RELATES TO:
KRS
205.520,
205.560,
205.8451(2),(7),(8),(9),
205.8477,
304.17A-545(5),
311.621-311.643,
42 U.S.C.
1396a(w),
42
C.F.R. 455.100-455.106,
42
C.F.R. 1003.101
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law for the provision of medical
assistance to Kentucky's indigent citizenry.
KRS
205.560(12) requires the
Medical Assistance Program to use the form and guidelines established pursuant
to
KRS
304.17A-545(5) for assessing
the credentials of those applying for participation in the Medical Assistance
Program.
KRS
205.560(13) requires the
department to develop a specific form and establish guidelines for assessing
the credentials of dentists applying for participation in the Medical
Assistance Program. This administrative regulation establishes provisions
related to Medicaid provider enrollment, disclosure, documentation
requirements, and guidelines for assessing the credentials of those applying
for participation in the Medicaid Program.
Section
1. Definitions.
(1) "Applicant"
means a person or entity who applies for enrollment as a participating Medicaid
provider.
(2) "Cabinet" means the
Cabinet for Health and Family Services.
(3) "Claim" means a request for payment under
the Medicaid Program that:
(a) Relates to each
individual billing submitted by a provider to the department;
(b) Details services rendered to a recipient
on a specific date; and
(c) May be
a line item of service or all services for one (1) recipient on a
bill.
(4) "Credentialed
provider" means a provider that is required to complete the credentialing
process in accordance with
KRS
205.560(12) and (13) and
includes the following individuals who apply for enrollment in the Medicaid
Program:
(a) A dentist;
(b) A physician;
(c) An audiologist;
(d) A certified registered nurse
anesthetist;
(e) An
optometrist;
(f) An advance
registered nurse practitioner;
(g)
A podiatrist;
(h) A chiropractor;
or
(i) A physician
assistant.
(5)
"Department" means the Department for Medicaid Services or its designated
agent.
(6) "Disclosure" means the
provision of information required by
42
C.F.R.
455.100 through
455.106.
(7) "Evaluation" or "credentialing" means:
(a) A process for collecting and verifying
professional qualifications of a health care provider;
(b) An assessment of whether a health care
provider meets specified criteria relating to professional competence and
conduct; and
(c) A process to be
completed before a health care provider may participate in the Medicaid Program
on an initial or ongoing basis.
(8) "Exclusion" is defined by
42
C.F.R.
1003.101.
(9) "Furnish" means to provide medical care,
services, or supplies that are:
(a) Provided
directly by a provider;
(b)
Provided under the supervision of a provider; or
(c) Prescribed by a provider.
(10) "Managing employee" means a
general manager, business manager, administrator, director, or other individual
who exercises operational or managerial control over or conducts the day-to-day
operation of an institution, entity, organization, or agency.
(11) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(12) "Noncredentialed provider" means a
provider that is not required to complete the credentialing process in
accordance with
KRS
205.560(12) and includes any
individual or entity not identified in subsection (4) of this
section.
(13) "Provider" is defined
by
KRS
205.8451(7).
(14) "Recipient" is defined by
KRS
205.8451(9).
(15) "Reevaluation" or "recredentialing"
means a process for identifying a change that may have occurred in a health
care provider since the last evaluation or credentialing that may affect the
health care provider's ability to perform services.
(16) "Services" means medical care, services,
or supplies provided to a Medicaid recipient.
(17) "Subcontractor" means an individual,
agency, entity, or organization to which a Medicaid provider or the
department's fiscal agent has:
(a) Contracted
or delegated some of its management functions or responsibilities of providing
medical care or services to its patients; or
(b) Entered into a contract, agreement,
purchase order, or lease, including lease of real property, to obtain space,
supplies, equipment, or nonmedical services associated with providing services
and supplies that are covered under the Medicaid Program.
(18) "Terminated" means a provider's
participation in the Medicaid Program has ended and a contractual relationship
no longer exists between the provider and the department for the provision of
Medicaid-covered services to eligible recipients by the provider or its
subcontractor.
(19) "Unacceptable
practice" means conduct by a provider which constitutes "fraud" or "provider
abuse", as defined in
KRS
205.8451(2) or (8), or
willful misrepresentation, and includes the practices specified in Section 5 of
this administrative regulation.
Section 2. Enrollment Process for Provider
Participation in Medicaid.
(1) Scope.
(a) The department shall contract only with
an individual or entity who meets the conditions of Medicaid provider
participation in accordance with
907
KAR 1:671.
(b) The department shall reserve the right to
contract or not contract with any potential provider.
(c) An individual or entity that wishes to
participate:
1. in the Medicaid Program shall
be enrolled as a participating provider prior to being eligible to receive
reimbursement in accordance with federal and state laws; and
2. As a KenPAC primary care provider shall
meet the provider participation criteria established in
907 KAR
1:320, Kentucky Patient Access and Care System
(KenPAC).
(2)
To apply for enrollment in the Medicaid Program as a noncredentialed provider,
an individual or entity shall:
(a) Complete,
and submit to the department, the noncredentialed provider section of a
MAP-811, Provider Application; and
(b) Submit of a valid professional license,
registration, or certificate that allows the:
1. Individual to provide services within the
individual's scope of practice; or
2. Entity to operate or provide services
within the entity's scope of practice.
(3) To apply for enrollment in the Medicaid
Program as a credentialed provider, an individual shall:
(a) Complete, and submit to the department,
the individual provider application section of a MAP-811, Provider
Application;
(b) Submit proof of a
valid professional license, registration, or certificate that allows the
individual to provide services within the individual's scope of practice;
and
(c)
1. Except for a dentist, submit either:
a. A completed KAPER-1, Kentucky Application
for Provider Evaluation and Reevaluation; or
b. Pursuant to
806 KAR
17:480, Section 2(4), the provider application form of
the Council for Affordable Quality Healthcare; or
2. If licensed to practice as a dentist,
submit a completed Dental Credentialing Form.
(4)
(a)
Within forty-five (45) days of receipt of a required credentialing form, the
department shall notify the health care provider or entity applying for
enrollment in the Medicaid Program of any omitted information or questionable
information included on the form.
(b) The department shall deny enrollment if
the applicant does not:
1. Respond with the
requested information within the time period specified in the department's
notice of omitted or questionnaire information; or
2. Requests an extension of time that is:
a. Requested during the time period specified
in the department's notice; and
b.
Grant by the department.
(c) The department may require that an
on-site inspection be performed to ascertain compliance with applicable
licensure standards established in KRS Chapter 216B, and certification
standards, prior to an enrollment determination.
(d)
1. The
department shall make an enrollment determination within ninety (90) days of
receipt of:
a. The completed application
documents required by subsection (2) or (3) of this section; and
b. Any additional information requested by
the department.
2. The
department:
a. May take additional time beyond
ninety (90) days to render a decision if necessary for resolution of an issue
or dispute; and
b. Shall notify the
applicant that a decision will be issued after the ninety (90) day timeframe
established in subparagraph 1 of this paragraph if additional time is needed to
render a decision.
(5) Approval of enrollment in the Medicaid
Program as a participating provider.
(a) Upon
approval of enrollment, the department shall issue a provider number that shall
be used by the provider solely for billing and identification
purposes.
(b) A provider's
participation shall begin and end on the dates specified in the notification of
approval for program participation, unless the provider's participation is
terminated in accordance with this administrative regulation,
907
KAR 1:671, or other applicable state or federal
laws.
(6) By enrolling in
the Medicaid Program, a provider, the provider's officers, directors, agents,
employees, and subcontractors agree to:
(a)
Maintain the documentation for claims as required by Section 4 of this
administrative regulation;
(b)
Provide, upon request, all information regarding the nature and extent of
services and claims submitted by, or on behalf of the provider, to the:
1. Cabinet;
2. Department;
3. Attorney General;
4. Auditor of Public Accounts;
5. Secretary of the United States Department
of Health and Human Services; or
6.
Office of the United States Attorney;
(c) Comply with the disclosure requirements
established in Section 3 of this administrative regulation;
(d) Comply with the applicable advance
directive requirements established in
42 U.S.C.
1396a(w) regarding the right
to accept or reject life-saving medical procedures as described in
KRS
311.621 through
311.643;
(e) Accept payment from Medicaid as payment
in full for all care, services, benefits, or and supplies billed to the
Medicaid Program, except with regard to recipient cost-sharing charges and
beneficiary liability, if any;
(f)
Submit claims for payment only for care, services, benefits, or supplies;
1. Actually furnished to eligible recipients;
and
2. Medically necessary or
otherwise authorized by law;
(g) Provide true, accurate, and complete
information in relation to any claim for payment;
(h) Permit review or audit of all books or
records or, at the discretion of the auditing agency, a sample of books or
records related to services furnished and payments received from Medicaid,
including recipient histories, case files, and recipient specific data.
Failure to allow access to records may result in the provider's
liability for costs incurred by the cabinet associated with the review of
records, including food, lodging and mileage;
(i) Not engage in any activity that would
constitute an unacceptable practice;
(j) Comply with all terms and provisions
contained in the application documents required by subsection (2) or (3) of
this section;
(k) Comply with all
applicable federal laws, state statutes, and state administrative regulations
related to the applicant's provider type and provision of services under the
Medicaid Program; and
(l) Bill
third party payers in accordance with Medicaid statutes and administrative
regulations.
(7) Denial
of enrollment or reenrollment in the Medicaid Program.
(a) The department shall deny enrollment if
an applicant meets one (1) of the following conditions:
1. Falsely represents, omits, or fails to
disclose of any material fact in making an application for enrollments in
accordance with subsection (2) or (3) of this section;
2. Is currently suspended, excluded,
terminated, or involuntarily withdrawn from participation in any governmental
medical insurance program as a result of fraud or abuse of that
program;
3. Falsely represents,
omits, or fails to disclose any material fact in making an application for a
license, permit, certificate, or registration related to a health care
profession or business;
4. Has
failed to comply with applicable standards in the operation of a health care
business or enterprise after having received written notice of noncompliance
from:
a. The department; or
b. A state or federal licensing, certifying,
or auditing agency;
5. Is
under current investigation, indictment or conviction for fraud and abuse or
unacceptable practice in:
a. The Kentucky
Medicaid Program;
b. Another
state's Medicaid Program;
c. The
Medicare Program; or
d. Other
publicly funded health care program;
6. Fails to comply with any Medicaid policy
as specified in the Kentucky statutes or department's administrative
regulations;
7. Fails to pay any
outstanding debt owed to the department; or
8. Has engaged in an activity that would
constitute an unacceptable practice.
(b) If enrollment or reenrollment is denied,
the department shall consider reapplication only:
1. If the applicant corrects each deficiency
that led to the denial; and
2.
After the expiration of a period of exclusion imposed in accordance with
907
KAR 1:671, if applicable.
(c) Notice of denial of enrollment or
reenrollment. The department shall send written notice of denial to an
applicant's last known address and provide the reason for the denial.
(d) The denial shall be effective upon the
date of the written notice.
(8)
(a) A
provider may request limited enrollment for a period of time, not to exceed
thirty (30) days, in an exceptional situation for emergency services provided
to an eligible recipient.
(b) The
department shall make an enrollment determination regarding the exceptional
circumstances and notify the provider in writing of its decision.
(9) Recredentialing. A
credentialed provider currently enrolled in the Medicaid Program shall submit
to the department's recredentialing process three (3) years from the date of
the provider's initial evaluation or last reevaluation.
Section 3. Required Provider Disclosure.
(1) A provider shall comply with the
disclosure of information requirements contained in
42
C.F.R.
455.100 through
455.106
and
KRS
205.8477.
(2) Time and manner of disclosure.
Information disclosed in accordance with
42
C.F.R.
455.100 through
455.106
shall be provided:
(a) Upon application for
enrollment;
(b) Annually
thereafter; and
(c) Within
thirty-five (35) days of a written request by the department or the United
States Department of Health and Human Services.
(3) If a provider fails to disclose
information required by 42 C.F.R.
455,.100 through 455.106 within thirty-five
(35) days of the department's written request, the department shall terminate
the provider's participation in the Medicaid Program in accordance with
907
KAR 1:671, Section 6, on the day following the last
day for submittal of the required information.
(4)
(a) A
provider shall file an amended, signed ownership and disclosure form with the
department within thirty-five (35) days following a change in:
1. Ownership or control;
2. The managing employee or management
company; or
3. A provider's federal
tax identification number.
(b) Failure to comply with the requirements
of paragraph (a) of this subsection may result in termination from the Medicaid
Program.
Section
4. Required Provider Documentation.
(1) A provider shall maintain documentation
of:
(a) Care, services, benefits, or supplies
provided to an eligible recipient;
(b) The recipient's medical record or other
provider file, as appropriate, which shall demonstrate that the care, services,
benefits, or supplies for which the provider submitted a claim were actually
performed or delivered;
(c) The
diagnostic condition necessitating the service performed or supplies provided;
and
(d) Medical necessity as
substantiated by appropriate documentation including an appropriate medical
order.
(2) A provider who
is reimbursed using a cost-based method shall maintain all:
(a) Fiscal and statistical records and
reports used for the purpose of establishing rates of payment made in
accordance with Medicaid requirements established in 907 KAR Chapters 1, 3, 4,
and 23, as applicable; and
(b)
Underlying books, records, documentation and reports that formed the basis for
the fiscal and statistical records and reports.
(3) All documentation required by this
section shall be maintained by the provider for a minimum of five (5) years
from the latter of:
(a) The date of final
payment for services;
(b) The date
of final cost settlement for cost reports; or
(c) The date of final resolution of disputes,
if any.
(4) If any
litigation, claim, negotiation, audit, investigation, or other action involving
the records started before expiration of the five (5) year retention period,
the records shall be retained until the latter of:
(a) The completion of the action and
resolution of all issues which arise from it; or
(b) The end of the regular five (5) year
period.
Section
5. Unacceptable Practice. The activities listed in this section
shall constitute unacceptable practice:
(1)
Knowingly submitting, or causing the submission of false claims, or inducing,
or seeking to induce, a person to submit false claims;
(2) Knowingly making, or causing to be made,
or inducing, or seeking to induce a false, fictitious or fraudulent statement
or misrepresentation of material fact in claiming a Medicaid payment, or for
use in determining the right to payment;
(3) Having knowledge of an event that affects
the right of a provider to receive payment and concealing or failing to
disclose the event or other material omission with the intention that a payment
be made or the payment is made in a greater amount than otherwise
owned;
(4) Conversion;
(5) Soliciting or accepting bribes or
kickbacks;
(6) Failing to maintain
or to make available, for purposes of audit or investigation, administrative
and medical records necessary to fully disclose the medical necessity for the
nature and extent of the medical care, services and supplies furnished, or to
comply with other requirements established in
907 KAR 1:673,
Section 2;
(7) Knowingly submitting
a claim or accepting payment for medical care, services, or supplies furnished
by a provider who has been terminated or excluded from the program;
(8) Seeking or accepting additional payments,
for example, gifts, money, donations, or other consideration, in addition to
the amount paid or payable under the Medicaid Program for covered medical care,
services, or supplies for which a claim is made;
(9) Charging or agreeing to charge or collect
a fee from a recipient for covered services which is in addition to amounts
paid by the Medicaid Program, except for required copayments recipient
liability, if any, required by the Medicaid Program;
(10) Engaging in conspiracy, complicity, or
criminal syndications;
(11)
Furnishing medical care, services, or supplies that fail to meet professionally
recognized standards, or which are found to be non compliant with licensure
standards promulgated under KRS Chapter 216B and failing to correct the
deficiencies or violation as reported to the department by the Office
provider's professional qualifications or licensure;
(12) Discriminating in the furnishing of
medical care, services, or supplies as prohibited by
42
U.S.C.
2000d;
(13) Having payments made to or through a
factor, either directly or by power of attorney, as prohibited by
42 C.F.R.
447.10;
(14) Offering or providing a premium or
inducement to a recipient in return for the recipient's patronage of the
provider or other provider to receive medical care, services, or supplies under
the Medicaid Program;
(15)
Knowingly failing to meet disclosure requirements;
(16) Unbundling; or
(17) An act committed by a nonprovider on
behalf of a provider which, if committed by a provider, would result in the
termination of the provider's enrollment in the program.
Section 6. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "Kentucky Application for
Provider Evaluation and Reevaluation", Form KAPER-1, March 2007
edition;
(b) "Map-811, Provider
Application", July 2007 edition; and
(c) "Dental Credentialing form", July 2007
edition.
(2) This
material may be inspected, copied, or obtained, subject to applicable copyright
law, at the Department for Medicaid Services, 275 East Main Street, Frankfort,
Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m.