Iowa Admin. Code r. 441-79.14 - Provider enrollment
(1)
Application request. Iowa Medicaid providers, including those enrolled with a
managed care organization, shall begin the enrollment process by completing the
appropriate application on the Iowa Medicaid enterprise website. Managed care
organizations and fiscal agents are exempt from completing an application.
a. Providers of home- and community-based
waiver services shall submit Form 470-2917, Medicaid HCBS Provider Application,
at least 90 days before the planned service implementation date.
b. Providers enrolling as ordering or
referring providers shall submit Form 470-5111, Iowa Medicaid
Ordering/Referring Provider Enrollment Application.
c. All other providers shall submit Form
470-0254, Iowa Medicaid Provider Enrollment Application.
d. A nursing facility shall also complete the
process set forth in 441-subrule 81.13(1).
e. An intermediate care facility for persons
with an intellectual disability shall also complete the process set forth in
441-subrule 82.3(1).
f. Qualified
Medicare beneficiary (QMB) providers shall enroll using Form 470-5262,
Qualified Medicare Beneficiaries (QMB) or Health Insurance Premium Payment
(HIPP) Program Provider Enrollment Application.
g. Health insurance premium payment (HIPP)
providers shall enroll using Form 470-5262, Qualified Medicare Beneficiaries
(QMB) or Health Insurance Premium Payment (HIPP) Program Provider Enrollment
Application.
(2)
Submittal of application. The provider shall submit the appropriate application
forms, including the application fee, if required, to the Iowa Medicaid
enterprise provider services unit by personal delivery, by email, via online
enrollment systems, or by mail to P.O. Box 36450, Des Moines, Iowa 50315.
a. The application shall include the
provider's national provider identifier number or shall indicate that the
provider is an atypical provider that is not issued a national provider
identifier number.
b. With the
application form, an assertive community treatment program shall submit Form
470-4842, Assertive Community Services (ACT) Provider Agreement Addendum, and
agree to file with the department an annual report containing information to be
used for rate setting, including:
(1) Data by
practitioner on the utilization by Medicaid members of all the services
included in assertive community treatment, and
(2) Cost information by practitioner type and
by type of service actually delivered as part of assertive community
treatment.
c. With the
application Form 470-5273, or as a supplement to a previously submitted
application, providers of health home services must submit Form 470-5100,
Health Home Provider Agreement, or Form 470-5160, Integrated Health Home
Provider Agreement.
d. Application
fees.
(1) Providers who are enrolling or
reenrolling in the Iowa Medicaid program shall submit an application fee with
their application unless they are exempt as set forth in this
paragraph.
(2) Fee amount. The
application fee shall be in the amount prescribed by the Secretary of the U.S.
Department of Health and Human Services (the Secretary) for the calendar year
in which the application is submitted and in accordance with
42
U.S.C.
1395cc(j)(2)(C).
(3) Nonrefundable. The application fee is
nonrefundable, except if submitted with one of the following:
1. A hardship exception request that is
subsequently approved by the Secretary.
2. An application that is subsequently denied
as a result of a temporary moratorium under 2013 Iowa Acts, Senate File 357,
section 12.
3. An application or
other transaction in which the application fee is not required.
(4) The process for enrolling or
reenrolling a provider will not begin until the application fee has been
received by the department or a hardship exception request has been approved by
the Secretary.
(5) Exempt
providers. The following providers shall not be required to submit an
application fee:
1. Individual physicians or
nonphysician practitioners.
2.
Providers that are enrolled in Medicare, another state's Medicaid program or
another state's children's health insurance program.
3. Providers that have paid the applicable
application fee within 12 months of the date of application submission to a
Medicare contractor or another state.
(6) All application fees collected shall be
used for the costs associated with the screening procedures as described in
subrule 79.14(4). Any unused portion of the application fees collected shall be
returned to the federal government in accordance with 42 CFR §
455.460.
(3)
Program integrity information requirements.
a.
All providers, including but not limited to managed care organizations and
Medicaid fiscal agents, applying for participation in the Iowa Medicaid program
must disclose all information required to be submitted pursuant to 42 CFR Part
455. In addition, all providers shall disclose any current, or previous, direct
or indirect affiliation with a present or former Iowa Medicaid provider that:
(1) Has any uncollected debt owed to Medicaid
or any other health care program funded by any governmental entity, including
but not limited to the federal and state of Iowa governments;
(2) Has been or is subject to a payment
suspension under a federally funded health care program;
(3) Has been excluded from participation
under Medicaid, Medicare, or any other federally funded health care
program;
(4) Has had its billing
privileges denied or revoked;
(5)
Has been administratively dissolved by the Iowa secretary of state, or similar
action has been taken by a comparable agency in another state; or
(6) Shares a national provider identification
(NPI) number or tax ID number with another provider that meets the criteria
specified in subparagraph 79.14(3)"a"(1), (2), (3), (4), or
(5).
b. The Iowa
Medicaid enterprise may deny enrollment to a provider applicant or disenroll a
current provider that has any affiliation as set forth in this rule if the
department determines that the affiliation poses a risk of fraud, waste, or
abuse. Such denial or disenrollment is appealable under 441-Chapter 7 but,
notwithstanding any provision to the contrary in that chapter, the provider
shall bear the burden to prove by clear and convincing evidence that the
affiliation does not pose any risk of fraud, waste, or abuse. The Iowa Medicaid
enterprise shall deny enrollment to or shall immediately disenroll any person
that the Iowa Medicaid enterprise, Medicare, or any other state Medicaid
program has ever terminated under rule
441-79.2(249A) or a similar
provision and shall deny enrollment to any person presently suspended from
participation, or who would be subject to a suspension, under paragraph
79.2(3)"c." Further, a person sanctioned under rule
441-79.2(249A) or a similar
provision may not manage consumer choices option (CCO) funds for a
member.
c. For purposes of this
rule, the term "direct or indirect affiliation" includes but is not limited to
relationships between individuals, business entities, or a combination of the
two. The term includes but is not limited to direct or indirect business
relationships that involve:
(1) A compensation
arrangement;
(2) An ownership
arrangement;
(3) Managerial
authority over any member of the affiliation;
(4) The ability of one member of the
affiliation to control or influence any other; or
(5) The ability of a third party to control
or influence any member of the affiliation.
d. Notwithstanding any previous successful
enrollment in the medical assistance program, the passing of any background
check by the department or any other entity, or similar prior approval for
participation as a provider in the medical assistance program, in whole or in
part, disenrollment from the medical assistance program is mandatory when, in
the case of a corporation or similar entity, 5 percent or more of the
corporation or similar entity is owned, controlled, or directed by a person who
(1) has within the last five years been listed on any dependent adult abuse
registry, child abuse registry, or sex offender registry; (2) has pled guilty
or nolo contendere to, or was convicted of, any crime punishable by a term of
imprisonment greater than five years; (3) has, within the last five years, pled
guilty or nolo contendere to, or was convicted of, any controlled substance
offense; (4) has, within the last ten years, pled guilty or nolo contendere to,
or was convicted of, any crime involving an allegation of dishonesty punishable
by a term of imprisonment greater than one year but not more than five years;
or (5) within the last ten years, has on more than one occasion pled guilty or
nolo contendere to, or was convicted of, any crime involving an allegation of
dishonesty.
(4)
Screening procedures and requirements. Providers applying for participation in
the Iowa Medicaid program shall be subject to the "limited," "moderate," or
"high" categorical risk screening procedures and requirements in accordance
with 42 CFR §455.450.
a. For the types of
providers that are recognized as a provider under the Medicare program, the
Iowa Medicaid enterprise shall use the same categorical risk screening
procedures and requirements assigned to that provider type by Medicare pursuant
to 42 CFR §424.518.
b.
Provider types not assigned a screening level by the Medicare program shall be
subject to the procedures of the "limited" risk screening level pursuant to 42
CFR §455.450.
c. Adjustment of
risk level. The Iowa Medicaid enterprise shall adjust the categorical risk
screening procedures and requirements from "limited" or "moderate" to "high"
when any of the following occurs:
(1) The Iowa
Medicaid enterprise imposes a payment suspension on a provider based on a
credible allegation of fraud, waste, or abuse; the provider has an existing
Medicaid overpayment; or within the previous ten years, the provider has been
excluded by the Office of the Inspector General or another state's Medicaid
program; or
(2) The Iowa Medicaid
enterprise or the Centers for Medicare and Medicaid Services in the previous
six months lifted a temporary moratorium for the particular provider type, and
a provider that was prevented from enrolling based on the moratorium applies
for enrollment as a provider at any time within six months from the date the
moratorium was lifted.
(5) Notification. A provider shall be
notified of the decision on the provider's application within 30 calendar days
of receipt by the Iowa Medicaid enterprise provider services unit of a complete
and correct application with all required documents, including, but not limited
to, if applicable, any application fees or screening results.
(6) A provider that is not approved as the
Medicaid provider type requested shall have the right to appeal under
441-Chapter 7.
(7) Effective date
of approval. An application shall be approved retroactive to the date requested
by the provider or the date the provider meets the applicable participation
criteria, whichever is later, not to exceed 12 months retroactive from the
receipt of the application with all required documents by the Iowa Medicaid
enterprise provider services unit.
(8) A provider approved for certification as
a Medicaid provider shall complete a provider participation agreement as
required by rule 441-79.6(249A).
(9) No payment shall be made to a provider
for care or services provided prior to the effective date of the Iowa Medicaid
enterprise's approval of an application.
(10) Payment rates dependent on the nature of
the provider or the nature of the care or services provided shall be based on
information on the application, together with information on claim forms, or on
rates paid the provider prior to April 1, 1993.
(11) An amendment to an application shall be
submitted to the Iowa Medicaid enterprise provider services unit and shall be
approved or denied within 30 calendar days. Approval of an amendment shall be
retroactive to the date requested by the provider or the date the provider
meets all applicable criteria, whichever is later, not to exceed 30 days prior
to the receipt of the amendment by the Iowa Medicaid enterprise provider
services unit. Denial of an amendment may be appealed under 441-Chapter
7.
(12) A provider that has not
submitted a claim in the last 24 months will be sent a notice asking if the
provider wishes to continue participation. A provider that fails to reply to
the notice within 30 calendar days of the date on the notice will be terminated
as a provider. Providers that do not submit any claims in 48 months will be
terminated as providers without further notification.
(13) Report of changes. The provider shall
inform the Iowa Medicaid enterprise of all pertinent changes to enrollment
information within 35 days of the change. Pertinent changes include, but are
not limited to, changes to the business entity name, individual provider name,
tax identification number, mailing address, telephone number, or any
information required to be disclosed by subrule 79.14(3).
a. When a provider reports false, incomplete,
or misleading information on any application or reapplication, or fails to
provide current information within the 35-day period, the Iowa Medicaid
enterprise may immediately terminate the provider's Medicaid enrollment. The
termination may be appealed under 441-Chapter 7. Such termination remains in
effect notwithstanding any pending appeal.
b. When the department incurs an
informational tax-reporting fine or is required to repay the federal share of
medical assistance paid to the provider because a provider submitted inaccurate
information or failed to submit changes to the Iowa Medicaid enterprise in a
timely manner, the fine or repayment shall be the responsibility of the
individual provider to the extent that the fine or repayment relates to or
arises out of the provider's failure to keep all provider information current.
(1) The provider shall remit the amount of
the fine or repayment to the department within 30 days of notification by the
department that the fine has been imposed.
(2) Payment of the fine or repayment may be
appealed under 441-Chapter 7.
(14) Provider termination or denial of
enrollment. The Iowa Medicaid enterprise must terminate or deny any provider
enrollment when the provider has violated any requirements identified in 42 CFR
§455.416.
(15) Temporary
moratoria. The Iowa Medicaid enterprise must impose any temporary moratorium
pursuant to 2013 Iowa Acts, Senate File 357, section 12.
(16) Provider revalidation. Providers are
required to complete the application process and screening requirements as
detailed in this rule every five years.
(17) Recoupment. A provider is strictly
liable for any failure to disclose the information required by subrule 79.14(3)
or any failure to report a change required by subrule 79.14(13). The department
shall recoup as incorrectly paid all funds paid to the provider before a
complete disclosure or report of change was made. The department shall also
recoup as incorrectly paid all funds to any provider that billed the Iowa
Medicaid enterprise while the provider was administratively dissolved by the
Iowa secretary of state or comparable agency of another state, even if the
provider subsequently obtains a retroactive reinstatement from the Iowa
secretary of state or similar action was taken against the provider by a
comparable agency of another state.
This rule is intended to implement Iowa Code section 249A.4.
Notes
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