1.03-1
Enrollment Process
A. All
providers must complete an initial enrollment application followed by
subsequent enrollment applications to take place at various intervals as
follows:
1. Every three (3) years for
providers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS);
2. Every five (5) years
for all other providers; and
3.
Upon request by the Department.
B. Providers should enroll online through the
Department's Health PAS portal, located at
https://mainecare.maine.gov.
Consistent with
42 C.F.R. §
431.107, the provider understands and agrees
that an executed Provider Agreement by and between the provider and MaineCare
is mandatory for participation or continued participation in the MaineCare
Program. If upon request, a provider fails to timely furnish an executed
Provider Agreement to MaineCare, the provider will be out of compliance. No
reimbursement for claims submitted shall be paid to the provider until
compliance is established.
Providers have a continuing obligation to supply the
Department with complete, accurate, and updated information as required by the
MBM and the Provider Agreement.
The Department may request additional information beyond
the Provider Application from an applicant. The Department may require the
applicant to provide documentation demonstrating the applicant's ability to
provide high-quality care, services, and supplies and to be financially
responsible.
All providers are required to update any changes to their
NPI information or any other enrollment information within ten (10) days of the
change.
1. New MaineCare Provider
Agreement Required In the event of any of the following changes, the provider
will be required to sign a new provider agreement.
a. New enrollment application
submitted;
b. Subsequent enrollment
application submitted;
c.
Reactivation application submitted.
2. Requirements for Updated MaineCare
Provider Agreement Under the following circumstances, the provider is required
to change their MaineCare Provider Agreement (rather than sign a new provider
agreement):
a. New service
location;
b. Change of physical
address to a service location;
c.
Existing service location is terminated;
d. Change of provider name or "doing business
as" (DBA) name.
In the event that any requirement of this Chapter
governing provider participation is inconsistent with the requirements of any
other Chapter of the MBM, the requirements of this Chapter shall
control.
C.
Enrollment Fee
1. A prospective or re-enrolling provider
must submit the applicable application fee established in
42 CFR
424.514(d) to MaineCare
prior to executing a MaineCare Provider Agreement, except for the following
providers:
a. Individual physicians or
non-physician practitioners; and
b. Providers that are enrolled in either of
the following:
i. Title XVIII of the
Social Security Act; or
ii. Another State's Title XIX or XXI plan;
and
c. Providers that
have paid the applicable application fee to:
i. A Medicare contractor; or
ii. Another State Medicaid Agency.
2.
Institutional providers that submit an application to establish a new practice
location must submit the applicable application fee prior to executing a
MaineCare Provider Agreement.
3.
MaineCare will reject the enrollment application from a newly-enrolling
institutional provider, or an institutional provider that is applying to
establish a new practice location, that is submitted without the application
fee or documentation that CMS has granted the provider a hardship waiver for
the application fee.
4. Requests
for hardship waivers must be submitted to CMS pursuant to
42 CFR
424.514.
D. MaineCare does not reimburse in-state
providers, including rendering providers, for services provided to members
prior to enrollment approval or after a provider's enrollment has been
terminated (end-dated).
E. Once
the enrollment application has been submitted online through the Department's
Health PAS portal, notification of MaineCare's decision will be sent to
providers via electronic notification or U.S. mail. The effective enrollment
date is the effective date of the Provider Agreement.
F. In the case of retroactive enrollment for
Federally Qualified Health Centers (FQHCs), the retroactive FQHC enrollment
will be effective on the date of the FQHC's Health Resources and Services
Administration (HRSA) or CMS approval, not before. In the case of retroactive
enrollment for Rural Health Clinics (RHC), retroactive enrollment will be
effective on the date of the Medicare approval. In the case of retroactive
enrollment for Indian Health Centers (IHCs), the retroactive IHC enrollment
will be effective on the date of the HRSA grant.
Retroactive enrollment for all other providers is subject
to review and approval by the Department in accordance with
42 C.F.R. §
431.108. The provider must supply all
information requested by the Department, including all reasons justifying the
request for retroactive enrollment, as well as proof of any required licensure
or certification for the period. A request for retroactive enrollment is
subject to the Department's review and discretion and is not a guarantee of
claim payment or prior authorization. The Department may grant retroactive
enrollment back to the Medicare certification date, but will not grant a
retroactive enrollment date that is more than three hundred and sixty-five
(365) days prior to the date of the provider's MaineCare application
submission.
G. The
Department will pay for MaineCare covered services provided only to the
following members:
1. Those who are eligible
for the specific services on the date the services are actually provided,
unless otherwise specified in the MBM; or
2. Those who have been granted retroactive
MaineCare eligibility after services have been provided. For more information
on retroactive eligibility see Section 1.04-1.
H. Certain providers will be required to use
rendering provider NPI in accordance with the appropriate billing instructions.
For some types of new providers not previously reimbursed under MaineCare,
reimbursement rates must be established before the provider may be enrolled and
reimbursed for covered services.
Chapter II outlines additional requirements that may
apply in specific instances including state contracts, and certification of
state share. Certain providers will be required to: attend provider education
sessions; have prior authorization of services; and/or have one hundred (100%)
percent review of claims prior to payment.
I.
National Provider Identifier
In order to enroll with MaineCare, providers must obtain
a NPI. If a provider is not eligible for an NPI, the Provider Enrollment Health
PAS portal will assign an Atypical Provider Identifier (API) to qualified
providers. In addition, this system will assign three-digit identifiers to each
service location enrolled by the provider.
These identifying numbers must be used in submitting all
claims for payment.
J.
Fingerprint-based Criminal Background Checks
1. Any provider or provider applicant whose
categorical risk level is high, as defined below, must consent to a
fingerprint-based criminal background check (FCBC) and submit fingerprints to
the Department or its vendor in the form and manner required by the Department.
The provider or provider applicant and any person with a five (5) percent or
greater direct or indirect ownership interest in the provider or provider
applicant must submit fingerprints as directed by the Department and shall be
responsible for the costs of the FCBC.
The Department shall terminate or deny enrollment of a
provider if the provider, provider applicant, or any person with a five (5)
percent or greater direct or indirect ownership interest in the provider or
provider applicant who is required to submit fingerprints:
a. Fails to submit them within thirty (30)
days of the Department's request;
b. Fails to submit them in the form and
manner requested by the Department; or
c. Has been convicted of a criminal offense
related to that person's involvement with the Medicare, Medicaid, or CHIP
programs in the last ten (10) years.
The Department may rely upon a provider or provider
applicant's Medicare enrollment if that provider or provider applicant is
considered high risk by Medicare, has been enrolled by Medicare, has undergone
an FCBC, and if the provider or provider applicant has passed or failed the
FCBC.
The Department may also rely upon the results of an FCBC
conducted by another state's Medicaid program if the provider or provider
applicant is enrolled in the other state's Medicaid or CHIP program and has met
the revalidation requirement of
42 CFR §
455.414.
2.
High Categorical Risk
a. In accordance with
42 CFR
424.518, the following provider types have
high categorical risk:
i. Prospective (newly
enrolling) home health agencies;
ii. Prospective (newly enrolling) DME
suppliers;
iii. Prospective (newly
enrolling) Medicare Diabetes Prevention Program suppliers; and
iv. Prospective (newly enrolling) opioid
treatment programs that have not been fully and continuously certified by
SAMHSA since October 23, 2018.
b. The categorical risk for a provider or
supplier shall be adjusted to high if the following occurs:
i. MaineCare has imposed a payment suspension
on a provider based on credible allegations of fraud, waste or abuse within the
past ten years;
ii. The provider
has an existing Medicaid overpayment of $1,000 or more owed to the Department
which is not currently under appeal or in a payment plan;
iii. The provider has been excluded by the
Office of the Inspector General or another State's Medicaid program within the
previous 10 years;
iv. MaineCare or
CMS in the previous six (6) months lifted a temporary moratorium for a
particular provider or supplier type, and a provider or supplier that was
prevented from enrolling based on the moratorium applies for enrollment as a
MaineCare provider or supplier at any time within 6 months from the date the
moratorium was lifted; or
v. The
provider or supplier:
A. Has been excluded
from Medicare by the Office of the Inspector General;
B. Had billing privileges revoked by a
Medicare contractor within the previous 10 years and is attempting to:
1. Enroll as a new provider or supplier; or
2. Establish billing privileges
for a new service location;
C. Has been terminated or is otherwise
precluded from billing Medicaid;
D.
Has been excluded from any federal health care program; or
E. Has been subject to any final adverse
action within the previous ten (10) years, which includes the following:
1. A Medicare-imposed revocation of any
Medicare-imposed privileges;
2.
Suspension or revocation of a license to provide health care by any State
licensing authority;
3. Revocation
or suspension by an accreditation organization;
4. A conviction of a Federal or State felony
offense (as defined in
42
CFR §
424.535(a)(3)(i)
) within the last 10 years preceding enrollment, revalidation, or
re-enrollment; or
5. An exclusion
or debarment from participation in a Federal or State health care program.
1.03-2
Additional Enrollment
Requirements for Out-of-State Providers
A. All out-of-state providers, with the
exception of NOPRs, must be fully enrolled with MaineCare, including those
providers that provide emergency services. Out-of-state providers are subject
to all requirements as described in 1.03-1. Out-of-state NOPRs must follow the
same enrollment requirements as in-state NOPRs.
B. Out-of-state providers may enroll after
services have been provided but must do so before billing for the services
rendered. The Department may terminate the enrollment status of an out-of-state
provider at any time there are no MaineCare members receiving authorized
services from that provider.
C.
Out-of-state providers that only provide emergency services to MaineCare
members traveling out-of-state may bill MaineCare for those services. These
providers must notify the Department, or its Authorized Entity, within one
business day of an emergency admission for a MaineCare member. Inpatient
emergency admissions will be reviewed for medical appropriateness. Length of
stay will be authorized by the Department, or its Authorized Entity, and will
be based upon medical documentation supporting the member's need for services.
In order to be reimbursed by MaineCare for emergency inpatient services
provided, the provider must receive and submit an authorization number on the
claim form submitted to the Department.
For emergency services that do not result in an inpatient
admission, the provider must notify the Department, or its Authorized Entity,
of the treatment provided to the member, also within one (1) business day.
In cases where the provider is unable to confirm proof of
MaineCare coverage (e.g., member is unconscious or the member does not have a
MaineCare card readily available), the provider may exceed the one-day
requirement by providing a sufficient explanation of the case.
D. Other instances in which an
out-of-state provider may enroll in MaineCare include, but are not limited to
the following:
1. Services and equipment
provided to a member who is residing out-of-state, at the discretion of the
Department, taking into account cost-effectiveness and medical
necessity;
2. A provider that is
the sole provider of a type of cost-effective medically necessary item or
service may be enrolled only for the purpose of providing that item or service
with prior authorization. An example would be an out-of-state laboratory that
conducts a test, or a manufacturer of a highly specialized item, not provided
by any in-state provider; and 3. An out-of-state provider of services to a
MaineCare member who is eligible for services as a Qualified Medicare
Beneficiary (QMB) may enroll as a MaineCare provider only for the purpose of
billing Medicare coinsurance and deductibles.
E. The Department reserves the right to issue
a request for proposals for provision of any service, pharmaceutical, supply,
or piece of equipment. The resulting contract may be awarded to an out-of-state
provider.
F. Out-of-state providers
located within fifteen (15) miles of the Maine/New Hampshire border are treated
the same as Maine providers in all aspects of policy requirements, enrollment,
rates of reimbursement, and payment methodologies with the exception of
out-of-state hospitals, which are excluded from in-state reimbursement
methodology as described in Chapter III, Section 45. MaineCare will not provide
payment to any entity outside the United States.
G. Maine-based providers that are providing
services out-of-state are considered out-of-state providers and as such are
bound by the same requirements as out-of-state providers, including prior
authorization and proper licensure within the state in which services are being
provided.
1.03-3
Denial of Enrollment and Subsequent Enrollment Applications
A. MaineCare shall deny enrollment or
subsequent enrollment of any individual or entity that meets any of the
following conditions:
1. The provider is
currently excluded by MaineCare;
2.
The provider has been terminated on or after January 1, 2011, by Medicare or by
the Medicaid program or CHIP of any other state, and remains
excluded;
3. The provider or any
person with a five percent (5%) or greater direct or indirect ownership
interest in the provider fails to submit timely and accurate information and
cooperate with any screening methods required under 42 CFR PART 455, Subpart
E;
4. Any provider or any person
with a five percent (5%) or greater direct or indirect ownership interest in
the provider who has been convicted of a criminal offense related to that
person's involvement with the Medicare, Medicaid, or title XXI program in the
last 10 years;
5. Any 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; or
6. The provider fails to permit
access to provider locations for a site visit.
B. MaineCare may deny enrollment of any
individual or entity that meets any of the following conditions:
1. The provider has falsified any information
or omitted any material fact on the application;
2. The Department is unable to verify the
identity of the provider;
3. The
provider has any previous suspension, exclusion or involuntary withdrawal from
participation in MaineCare, Medicare, or the Medicaid program of any
state;
4. The provider is, has been
previously, or is currently suspended, excluded, or has involuntarily withdrawn
from participation in any private medical insurance program;
5. The provider is in receipt of, but has not
made restitution for, a MaineCare, Medicare, or other state Medicaid program's
overpayment, as determined to have been made pursuant to a final decision or
determination of an agency having the powers to conduct the proceeding and
after an adjudicatory proceeding in which no appeal is pending or after
resolution of the proceeding by stipulation or agreement; however, if a
provider has entered into a plan of restitution of such overpayments, an
application will not be denied solely on this factor unless the provider has
defaulted in repayment;
6. The
provider has made any false representation or omission of a material fact in
making application in any state for any license, permit, certificate, or
registration related to a profession or business;
7. The provider has failed to correct
deficiencies in the operation of a business or enterprise after having received
written notice of the deficiencies from a state or federal licensing or
auditing agency;
8. The provider
fails to supply further information concerning the application after receiving
a written request for such further information;
9. The provider submits an application which
conceals an ownership or control interest of any person who would otherwise be
ineligible to participate;
10. The
provider has been indicted for or convicted of any crime relating to the
furnishing of, or billing for, medical care, services, or supplies which is
considered an offense involving theft or fraud or an offense against public
administration or against public health and morals;
11. The provider has a prior finding by a
licensing, certifying, or professional standards board or agency of the
violation of the standards or conditions relating to licensure or certification
or as to the quality of services provided;
12. The provider has a prior history of
excessive claims or furnishing of unnecessary or substandard services and/or
items, or any prior improper conduct under any private or publicly funded
program or insurance policy;
13.
The provider demonstrates any other factor having a direct bearing on the
applicant's ability to provide high-quality medical care, services or supplies
to recipients of MaineCare benefits, or to be fiscally responsible to the
program for care, services or supplies to be furnished under the program,
including actions by persons affiliated with the applicant;
14. Any other factor which may affect the
effective and efficient administration of the program, including, but not
limited to, the current availability of medical care, services or supplies to
members, or the inability to bill appropriately for services
rendered.
1.03-6
Changes of Ownership, Closures,
and Disenrollment
A. Providers must
notify the Provider Enrollment Unit of any Change in Ownership (CHOW), closure,
or intention to disenroll from the MaineCare program no less than thirty (30)
days prior to the intended change, except in the case of reasonably unforeseen
circumstances. Providers must take all reasonable and appropriate steps
requested by the Department to transition members before the intended change
and, upon request, submit a transition plan to the Department for review and
approval.
B. Providers undergoing a
CHOW must update the change on the Health PAS portal. As part of that process,
the providers will be required to complete the CHOW questionnaire and follow
the online instructions for submission. Depending on the questionnaire
responses, the provider may be required to submit a new application.
1.03-8
Requirements of Provider
Participation
Enrolled providers must:
A. Maintain current licenses, as applicable,
and must submit copies of license renewals to the Provider Enrollment Unit to
ensure continuity of services through license expiration dates. Providers that
are "covered health care providers" are required to obtain an NPI from the CMS
National Provider System. Providers must write their NPI and API ID number(s)
and the three (3) digit service location identifier, if applicable, on the copy
of their license renewals to ensure accurate data entry.
License renewals or updates must be submitted to and
received by the Department at least thirty (30) days prior to the date of the
license expiration or change. If the provider has not received the renewed or
updated license in sufficient time, the provider must submit proof of
application for the license renewal or update at least thirty (30) days before
the license expiration and then provide the license renewal or change with the
numbers required above within ten (10) days of receipt.
B. Notify the Department whenever there is a
change in any of the information that the provider previously submitted to the
Department using the MaineCare Services portal at
https://mainecare.maine.gov.
An example would be: a change in address, or the addition or deletion of staff
from the practice. This must be done within ten (10) days of each occurrence.
Failure to provide complete and accurate information in a timely fashion will
constitute good cause for the Department to terminate the agreement.
C. Not interfere with a member's freedom of
choice in seeking medical care from any institution, agency, pharmacy or person
who is qualified to perform a required service and is a MaineCare provider.
D. Not discourage or interfere
with a MaineCare member accessing medically necessary MaineCare services for
which the member is eligible.
E.
Allow members the freedom to reject medical care and treatment.
F. Not discriminate against any member,
because of race, color, sex, gender identity, sexual orientation, religious
creed, ancestry, national origin, age, or physical or mental handicap or
disability, or any other factor as specified in the Maine Human Rights
Act,
5 M.R.S. §4551
et seq., the Federal Civil Rights Act,
42 U.S.C. §
1981
et seq., The
Americans With Disabilities Act of 1990,
42 U.S.C. §
12101, or the Federal Rehabilitation
Act,
29 U.S.C. §
504
et seq. The provider
will comply with
5 M.R.S.
§784(2) and any and all
appropriate federal and state laws and regulations regarding
non-discrimination.
G. Provide
services and supplies to members in the same quality and mode of delivery as
they are provided to the general public.
H. Charge and bill MaineCare for the
provision of services and supplies to members in an amount not to exceed the
provider's usual and customary charges to the general public or, the
contractual agreement for a member with a liable third party.
I. Accept as payment in full the MaineCare
rate as specified in Section 1.08-1.
J. Bill only for covered services and
supplies delivered. In cases where a partial unit of service is delivered, the
provider may bill for the partial unit. A provider also has the option to round
up a partial unit and bill for the nearest whole unit, if the partial unit of
service provided is equal to or greater than eighty percent (80%) of the unit
of service: e.g. providers may round 1.8 units of service up to two (2) units
of service; the provider may bill 1.7 units of service provided either as 1.7
units of service if it bills the partial unit or as 1.0 unit of service if it
does not. If the provider rounds up to the next unit from eighty percent (80%)
or greater, the provider must document the actual units of service delivered in
the member's record.
Providers may bill partial units of service delivered to
one or two decimal places, and providers may round partial units of service to
the first or second decimal place. For example, to bill ten minutes of a
15-minute service (.667 units), providers may choose to use the first decimal
place, not round, and bill .6 units; use the second decimal place, not round,
and bill .66 units; round to the second decimal place and bill .67 units; or
round to the first decimal place and bill .7 units. Providers shall not round
up to .8 units and then round up again to bill the whole unit.
In cases where an unforeseen and uncontrollable
circumstance prevents a provider from delivering a whole unit of service, the
provider may round up the partial unit to the nearest whole unit if the partial
unit is equal to or greater than fifty percent (50%) of the unit of service:
e.g. providers may round 1.5 units of service up to two (2) units of service in
the case of an unforeseen and uncontrollable circumstance; 1.4 units of service
provided would be billed at either 1.4 units of service if the provider bills a
partial unit or 1.0 unit of service if it does not. Unforeseen and
uncontrollable circumstances may include, but are not limited to, a power
outage, a fire or other event that necessitates evacuation from the place of
service, or a medical emergency. If rounding up from 50% or greater, the
provider must document the actual units of service provided and fully describe
the unforeseen and uncontrollable circumstance in the member's record.
The procedure code for the smallest unit of service must
be used. Specific provisions in any other Chapters or Sections of this Manual
will supersede this rounding requirement.
K. Accept assignment of Medicare benefits for
eligible MaineCare members (as set forth in Section 1.07-5).
L. Use designated Health Insurance
Portability and Accountability Act (HIPAA) compliant billing forms, or
accepted 837 transactions, for submission of charges and follow the appropriate
MaineCare billing instructions. 837 filings are transactions using the HIPAA
standard format for submission of electronic claims. There are three (3)
versions of the 837: the Institutional (similar to the UB-04 paper claim); the
Professional (comparable to the CMS 1500 paper claim) and the Dental
(comparable to the ADA paper claim).
M. Maintain and retain contemporaneous
financial, provider, and professional records sufficient to fully and
accurately document the nature, scope and details of the health care and/or
related services or products provided to each individual MaineCare member.
1. Records must be consistent with the unit
of service specified in the applicable policy covering that service. Records
must include, but are not limited to all required signatures, treatment plans,
progress notes, discharge summaries, date and nature of services, duration of
services, titles of persons providing the services, all service/product orders,
verification of delivery of service/product quantity, and applicable
acquisition cost invoices. Providers must make a notation in the record for
each service billed. For example, if a service is billed on a per diem basis
the provider must make a notation for each day billed.
2. If a service is billed on a fifteen (15)
minute unit basis, a notation for each visit is sufficient.
3. Records must be kept in chronological
order with like information together as appropriate. For MaineCare purposes
such records must be retained for a period of not less than five (5) years from
the date of service or longer if necessary to meet other statutory
requirements. If an audit is initiated within the required retention period,
the records must be retained until the audit is completed and a settlement has
been made.
4. At all reasonable
times during the prescribed retention period, persons duly authorized by the
Department or the federal government, whether employees or contractors, shall
be given the right to full access to inspect, review, or audit all medical,
quality assurance documents, financial, administrative records, and other
documents and reports required to be kept under federal and state laws and
regulations. Those duly authorized shall also have the right to obtain copies
of such records at no expense to the Department, federal or state government.
The provider and any approved subcontractor shall give
the Department or the Federal government complete and private access to the
Provider's staff and to any resident or member for the purpose of reviewing the
provider's compliance with the provider agreement, and other applicable federal
and state laws and regulations, including laws and regulations governing
licensing and certification.
5. MaineCare providers, all rendering
providers, and any subcontractors shall make available, during regular business
hours, all pertinent provider financial records, all records of the requisite
insurance coverage, all records concerning the provision of health care
services to MaineCare members, and all financial records of MaineCare members,
to any duly authorized representative of DHHS, the Department's Authorized
Entity, the Maine Attorney General's MaineCare Fraud Unit, and the Director of
the United States Centers for Medicare and Medicaid Services. MaineCare
providers, all rendering providers, and any subcontractors shall provide, if
requested by any of the above, copies of records and documentation, including
copies of consolidated financial statements of all related corporations.
Failure to comply with any request to examine or receive copies of such records
shall be grounds for immediate suspension from participation in the MaineCare
program.
6. MaineCare providers,
all rendering providers, and any subcontractors will make their premises
available to any of the above, for announced visits or unannounced visits, for
the purpose of determining whether enrollment or continued enrollment in the
MaineCare program is warranted, to investigate and prosecute fraud against the
MaineCare program, to investigate complaints of abuse and neglect of MaineCare
members, and as necessary for the administration of the MaineCare program.
Failure to permit inspection by DHHS, the Maine Attorney General's MaineCare
Fraud Unit, or the Secretary of the United States Centers for Medicare and
Medicaid Services shall be grounds for immediate suspension from participation
in the MaineCare program.
N. Have safeguards and security measures in
place that allow only authorized persons to enter information into electronic
records. Passwords or other secure means of authorization must be used that
will identify the individual and the date and time of entry. Such
identification will be accepted as an electronic "signature." With security
measures in place, limited access may be allowed for certain individuals for
changes such as member demographic information. There shall be a signature of
record on file.
O. Maintain and
retain contracts with subcontractors for a period of at least five (5) years
after the expiration date of the contract. In addition, records of contractors
or subcontractors shall be subject to the same record maintenance and retention
rules as are all enrolled providers (refer to Section 1.03-8 M).
Providers must submit within thirty-five (35) days of
the Department's request, full and complete information regarding the ownership
of any subcontractor with whom the provider has had business transactions
totaling twenty-five thousand dollars ($25,000.00) or more, during a twelve
(12) month period prior to the date of the request. Updates to ownership
information will be required on an annual basis.
P. Transfer at no charge clinical records and
other pertinent information to other clinicians involved in the member's case,
upon request and, when necessary, with the member's signed release of
information. Members may only be charged for copies of their own records if the
member is requesting that the copies be given directly to them. Charges to the
MaineCare member must be in a manner comparable to any charges providers may
require from private pay patients.
Enrolled providers must furnish to the Department or its
Authorized Entity without charge, in the form and manner requested, pertinent
information, including clinical, professional and financial records, regarding
services for which charges are made. Where appropriate, as determined by the
Department, this will include information necessary to support requests for
exemption from managed care requirements and correspondence that substantiates
services billed by providers. A release of information signature is not
required in order to send records to the Department or its Authorized
Entity.
Q. Comply with the
requirements of the Department regarding faxed and e-signatures. The Department
will accept e-signatures and faxed (facsimile) copies of signatures as evidence
of compliance with MaineCare documentation requirements only when the original
signature is subsequently forwarded to the Department within (30) calendar days
of the date of service or is already on file.
1. Providers must maintain evidence of the
faxed and e-signatures in the member's record;
2. A faxed signature by itself without the
original signature on record will not be acceptable proof of
signature.
R. Hold
confidential, and use for authorized program purposes only, all MaineCare
information regarding members. In situations where it is medically necessary
for the member's well-being, information may be shared between providers. The
rules of confidentiality apply to all providers involved as referenced in
Section 1.03-9 of this Manual. Confidentiality requirements described in
22 M.R.S.
§1711-C also apply.
S. Comply with requirements of applicable
federal and state law, and with the provisions of this Manual.
T. Enter into a MaineCare Provider Agreement
with the Department, including any necessary Riders.
U. Providers, contractors and intermediaries
in public, private or voluntary agencies that have Provider agreements with the
Department, are obligated to:
1. Report any
suspected or identified fraud or abuse by providers or members and submit
supporting documentation to the Program Integrity Unit, Division of
Audit;
2. Furnish available
information, when requested, on excluded individuals and entities requesting
reinstatement into the MaineCare Program; and 3. Ensure that the provisions of
42 C.F.R. 1000, et seq., pertaining to the exclusions of
individuals and entities are abided by at all times.
V.
Disclosure of ownership or
control
Provider must disclose the following information to the
department upon enrollment and within thirty (30) days of any change.
1. Providers other than individual
practitioners or groups of practitioners must disclose all persons with an
ownership or control interest in the provider. Persons with an ownership or
control interest include the following:
a.
Those with an ownership interest totaling five percent (5%) or more in the
provider;
b. Those with an indirect
ownership interest equal to five percent (5%) or more in the
provider;
c. Those with a
combination of direct and indirect ownership interest equal to five percent
(5%) or more in the provider;
d.
Those with 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 five percent (5%) or more of the value of the property or
assets of the provider;
e.
Individuals who are officers or directors if the provider organization of the
provider is organized as a corporation; and
f.
Individuals who are partners in the provider's
partnership.
2. Providers
other than individual practitioners or groups of practitioners must disclose
all corporations or other forms of business entities with an ownership or
control interest in the provider. Corporations or other forms of business
entities with an ownership or control interest include the following:
a. Those with an ownership interest totaling
five percent (5%) or more in the provider;
b. Those with an indirect ownership interest
equal to five percent (5%) or more in the provider;
c. Those with a combination of direct and
indirect ownership interest equal to five percent (5%) or more in the
provider;
d. Those with 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 five
percent (5%) or more of the value of the property or assets of the
provider;
e. Entities who are
officers or directors of the provider organization if the provider is organized
as a corporation; and
f. Entities
who are partners in the provider's partnership.
3. Providers other than individual
practitioners or groups of practitioners must disclose all subcontractors in
which the provider has an ownership interest of five percent (5%) or more.
4. Providers other than individual
practitioners or groups of practitioners must disclose any individual owners of
the provider who is related to other individual owner as a spouse, parent,
child, or sibling. Providers must also disclose any individual owners of the
provider's subcontractor in which the provider has an ownership interest who is
related to other individual owner as a spouse, parent, child, or sibling.
5. Providers other than individual
practitioners or groups of practitioners must disclose any ownership or control
interest in any "other disclosing entity." "Other disclosing entity" means any
other Medicaid disclosing entity and any entity that does not participate in
Medicaid, but if required to disclose certain ownership and control information
because of participation in any program established under Title V, XVIII, or XX
of the
Social Security 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 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 Social
Security Act.
W. Provide adequate access to medically
necessary covered health care services for MaineCare members.
X. Refer to the Department any evidence
demonstrating fraudulent or abusive provider and/or employee practice or
overuse of member services by contacting the Program Integrity Unit.
Y. Abide by the provisions of 42 C.F.R. 1000,
et seq., pertaining to the exclusions of individuals and
entities from participation in Medicare or MaineCare and ensure that excluded
individuals or entities are not employed or utilized to provide services,
receive payments, or submit claims, to the MaineCare Program. Excluded provider
information can be referenced at the Health and Human Services Office of
Inspector General web site:
http://exclusions.oig.hhs.gov and
the Division of Audit, Program Integrity Unit web site:
https://mainecare.maine.gov/mhpviewer.aspx?FID=MEEX.
Z. Maintain accurate, auditable
and sufficiently detailed financial and statistical records to substantiate
cost reports, negotiated rates, by report items, or any other fee for service
rate for a period of at least five (5) years following the date of final
settlement or established rate with the Department. These records must include,
but not be limited to: matters of provider ownership; organization; operation;
fiscal and other record-keeping systems; federal and state income tax
information; asset acquisition; lease, sale or other action; cost of ownership
information on leased property even if the property is leased from an unrelated
party; franchise or management arrangement; patient service charge schedule;
matters pertaining to cost of operation; amounts of income received by service
and purpose; and flow of funds and working capital.
AA. Attend provider education sessions when
required by the Department.
BB.
Submit all claims for review prior to payment, when required by the
Department.
CC. Comply with the
requirements of the Federal False Claims Act as referenced in
Appendix 2 of this Chapter.
DD.
Comply with this Chapter and all other applicable Chapters and Sections of the
MBM.
The Department may sanction providers that fail to comply
with these requirements.
1.03-9
Confidentiality
Providers may disclose information regarding individuals
participating in MaineCare only for purposes directly connected with the
administration of MaineCare. Providers must maintain the confidentiality of
information regarding MaineCare members in accordance with 42 C.F.R. 431,
et seq. and other applicable sections of state and federal law
and regulations, including compliance with the privacy and security
requirements of HIPAA.
The Department will ensure that criteria exist specifying
the conditions for release and use of information about MaineCare members.
Access to information concerning members is restricted to persons or Department
representatives who are subject to standards of confidentiality set by the
Department.
The Department may not publish or disseminate, in any
way, names of members. Permission must be obtained from a family or individual,
whenever possible, before responding to a request for information from an
outside source, unless the information is to be used to verify income,
eligibility and the amount of a MaineCare payment.
Parents or guardians of minors may be required to provide
annual reauthorization regarding the release of confidential
information.
