federal Acquisition Regulations, Executive Order No. 12549
6. Social Security Act, Section 1128 and 1156
7. Medicaid Managed Specialty Supports and Services Concurrent 1915(b)/(c) Waiver
Program Contract
Submission Form
Approving Body/Committee/Supervisor: Author/Reviewer: Approval/Review Date:
Corporate Compliance-Payor M. Bartlett 4/23/2008
Corporate Compliance Payor/OPS J. Pinter 7/9/10
Result:
Deletion New No Changes Replacement Revision
List reason for deletion/replacement/revision here. If replacement, list policy to be replaced.
Added language based on the Federal Acquisition Regulation to capture "associates" language
to ensure not debarred from Medicare/Medicaid
Revision of entire policy statement/procedure changes
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