13 CSR 65-2.030 - Denial or Limitations of Applying Provider
(1) Missouri Medicaid Audit Compliance (MMAC)
may terminate the provider's enrollment or deny enrollment-
(A) Where the provider did not submit timely
and accurate information or did not cooperate with screening methods required
under applicable statutes and regulations unless the provider cures the failure
to comply with this subsection within thirty (30) days of MMAC's notice that it
intends to terminate the provider or deny enrollment;
(B) Where the provider or any person with an
ownership or control interest has been convicted of or pled guilty to a
criminal offense, including any suspended imposition of sentence, any suspended
execution of sentence, or any period of probation or parole, related to their
involvement with the Medicare, Medicaid, or Title XXI program in the last ten
(10) years, unless MMAC determines that denial or termination of enrollment is
not in the best interests of the MO HealthNet Program and MMAC documents that
determination in writing;
(C) Where
the provider or any person with an ownership or control interest has been
convicted of or pled guilty to a misdemeanor or felony charge, including any
suspended imposition of sentence, any suspended execution of sentence, or any
period of probation or parole relating to:
1.
Endangering the welfare of a child;
2. Abusing or neglecting a resident, patient,
or client;
3. Misappropriating
funds or property belonging to a resident, patient, or client; or
4. Falsifying documentation verifying
delivery of services to a personal care assistance services consumer;
(D) Where the provider or any
person with an ownership or control interest has been placed on the Family Care
Safety Registry as mandated by sections 210.900-210.936, RSMo; or been placed
on the Missouri Sex Offender Registry as mandated by sections 589.400-589.425
and 43.650, RSMo;
(E) Where the
provider is terminated under Title XVIII of the Social Security Act or under
the Medicaid Program or Children's Health Insurance Program (CHIP) of any other
state unless MMAC determines that the termination was not for cause, which may
include, but is not limited to, fraud, integrity, or quality. Termination or
denial of enrollment will not be required if MMAC determines it would not be in
the best interests of the MO HealthNet Program and MMAC receives a waiver from
the United States Department of Health and Human Services, Centers for Medicare
and Medicaid Services pursuant to
42 U.S.C.
1320a-7;
(F) Where the provider or a person with an
ownership or control interest or who is an agent or managing employee of the
provider fails to submit timely or accurate information, unless MMAC determines
that termination or denial of enrollment is not in the best interests of the MO
HealthNet Program, and MMAC documents that determination in writing;
(G) Where the provider, or any person with
ownership or control interest, fails to submit fingerprints in a form and
manner to be determined by MMAC within thirty (30) days of a request by Centers
for Medicare and Medicaid Services (CMS) or MMAC, unless MMAC determines that
termination or denial of enrollment is not in the best interests of the MO
HealthNet Program, and MMAC documents that determination in writing;
(H) Where the provider fails to permit access
to provider locations for any site visits under
13 CSR
65-2.020, unless MMAC determines that termination or
denial of enrollment is not in the best interests of the MO HealthNet Program,
and MMAC documents that determination in writing;
(I) Where the provider fails to complete an
application for provider direct deposit as required by
13 CSR
70-3.140;
(J) Where the provider or a person with an
ownership or control interest submitted false information to MMAC; or
(K) Where the identity of any provider or
person with an ownership or control interest cannot be
verified.
(2) Denial of
enrollment shall preclude any provider or person from submitting claims for
payment, either personally or through claims submitted by any clinic, group,
corporation, affiliate, partner, or any other association to the single state
agency or its fiscal agents for any services or supplies delivered under the MO
HealthNet program whose enrollment as a MO HealthNet provider has been denied.
Any claims submitted by a nonprovider through any clinic, group, corporation,
affiliate, partner, or any other association and paid shall constitute
overpayments.
(3) No clinic, group,
corporation, partnership, affiliate, or other association may submit claims for
payment to the MO HealthNet Division or its fiscal agent for any services or
supplies provided by a provider or person within each association who has been
denied enrollment in the MO HealthNet program. Any claims for payment submitted
and paid under these circumstances shall constitute overpayments.
(4) Except to the extent inconsistent with
this rule, the requirements of
13 CSR
70-3.030 remain in force, including any provisions
regarding denial of applications and termination, until those provisions are
rescinded.
(5) The provisions of
this rule are declared severable. If any provision of this rule is held invalid
by a court of competent jurisdiction, the remaining provisions of this rule
shall remain in full force and effect, unless otherwise determined by a court
of competent jurisdiction to be invalid.
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.