[Code of Federal Regulations]
[Title 5, Volume 2]
[Revised as of January 1, 2005]
From the U.S. Government Printing Office via GPO Access
[CITE: 5CFR890.1003]

[Page 485-486]
 
                    TITLE 5--ADMINISTRATIVE PERSONNEL
 
          CHAPTER I--OFFICE OF PERSONNEL MANAGEMENT (CONTINUED)
 
PART 890_FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM--Table of Contents
 
Subpart J_Administrative Sanctions Imposed Against Health Care Providers
 
Sec. 890.1003  Definitions.

    In this subpart:
    Carrier means an entity responsible for operating a health benefits 
plan described by 5 U.S.C. 8903 or 8903a.
    Community means a geographically-defined area in which a provider 
furnishes health care services or supplies and for which he may request 
a limited waiver of debarment in accordance with this subpart. Defined 
service area has the same meaning as community.
    Contest means a health care provider's request for the debarring or 
suspending official to reconsider a proposed sanction or the length or 
amount of a proposed sanction.
    Control interest means that a health care provider:
    (1) Has a direct and/or indirect ownership interest of 5 percent or 
more in an entity;
    (2) Owns a whole or part interest in a mortgage, deed of trust, 
note, or other obligation secured by the entity or the entity's property 
or assets, equating to a direct interest of 5 percent or more of the 
total property or assets of the entity;
    (3) Serves as an officer or director of the entity, if the entity is 
organized as a corporation;
    (4) Is a partner in the entity, if the entity is organized as a 
partnership;
    (5) Serves as a managing employee of the entity, including but not 
limited to employment as a general manager, business manager, 
administrator, or other position exercising, either directly or through 
other employees, operational or managerial control over the activities 
of the entity or any portion of the entity;
    (6) Exercises substantive control over an entity or a critical 
influence over the activities of the entity or some portion of thereof, 
whether or not employed by the entity; or
    (7) Acts as an agent of the entity.
    Conviction or convicted has the meaning set forth in 5 U.S.C. 
8902a(a)(1)(C).
    Covered individual means an employee, annuitant, family member, or 
former spouse covered by a health benefits plan described by 5 U.S.C. 
8903 or 8903a or an individual eligible to be covered by such a plan 
under 5 U.S.C. 8905(d).
    Days means calendar days, unless specifically indicated otherwise.
    Debarment means a decision by OPM's debarring official to prohibit 
payment of FEHBP funds to a health care provider, based on 5 U.S.C. 
8902a (b), (c), or (d) and this subpart.
    Debarring official means an OPM employee authorized to issue 
debarments and financial sanctions under this subpart.
    FEHBP means the Federal Employees Health Benefits Program.
    Health care services or supplies means health care or services and 
supplies such as diagnosis and treatment; drugs and biologicals; 
supplies, appliances and equipment; and hospitals, clinics, or other 
institutional entities that furnish supplies and services.
    Incarceration means imprisonment, or any type of confinement with or 
without supervised release, including but not limited to home detention, 
community confinement, house arrest, or similar arrangements.
    Limited waiver means an approval by the debarring official of a 
health care provider's request to receive payments of FEHBP funds for 
items or services rendered in a defined geographical area, 
notwithstanding debarment, because the provider is the sole community 
provider or sole source of essential specialized services in a 
community.
    Mandatory debarment means a debarment based on 5 U.S.C. 8902a(b).
    Office or OPM means the United States Office of Personnel Management 
or the component thereof responsible for conducting the administrative 
sanctions program described by this subpart.

[[Page 486]]

    Permissive debarment means a debarment based on 5 U.S.C. 8902a(c) or 
(d).
    Provider or provider of health care services or supplies means a 
physician, hospital, clinic, or other individual or entity that, 
directly or indirectly, furnishes health care services or supplies.
    Reinstatement means a decision by OPM to terminate a health care 
provider's debarment and to restore his eligibility to receive payment 
of FEHBP funds.
    Sanction or administrative sanction means any administrative action 
authorized by 5 U.S.C. 8902a or this subpart, including debarment, 
suspension, civil monetary penalties, and financial assessments.
    Should know or should have known has the meaning set forth in 5 
U.S.C. 8902a(a)(1)(D).
    Sole community provider means a provider who is the only source of 
primary medical care within a defined service area.
    Sole source of essential specialized services in a community means a 
health care provider who is the only source of specialized health care 
items or services in a defined service area and that items or services 
furnished by a non-specialist cannot be substituted without jeopardizing 
the health or safety of covered individuals.
    Suspending official means an OPM employee authorized to issue 
suspensions under 5 U.S.C. 8902a and this subpart.

                          Mandatory Debarments