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terminated pursuant to 42 CFR Section 402, Subpart C, may exercise his appeal rights as set forth in the written notice of exclusion, suspension or termination from the Centers for Medicare and Medicaid Services. Appeals to the Centers for Medicare and Medicaid Services shall be processed exclusively in accordance with 42 CFR Part 1005. HISTORY: Amended by State Register Volume 20, Issue No. 6, Part 1, eff June 28, 1996; SCSR42–5 Doc. No. 4746, eff May 25, 2018. 126–405. Reinstatement. An individual or entity who has been excluded from Medicaid may be reinstated only by the Medicaid agency that imposed the exclusion. An individual or entity may submit to the State agency a request for reinstatement at any time after the date specified in the notice of exclusion [42 CFR § 1002.214(b) and (c)]. HISTORY: Amended by SCSR42–5 Doc. No. 4746, eff May 25, 2018. SUBARTICLE 2 PROGRAM INTEGRITY 126–425. Beneficiary Utilization. A. Definitions. (1) The Division of Program Integrity of the South Carolina Department of Health and Human Services (DHHS) is designed to safeguard against unnecessary, harmful, wasteful, and uncoordinated utilization of services by Medicaid eligible beneficiaries and health care providers. (2) Medicaid Beneficiary - an individual who has been determined to be eligible for health services as described in the State Plan under Title XIX and Title XXI of the Social Security Act, as amended. (3) Beneficiary Profile - a comprehensive statistical and utilization profile of a Medicaid beneficiary who has deviated from predefined thresholds, standards of medical care, and other criteria for the purposes of analysis and review. (4) Misutilization (‘‘misuse’’) - overuse, underuse, harmful, wasteful, and uncoordinated use of Medicaid services or improper or incorrect use of services provided under the Medicaid Program, whether intentional or unintentional. (5) Restriction (‘‘restricted’’) - The limitation of a Medicaid beneficiary to Medicaid services provided by a designated primary physician practitioner, pharmacy, hospital, or mental health provider for other than emergency health care. A restriction may be to more than one provider. A designated primary physician practitioner may make referrals to other health care providers, which will not be affected by the restriction designation. (6) Provider - an individual, partnership, corporation, association, or institution that is eligible to provide medical assistance to a beneficiary pursuant to the State Medical Assistance Plan in accordance with Title XIX and Title XXI of the Social Security Act, as amended. A provider must be licensed, as applicable, under State law, is in good standing with applicable professional review boards, has not had a license revoked or suspended, and has not been convicted of fraud in any legal jurisdiction. (7) Practitioner - a physician or other health care professional licensed under State law to practice his or her profession, is in good standing with applicable professional review boards, has not had a license revoked or suspended, and has not been convicted of fraud in any legal jurisdiction. (8) Treatment Pathway - is the most appropriate medical condition specific treatment protocol. Treatment pathways have been researched and approved by professional associations, provide desired outcomes, include definitive evaluation and re-evaluation plateaus, offer a coordinated health team approach to care, eliminate duplication of costly services, and reduce errors. (9) Medically Reasonable and Necessary (‘‘medically necessary’’) - means procedures, treatments, medications or supplies ordered by a physician, dentist, chiropractor, mental health care provider, or other approved, licensed health care practitioner to identify or treat an illness or injury. Procedures, treatments, medications or supplies must be administered in accordance with recognized