13 CSR 65-2.010 - Definitions
PURPOSE: This amendment combines and clarifies definitions found in this regulation and definitions formerly found in 13 CSR 70-3.020, which is being rescinded, making it easier for providers to locate and understand the definitions. Additionally, this regulation now mirrors federal Medicaid program integrity regulatory requirements that Missouri must follow as a condition of its federal Medicaid funding.
(1) Affiliates means
persons having an overt, covert, or conspiratorial relationship so that any one
(1) of them directly or indirectly controls or has the power to control
another.
(2) Agent means any person
who has been delegated the authority to obligate or act on behalf of a
provider.
(3) 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
Missouri Medicaid Audit and Compliance (MMAC) needs, under applicable federal
or state laws and regulations as they pertain to the Medicaid program, in order
to enroll a MO HealthNet Program provider.
(4) 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.
(5)
Applying provider means any person submitting an application as defined in
section (3) above.
(6)
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.
(7) 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 non-billing Medicaid
number.
(8) 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.
(9) 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.
(10) Closed-end
provider agreement means an agreement which is for a specific period of time
not to exceed twenty-four (24) months and which must be renewed in order for
the provider to continue to participate in the Missouri Medicaid
Program.
(11) Conviction or
convicted means that-
(A) A judgment of
conviction has been entered by a federal, state, or local court, regardless of
whether an appeal from that judgment is pending;
(B) A person has pled guilty to a criminal
offense; or
(C) A person is serving
any period of probation or parole, regardless of any suspended imposition of
sentence or suspended execution of sentence resulting from that
offense.
(12) Deactivate
means that the provider's participation in the MO HealthNet program is
stopped.
(13) Deny/denial means
the applying provider has been determined to be ineligible under Medicaid rules
and regulations to participate in the MO HealthNet program.
(14) Department means the Department of Social
Services or its designated divisions or units.
(15) Enroll/enrollment means the process that MMAC
uses to establish eligibility to participate as a provider in the MO HealthNet
program. The process includes:
(A)
Identification of a provider and any owners;
(B) Validation of the provider's
qualifications to meet program requirements;
(C) Screening the provider and owners through
all required federal and state databases;
(D) Identification and confirmation of the provider's
practice location(s) and owner(s); and
(E) Granting the provider a MO HealthNet
number.
(16) Enrollment
application means a MMAC approved paper enrollment application or a MMAC
approved electronic enrollment process.
(17) Exclusion from participation in a
federal health care program (e.g., Medicare and Medicaid) is a penalty imposed
on a provider by the Office of Inspector General (OIG) under section 1128 or
1128A of the Social Security Act. States may also exclude providers from their
Medicaid Programs under state law or pursuant to
42 CFR section
1002.2.
(18) Federal health care program means a program as
defined in section 1128B(f) of the Social Security Act.
(19) Fiscal agent means an organization under contract
to the state of Missouri for providing services related to the administration
of the MO HealthNet Program.
(20)
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
(21) 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.
(22)
Indirect ownership interest means an ownership interest in an entity that has
an ownership interest in the disclosing entity. This term includes an ownership
interest in any entity that has an indirect ownership interest in the
disclosing entity.
(23) 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.
(24) Managed care
entity means managed care organizations (MCOs), pre-paid inpatient health plans
(PIHPs), pre-paid ambulatory health plans (PAHPs), primary care case management
(PCCMs), and health improvement organizations (HIOs) or any similar managed
care program type created by the state Medicaid agency.
(25) Managing employee means an owner, member,
partner, director, general manager, business manager, administrator, school
district superintendent, 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.
(26) Medicaid agency or
the agency means the single state agency administering or supervising the
administration of the state Medicaid plan.
(27) Missouri Medicaid Audit and Compliance Unit
(MMAC) means the unit within the Department of Social Services that is
responsible for program integrity and compliance in the Medicaid Title XIX,
CHIP Title XXI, and Waiver Programs in Missouri, which includes the enrollment
and auditing 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 Programs.
(28) Medical assistance benefits means those benefits
authorized to be provided by Chapter 208, RSMo.
(29) 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.
(30)
MO HealthNet means the division within the department, pursuant to sections
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.
(31) The National Provider Identifier (NPI)
is a Health Insurance Portability and Accountability Act (HIPAA) Administrative
Simplification Standard. The NPI is a unique identification number for covered
health care providers. Covered health care providers and all health plans and
health care clearinghouses must use NPIs in administrative and financial
transactions adopted under HIPAA.
(32) Network Provider means any provider,
group of providers, or entity that has a network provider agreement with a MCO,
or a subcontractor, and receives Medicaid funding directly or indirectly to
order, refer or render covered services as a result of the state's contract
with an MCO. A network provider is not a subcontractor by virtue of the network
provider agreement.
(33) Open-end
provider agreement means an agreement that has no specific termination date and
continues in force as long as it is agreeable to both the state Medicaid agency
and the enrolled provider.
(34)
Organizational provider is a non-corporeal provider. Individual physicians or
other individually licensed practitioners are not institutional providers.
Organizational provider includes, but is not limited to:
(A) Ambulance service suppliers, health
clinics, hospitals, pharmacies, and skilled nursing facilities;
(B) Other organizational entities that bill
the MO HealthNet Program on a fee-for-service basis, such as personal care
agencies, nonemergency 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; and
(C) Any other types of non-corporeal MO
HealthNet Program providers consistent with the state plan, the Waiver Program,
and CHIP Title XXI.
(35)
Other disclosing entity means any other Medicaid disclosing entity and any
entity that does not participate in Medicaid, but is required to disclose
certain ownership and control information because of participation in any of
the programs established under title V, XVIII, or XX of the Act. This includes:
(A) Any hospital, skilled nursing facility,
home health agency, independent clinical laboratory, renal disease facility,
rural health clinic, or health maintenance organization (meaning all MCOs) that
participates in Medicare (title XVIII);
(B) Any Medicare intermediary or carrier;
and
(C) Any entity (other than an
individual practitioner or group of practitioners) that furnishes, or arranges
for the furnishing of, health-related services for which it claims payment
under any plan or program established under title V or title XX of the
Act.
(36) Participant
means a person who is eligible to receive benefits allocated through the
department as part of the MO HealthNet Program.
(37) Participation means the ability and
authority to provide services or merchandise to eligible MO HealthNet
participants.
(38) Performing
provider means a provider or supplier who provides items or services to
Medicaid participants, but who does not directly bill or receive payment from
the MO HealthNet Program. Performing provider can also include referring,
ordering, prescribing, and/or attending physicians, and non-physician
practitioners.
(39) 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.
(40) Person with an
ownership or control interest, as defined in sections 1124 and 1124A(a) of the
Social Security Act, means a person or corporation that-
(A) Has an ownership interest totaling five
percent (5%) or more in a disclosing entity;
(B) Has an indirect ownership interest equal
to five percent (5%) or more in a disclosing entity;
(C) Has a combination of direct and indirect
ownership interests equal to five percent (5%) or more in a disclosing
entity;
(D) Owns an interest of
five percent (5%) or more in any mortgage, deed of trust, note, or other
obligation secured by the disclosing entity if that interest equals at least
five percent (5%) of the value of the property or assets of the disclosing
entity;
(E) Is an officer or
director of a disclosing entity that is organized as a corporation;
(F) Is a partner in a disclosing entity that
is organized as a partnership; or
(G) Is a managing employee.
(41) Practitioner means a
physician or other individual licensed under state law to practice his or her
profession.
(42) 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,
referring, prescribing, and/or attending physicians, and non-physician
practitioners.
(43) Provider
agreement means an agreement with MMAC which authorizes a provider to furnish
items or services to eligible Missouri Medicaid participants.
(44) 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 information and
documentation requested by MMAC.
(45) Provider direct deposit means a form specified 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.
(46) Reject/rejected means that the provider's
enrollment application was not approved due to incomplete or incorrect
information, failure to submit an application fee, or the applying provider is
not eligible to participate in the MO HealthNet Program.
(47) Revalidation means the requirement that all
existing providers must go through an application process to verify their
enrollment information is current, and they are still eligible to participate
in the MO HealthNet Program.;
(48)
Revalidation application means an approved MMAC revalidation application and
supplemental forms which are required to be submitted by all existing
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.
(49) Site visit may include any or all of the
following:
(A) Physical visit to, and
inspection of, the premises of the provider or a beneficiary's home if the
provider has no central operational facility;
(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.
(50) 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.
(51) Subcontractor means-
(A) An individual, agency, or organization to
which a disclosing entity has contracted or delegated some of its management
functions or responsibilities of providing medical care to its patients;
or
(B) An individual, agency, or
organization with which a fiscal agent has entered into a contract, agreement,
purchase order, or lease (or leases of real property) to obtain space,
supplies, equipment, or services provided under the Medicaid
agreement.
(52) Supplier
means an individual, agency, or organization from which a provider purchases
goods and services used in carrying out its responsibilities under Medicaid
(e.g., a commercial laundry, a manufacturer of hospital beds, or a
pharmaceutical firm).
(53)
Suspension from participation means a provider is not authorized to provide MO
HealthNet Program services for a specified or indefinite period of
time.
(54) Suspension of payments
means withholding of MO HealthNet Program payments otherwise due to a provider
for a specified or indefinite period of time.
(55) Termination means the department's
discontinuation of a provider's participation in the MO HealthNet
program.
(56) Voluntary
termination means that a provider submits written confirmation to MMAC of its
decision to discontinue participation in the MO HealthNet Program.
(57) Waiver program means programs
authorized in section 1915 of the Social Security Act (or other waiver programs
authorized by federal law).
(58)
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.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.