13 CSR 65-2.010 - Cost Certification

13 CSR 65-2.010. Cost Certification

PURPOSE: This rule implements federal regulatory requirements promulgated by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services at 76 Fed. Reg. 5862 (February 2, 2011), 42 CFR Parts 455 and 457, defining the terms used in the rules of the Missouri Medicaid Audit and Compliance Unit.

(1) Application shall include:

(A) Enrollment application to become a MO HealthNet Program provider;

(B) Revalidation application to remain a MO HealthNet Program provider;

(C) New practice location application;

(D) Provider direct deposit application;

(E) Change of ownership application;

(F) Hardship waiver request; or

(G) Other information MMAC needs, under applicable federal or state laws and regulations, in order to enroll a MO HealthNet program provider.

(2) Application fee means a fee required to be paid by a MO HealthNet Program institutional provider at the time of-

(A) Initial application;

(B) Revalidation application;

(C) Change of ownership application; or

(D) New practice location application.

(3) Applying provider means any person submitting an application to become a MO HealthNet Program provider, submitting a renewal or revalidation application to continue to be a MO HealthNet Program provider and/or submitting an application to establish a new practice location.

(4) Approve/Approval as to a billing provider means the billing provider has been determined to be eligible under Medicaid rules and regulations to receive a Medicaid billing number and be granted Medicaid billing privileges.

(5) Approve/Approval as to a performing provider means the performing provider has been determined to be eligible under Medicaid rules and regulations to receive a Medicaid billing number.

(6) Best interests of the MO HealthNet Program shall include consideration of the following factors:

(A) Ensuring reasonable access to MO HealthNet Program services;

(B) Promoting health, safety, and welfare of participants;

(C) The provider's history of compliance with applicable rules and regulations related to the MO HealthNet Program; and

(D) Any other factors related to MO HealthNet Program integrity.

(7) Billing provider means a provider or supplier who is authorized to bill the MO HealthNet Program for items or services provided to Medicaid participants. Billing provider includes providers who are authorized to bill Medicaid for items or services provided by performing providers.

(8) Closed-end provider agreement means an agreement which is for a specific period of time not to exceed twelve (12) months and which must be renewed in order for the provider to continue to participate as a Missouri Medicaid Title XIX, SCHIP Title XXI, or Waiver program provider.

(9) Deactivate means that the provider's billing privileges were stopped, but such provider's billing number was not terminated.

(10) Deny/Denial means the applying provider has been determined to be ineligible under Medicaid rules and regulations to receive a Medicaid billing number and/or Medicaid billing privileges.

(11) Department means the Department of Social Services or its designated divisions or units.

(12) Enroll/Enrollment means the process that MMAC uses to establish eligibility to receive a Medicaid billing number and/or Medicaid billing privileges. The process includes:

(A) Identification of a provider;

(B) Validation of the provider's eligibility to provide items or services to Medicaid beneficiaries;

(C) Identification and confirmation of the provider's practice loca-tion(s) and owner(s); and

(D) Granting the provider Medicaid billing privileges and/or a Medicaid billing number.

(13) Enrollment application means a MMAC-approved paper enrollment application or an electronic MMAC-approved enrollment process.

(14) Federal health care program means a program as defined in section 1128B(f), of the Social Security Act.

(15) Fiscal agent means an organization under contract to the state of Missouri for providing services related to the administration of the MO HealthNet Program.

(16) Hardship means a financial condition in which paying the application fee would impose a significant financial burden on the provider, and the provider is otherwise eligible to be a MO HealthNet Program provider. Other factors which may indicate that a hardship exists include:

(A) Considerable bad debt expenses incurred by the provider;

(B) Considerable amount of charity care/financial assistance furnished to patients;

(C) Presence of substantive partnerships (whereby clinical, financial integration are present) with those who furnish medical care to a disproportionately low-income population;

(D) Whether an institutional provider receives considerable amounts of funding through disproportionate share hospital payments; or

(E) Whether the provider is enrolling in a geographic area that is a presidentially-declared disaster area under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121 - 5206 (Stafford Act).

(17) Hardship waiver request means a request submitted to MMAC (defined below) along with the provider application requesting that the application fee be waived due to hardship, detailing the hardship, and providing any documentation in support of the hardship waiver request.

(18) Institutional provider is a non-corporeal provider. Individual physicians, individual dentists, and individual non-physician practitioners are not institutional providers. Institutional provider includes, but is not limited to:

(A) Ambulance service suppliers (ambulance);

(B) Ambulatory surgical centers;

(C) Community mental health centers;

(D) Comprehensive outpatient rehabilitation centers (comprehensive rehabilitation centers);

(E) End stage renal disease facilities (dialysis clinic);

(F) Federally qualified health centers;

(G) Health clinics;

(H) Histocompatibility laboratories;

(I) Home health agencies;

(J) Hospices;

(K) Hospitals;

(L) Inpatient psychiatric facilities;

(M) Inpatient rehabilitation facilities;

(N) Independent clinical laboratories;

(O) Independent diagnostic testing facilities;

(P) Mammography centers;

(Q) Mass immunizers (roster billers);

(R) Mental health hospitals or inpatient facilities;

(S) Organ procurement organizations;

(T) Outpatient physical therapy facilities;

(U) Outpatient occupational therapy facilities;

(V) Outpatient rehabilitation centers;

(W) Outpatient speech pathology services;

(X) Pharmacies;

(Y) Portable x-ray suppliers (independent x-ray supplier);

(Z) Public health department clinics;

(AA) Skilled nursing facilities (nursing home);

(BB) Radiation therapy centers;

(CC) Religious nonmedical healthcare institutions;

(DD) Rural health clinics;

(EE) Other institutional entities that bill the MO HealthNet Program on a fee-for-service basis, such as personal care agencies, non-emergency transportation providers, residential care facilities, adult day care facilities, assisted living facilities, residential treatment centers, providers billing under the Consumer Directed Services Program or entities established under sections 205.968-205.973, RSMo;

(FF) Durable medical equipment, prosthetics, orthotics, and supplies suppliers whether owned by physicians or otherwise;

(GG) Institutional non-profit and public providers;

(HH) Institutional providers establishing a new practice location in a different enrollment jurisdiction or as a new provider type;

(II) Local education agencies, which are institutional providers consistent with the state plan; or

(JJ) Any other types of non-corporeal MO HealthNet Program providers consistent with the state plan, the Waiver Program, and CHIP Title XXI.

(19) Limited provider agreement means an agreement with an applying provider which has been accepted as a MO HealthNet Program provider by MMAC (defined below) conditional upon the applying provider performing services, delivering supplies, or otherwise participating in the program only in adherence to, or subject to, specially set out conditions agreed to by the applying provider prior to enrollment.

(20) Managed care entity has the same meaning as set forth in 42 CFR Section 455.101 (2011).

(21) Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider, either under contract or through some other arrangement, whether or not the individual is a W-2 employee of the provider.

(22) Missouri Medicaid Audit and Compliance Unit (MMAC) means the unit within the Department of Social Services that is responsible for the oversight and auditing of compliance for the Medicaid Title XIX, CHIP Title XXI, and Waiver Program in Missouri, which includes the oversight and auditing of compliance of MO HealthNet providers and Medicaid participants through the lock-in program. MMAC is charged with the responsibility of detecting, investigating, and preventing fraud, waste, and abuse of the Missouri Medicaid Title XIX, CHIP Title XXI, and waiver program.

(23) Medical assistance benefits means those benefits authorized to be provided by Chapter 208, RSMo.

(24) MO HealthNet Program means programs operated pursuant to Title XIX of the Social Security Act, Title XXI of the Social Security Act and/or waiver programs authorized by the United States Department of Health and Human Services.

(25) MO HealthNet Program provider means applying provider, billing provider, and/or performing provider.

(26) MO HealthNet means the division within the department, pursuant to 208.001 and 208.201, RSMo that administers the Medicaid Title XIX, CHIP Title XXI, and waiver programs, approves claims from MO HealthNet providers for services or merchandise provided to eligible Medicaid participants and authorizes and disburses payment for those services or merchandise accordingly.

(27) Non-physician practitioner means any person other than a physician or dentist that provides medical, dental, or professional items or services such as, but not limited to, nurses, therapists, counselors, social workers, pharmacists, pharmacies, and dental hygienists. This does not include persons that provide nonmedical support services such as clerical staff, carpenters, janitorial staff, food service workers, home health aides, personal care aides, Adult Day Health Care employees and Adult Day Care waiver employees, community support workers and case managers, peer specialists, family support workers, family assistance workers, psychosocial rehabilitation workers, detox technicians/aides, residential technicians/aides, personal assistants, non-professional direct care staff and other secondary support services, but does include the organizations that bill for services provided by these persons.

(28) Owner means any individual or entity that has any partnership interest in, or that has five percent (5%) or more direct or indirect ownership of, the provider as defined in sections 1124 and 1124A(a) of the Social Security Act.

(29) Ownership or control interest means a person has a direct or indirect ownership of five percent (5%) or more, or is a managing employee, of a provider.

(30) Participant means a person who is eligible to receive benefits allocated through the department as part of the MO HealthNet Program.

(31) Performing provider means a provider or supplier who provides items or services to Medicaid participants but who does not directly bill the MO HealthNet Program for such items or services or does not directly receive payment from the MO HealthNet Program for such items or services. Performing provider also includes referring and/or ordering physicians, dentists, and non-physician practitioners.

(32) Person means any corporeal person or individual; or any legal or commercial entity, including but not limited to, any partnership, corporation, not-for-profit, professional corporation, business trust, estate, trust, limited liability company, association, joint venture, governmental agency, or public corporation.

(33) Provider means billing and performing providers and includes any person that enters into a contract or provider agreement with MMAC for the purpose of providing items or services to Missouri Medicaid participants. Provider includes ordering and referring physicians, dentists, and non-physician practitioners.

(34) Provider agreement means an agreement, no greater than five (5) years in duration, and no less than twelve (12) months in duration, requiring revalidation prior to expiration of the agreement, with MMAC which provides a provider with the authority to provide items or services to eligible Missouri Medicaid participants.

(35) Provider application means the MMAC-approved application and supplemental forms required to be submitted for the purpose of becoming a MO HealthNet Program provider, containing all information and documentation requested by MMAC.

(36) Provider direct deposit means a signed writing utilizing forms specified by MMAC containing all information requested by MMAC and submitted by a provider of Medicaid Title XIX, CHIP Title XXI, or waiver program services for the purpose of having Missouri Medicaid checks automatically deposited to an authorized bank account.

(37) Reject/Rejected means that the provider's enrollment application was not processed due to incomplete information, failure to submit application fee, or hardship waiver request, or that additional information or corrected information was not received from the provider in a timely manner.

(38) Revalidation means the requirement that all existing MO HealthNet Program providers must go through a revalidation application process in accordance with this rule to continue to be a MO HealthNet Program provider.

(39) Revalidation application means an approved MMAC revalidation application and supplemental forms which are required to be submitted by all existing MO HealthNet Program providers containing all information and documentation requested by MMAC under applicable federal or state laws and regulations and submitted at the time revalidation is required pursuant to this rule.

(40) Site visit may include any or all of the following:

(A) Physical visit to, and inspection of, the premises of the provider;

(B) Obtaining photographs of the provider or the provider's business for inclusion in the provider's enrollment file;

(C) Full documentation of observations made at the provider's premises including such facts as:

1. The facility was vacant and free of all furniture;

2. A notice of eviction or similar documentation is posted at the facility; and

3. The premises are not occupied by the provider, but by another person;

(D) A written report of the findings regarding each site visit;

(E) Verification that the facility is operational, open for business, and staff is present;

(F) Verification that customers are present at the facility where appropriate for the provider type;

(G) Acceptance of attestation with documentation when deemed appropriate by MMAC and consistent with applicable federal or state laws and regulations; or

(H) Acceptance of proof of a recent site visit under the Medicare program or other state Medicaid program when deemed appropriate by MMAC and consistent with applicable federal or state laws and regulations.

(41) State plan means a document completed by the state of Missouri to tell the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) how the state will administer the MO HealthNet program according to federal laws and regulations.

(42) Suspension from participation means an exclusion from being a provider for a specified or indefinite period of time.

(43) Suspension of payments means withholding of payments otherwise due to a provider for a specified or indefinite period of time.

(44) Termination means the department's non-temporary discontinuation of a provider's billing privileges and/or elimination of the provider's number.

(45) Voluntary termination means that a provider submits written confirmation to MMAC of its decision to discontinue enrollment in the MO HealthNet Program. In addition, if a provider's agreement, on March 25, 2016, has an effective date of March 25, 2011, or earlier, that provider agreement shall be deemed voluntarily terminated.

(46) Waiver program means programs authorized in section 1915 of the Social Security Act (or other waiver programs authorized by federal law). These programs permit states to furnish an array of services that complement and/or supplement the services that are available to participants through the state plan.

(47) Written notice means a notice to the address of the provider as listed in MMAC's system, in writing, transmitted via the US mail, other public or private service for the delivery of correspondence, packages or other things, facsimile, e-mail, or any other method/mode of transmittal that is deemed by MMAC to be an efficient, cost-effective, verifiable and reliable method/mode of communication with the provider or applying provider.

(AUTHORITY: sections 660.017 and 208.159, RSMo 2000. Original rule filed Dec. 12, 2013, effective July 31, 2014.)

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