Missouri Code of State Regulations
Title 13 - DEPARTMENT OF SOCIAL SERVICES
Division 65 - Missouri Medicaid Audit and Compliance
Chapter 2 - Medicaid
Section 13 CSR 65-2.020 - Provider Enrollment and Application
Universal Citation: 13 MO Code of State Regs 65-2.020
Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This amendment combines and clarifies the procedures found in this regulation and the procedure formerly found at 13 CSR 70-3.020, which is being rescinded. MO HealthNet providers will no longer have to look in two (2) locations to find Medicaid provider enrollment requirements. The amendment clarifies the circumstances under which the department may deny a provider's enrollment application or terminate the participation of an enrolled provider. Additionally, the regulation now mirrors federal Medicaid program integrity regulatory requirements that Missouri must follow as a condition of its federal Medicaid funding.
(1) Enrollment.
(A) All persons are required to enroll with
MMAC as a billing or performing provider in the MO HealthNet Program if the
services or items they provide will be billed to the MO HealthNet
Program.
(B) For any person to
receive payment from the MO HealthNet Program for items or services other than
out-of-state emergency services, the billing providers and the performing
providers of such items or services must be enrolled providers in the MO
HealthNet Program on the date the items or services are provided unless
applicable rules or manuals permit enrollment as of an earlier date, up to a
maximum of three hundred sixty-five (365) days prior to the actual enrollment
date.
(C) All claims for payment for
items and services that were ordered, prescribed, or referred must contain the
National Provider Identifier (NPI) of the provider who ordered, prescribed, or
referred such items or services.
(D) All persons enrolled as MO HealthNet
providers shall abide by the policies and procedures set forth in the MO
HealthNet provider manual(s) applicable to the provider's provider type(s). The
MO HealthNet provider manuals are incorporated by reference and made a part of
this rule as published by the Department of Social Services, MO HealthNet
Division, 615 Howerton Court, Jefferson City, MO 65109 and available at
http://manuals.momed.com/manu-als/, August 20, 2021. This rule does not
incorporate any subsequent amendments or additions. A MO HealthNet provider's
breach of any MO HealthNet provider manual may result in imposition of
sanctions, including but not limited to termination.
(2) Applications.
(A) All applying providers shall have a valid
email address and shall submit a MMAC-approved application and any supplemental
forms, information, and documentation required by MMAC for the appropriate
provider type for which the person is applying.
(B) All information and documentation
requested in the application and supplemental forms must be provided to MMAC
prior to the application being approved.
(C) Specific application instructions are
modified as necessary for efficient and effective administration of the MO
HealthNet Program as required by federal or state laws and regulations.
Providers applying on or after the promulgation of this rule should refer to
the appropriate MMAC application filing instructions, which are incorporated by
reference and made a part of this rule as published by the Department of Social
Services, Missouri Medicaid Audit and Compliance Unit, 205 Jefferson Street,
Second Floor, Jefferson City, MO 65109, at its website mmac.mo.gov, August 20,
2021. This rule does not incorporate any subsequent amendments or
additions.
(D) The application
shall include all information required in the mandatory disclosures pursuant to
section (3) of this rule. Upon submission of any application(s), supplemental
form(s), information and documentation requested in the application(s) and
supplemental form(s), MMAC may, at its discretion, request additional or
supplemental information and documentation from the applying provider prior to
considering the application and/or conducting screening pursuant to this rule
in order to clarify any information previously submitted and to verify that the
provider meets all applicable requirements of state or federal laws and
regulations.
(3) All providers, fiscal agents, managed care entities, and persons with an ownership or control interest in the provider are required to disclose as follows:
(A) The following disclosures are mandatory:
1. The name and address of the applying
provider and any person(s) with ownership in the provider. The address must
include the provider's primary business address, each additional practice
location(s), and any corresponding PO Box addresses;
2. Dates of birth and Social Security numbers
(in the case of a corporeal person);
3. Other tax identification number(s) of any
person with ownership in the provider or in any subcontractor in which the
provider has a five percent (5%) or more interest;
4. Whether any person with ownership in the
applying provider is related to another person with ownership in the provider
as a spouse, parent, child, or sibling;
5. Whether any person with ownership in any
subcontractor in which the provider has a five percent (5%) or more interest is
related to another person with ownership in the provider as a spouse, parent,
child, or sibling;
6. The name of
any other provider(s) in which an owner of the applying or enrolled provider
has ownership; and
7. The name,
address, date of birth, and Social Security number of any managing employee of
the provider;
(B)
Disclosures from any provider are due at the following times, and must be
updated within thirty (30) days of any changes in information required to be
disclosed:
1. Upon initial enrollment,
reenrollment, or revalidation; and
2. Upon request of MMAC;
(C) Disclosures from fiscal agents are due at
the following times:
1. Upon the fiscal agent
submitting a proposal;
2. Upon
request of MMAC;
3. Ninety (90)
days prior to renewal or extension of a contract; and
4. Within thirty (30) days after any change
in ownership of the fiscal agent;
(D) Disclosures from managed care entities
(managed care organizations, prepaid inpatient health plans, prepaid ambulatory
health plans, and health insuring organizations), except primary care case
management programs, are due at the following times:
1. Upon the managed care entity submitting a
proposal;
2. Upon request of MMAC;
3. Ninety (90) days prior to
renewal or extension of the contract; and
4. Within thirty (30) days after any change
in ownership;
(E)
Disclosures from Primary Care Case Management Programs (PCCM). PCCMs will
comply with disclosure requirements under subsection (B) of this
section;
(F) All disclosures must
be provided to MMAC. Disclosures not made to MMAC will be deemed non-disclosed
and not in compliance with this section; and
(G) Administrative action(s) for failure to
provide required disclosures.
1. Any person's
failure to provide, or timely provide, disclosures pursuant to this section may
result in deactivation, denial, rejection, suspension, or termination of the
provider's participation in the MO HealthNet program. If the failure is
inadvertent or merely technical, MMAC may choose not to impose administrative
actions if, after notice, the provider promptly corrects the failure.
2. If federal financial participation (FFP)
is recouped or withheld from the MO HealthNet Program because of any person's
failure to provide, or timely provide, disclosures pursuant to this section,
the amount recouped or withheld from the MO HealthNet Program shall be an
overpayment, in addition to any other overpayment, assessed against the person
who failed to provide, or timely provide, the disclosures that resulted in the
recoupment and or withholding of FFP. If the person subsequently corrects the
failure such that FFP is restored, the overpayment shall be rescinded.
(4) Provider Revalidation.
(A) All providers shall
revalidate their enrollment with the MO HealthNet Division at least every five
(5) calendar years from the effective date of the provider's most recently
executed provider agreement, in order to remain a MO HealthNet provider. For
example, a provider whose initial or revalidated provider agreement was
effective on March 1, 2020, is required to revalidate their enrollment no later
than March 1, 2025. MMAC may request that the provider revalidate on an
off-cycle revalidation period.
(B)
The MMAC-approved revalidation application, supplemental forms, information,
and documentation requested by MMAC, along with the application fee and/or
hardship waiver request, if applicable, shall be submitted no later than one
hundred twenty (120) days prior to the expiration of the effective provider
agreement.
(C) Revalidating
providers must comply with the requirements of this rule and will be subject to
the screening process noted in this rule in order to have their applications
for revalidation approved.
(5) Application Fee.
(A) An application fee, hardship waiver
request, and/or an exemption reason provided in this rule must accompany every
organizational provider's application.
(B) The application fee must be in the form
of a cashier's check, money order, or an electronic payment acceptable to MMAC
and for the correct application fee amount in effect as of the date of receipt
by MMAC.
(C) Failure to submit the
application fee in an acceptable form and/or for the correct amount may result
in the return of the fee to the provider and rejection of the
application.
(D) Applying and
revalidating providers must submit an application fee, determined as follows:
1. As of the effective date of this rule for
calendar year 2021, five hundred ninety-nine dollars ($599.00); and
2. For calendar year 2022 and subsequent
years-
A. The amount of the application fee
shall be the amount for the preceding year adjusted by the percentage change in
the consumer price index for all urban consumers for the twelve- (12-) month
period ending with June of the previous year as published by the Bureau of
Labor Statistics of the United States Department of Labor.
(E) If MMAC determines
that a person is an organizational provider, that person is required to pay the
application fee.
(F) Exemptions
from Application Fee. MMAC may waive the application fee under the following
conditions:
1. Providers who are enrolled in
and paid the application fee required by CMS for Medicare or another state's
Title XIX or Title XXI program within two (2) years of the date the application
to enroll as a MO HealthNet Provider shall be exempt from paying an application
fee;
2. MMAC, in consultation with
other state of Missouri departments, divisions, and units, determines that
imposition of the application fee would impede Missouri Medicaid participants'
access to care;
3. A provider is
submitting a provider application as a result of a national or state public
health emergency situation as lawfully declared by a federal or state
authority; and
4. The provider is
owned and operated by the state of Missouri or an agency of the state of
Missouri.
(G) Providers
seeking an exemption from the application fee are responsible for notifying
MMAC, in writing, that they qualify for exemption and for providing proof of
such qualification.
(6) Hardship Waiver Request.
(A) Providers can
request a hardship waiver of the application fee from the Centers for Medicare
and Medicaid (CMS) when submitting their initial enrollment application or a
revalidation application, but the request must be received by MMAC before the
application will be processed by MMAC. A hardship waiver request will not be
considered if it is received by MMAC after MMAC approves the application or
revalidation. If CMS approves the hardship waiver, MMAC will refund the
application fee to the provider.
(B) A provider that requests a hardship
waiver must submit a letter and supporting documentation that describes the
hardship and why the hardship justifies an exception, including providing
comprehensive documentation (which may include, but is not limited to,
historical cost reports, recent financial statements such as balance sheets and
income statements, cash flow statements, or tax returns).
(C) Factors that may suggest a hardship
exception is appropriate include, but are not limited to, the following:
1. Considerable bad debt expenses;
2. Significant amount of charity
care/financial assistance furnished to patients;
3. Presence of substantive partnerships with
those who furnish care to a disproportionately low-income population;
4. Whether an institutional provider receives
considerable amounts of funding through disproportionate share hospital
payments; or
5. 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.
(D) Upon
receipt of a hardship waiver request with an application, MMAC will send the
request and all accompanying documentation to CMS. CMS will determine if the
request should be approved. CMS will communicate its decision to the
institutional provider and MMAC via letter.
(7) Appeal of the Denial of a Hardship Waiver Request. A provider may file a written reconsideration request with CMS within sixty (60) calendar days from the date of the notice of initial determination. The request must be signed by the individual provider, a legal representative, or any authorized official within the entity. The procedures for submitting an appeal will be provided on the denial letter from CMS.
(8) MMAC shall use the application fee to offset the costs associated with the provider screening program in its entirety. This includes, but is not limited to, the following:
(A) Implementation and augmentation of MMAC's
provider enrollment system; and
(B)
Any other administrative costs related to the provider screening program, which
include costs associated with processing fingerprints and conducting criminal
background checks. The application fee does not cover the cost associated with
capturing fingerprints and a provider may be charged additional costs for this
purpose in addition to the application fee.
(9) Refund of the Application Fee.
(A) If an institutional provider is granted a
hardship exception pursuant to this rule or if the application is rejected
because it was not properly signed or is missing other information required to
be provided on the application itself, and an application fee was included with
the application and the hardship waiver request, the application fee shall be
returned to the applying provider.
(B) Once the screening process has begun,
regardless whether the application goes through part or all of the screening
process, the application fee is non-refundable.
(10) Screening.
(A)
The screening requirements contained in this section apply to all applying
providers and to all persons disclosed, or required to be disclosed, in the
application.
(B) MMAC shall conduct
pre-enrollment screening and postenrollment monthly screenings. Screenings may
include the following:
1. Screening pursuant
to
42 CFR sections
455.410(a) and (b), 42 CFR
455.412,
42
CFR 455.432, 42 CFR 455.436, and
42 CFR
455.452;
2. Screening to ensure that the providers
meet all enrollment criteria for their provider type;
3. Announced or unannounced pre- and
post-approval site visits; and
4.
For screening purposes, utilization of databases and other sources of
information to prevent enrollment of fictitious providers, to ensure that
spurious applications are not processed, and to prevent fraud, waste, and abuse
in the MO HealthNet Program.
(C) The screening procedures and requirements are
applicable to all enrolled or applying providers. All providers are required to
revalidate their MO HealthNet enrollment(s) at least every five (5)
years.
(D) The following screening
categories are established for MO HealthNet providers, as required by federal
law and regulation for Medicare and Medicaid providers under
42 CFR
section 424.518 and section 1902(kk)(1) of
the Social Security Act. There are three (3) levels of screening: limited,
moderate, and high. Each provider type is assigned to one (1) of these
screening levels. If a provider could fit within more than one (1) screening
level described in this section, the highest risk category of screening is
applicable.
1. Limited Risk Category.
A. The following providers pose a limited
risk of fraud, waste, and abuse to the MO HealthNet Program and are subjected
to limited category screening:
(I) Physicians
or non-physician practitioners (except as otherwise listed in another risk
category) and medical groups or clinics;
(II) Ambulatory surgical centers
(ASCs);
(III) Competitive
acquisition program/Part B vendors;
(IV) End-stage renal disease (ESRD)
facilities;
(V) Federally qualified
health centers (FQHCs);
(VI)
Histocompatibility laboratories;
(VII) Home infusion therapy
suppliers;
(VIII) Hospitals,
including critical access hospitals (CAHs);
(IX) Health programs operated by an Indian Health
Program (as defined in section 4(12) of the Indian Health Care Improvement Act)
or an urban Indian organization (as defined in section 4(29) of the Indian
Health Care Improvement Act) that receives funding from the Indian Health
Service pursuant to Title V of the Indian Health Care Improvement
Act;
(X) Mammography screening
centers;
(XI) Mass immunization
roster billers;
(XII) Opioid
treatment programs (if
42 CFR
424.67(b)(3)(ii)
applies);
(XIII) Organ procurement
organizations (OPOs);
(XIV)
Pharmacies;
(XV) Radiation therapy
centers (RTCs);
(XVI) Religious
nonmedical health care institutions (RNHCIs);
(XVII) Rural health clinics (RHCs);
and
(XVIII) Skilled nursing
facilities (SNFs).
B. The
providers in the limited category are subject to the following screening
requirements:
(I) Verification that the
applying provider, and all persons disclosed or required to be disclosed, meet
all applicable federal regulations and MO HealthNet Program requirements for
the provider type;
(II)
Verification that the applying provider, and all persons disclosed, have a
valid license, operating certificate, or certification if required for the
provider type, and that there are no current limitations on such licensure,
operating certificate, or certification which would preclude
enrollment;
(III) Verification that
the applying provider's, and that of all persons disclosed, license(s) held in
any other state has/have not expired and that there is/are no current
limitations on such license(s) which would preclude enrollment;
(IV) Confirmation of the identity of the
applying provider and determination of the exclusion status of the applying
provider and any person with an ownership or control interest or who is an
agent or managing employee of the provider through routine checks of the
following federal databases:
(a) Social
Security Administration's Death Master File;
(b) National Plan and Provider Enumeration
System;
(c) List of Excluded
Individuals/Entities;
(d) The
Excluded Parties List System;
(e)
Medicare Exclusion Database; and
(f) Any such other databases as the Secretary
of the United States Department of Health and Human Services has prescribed as
of September 30, 2021, pursuant to section 455.436 of Title 42, Code of Federal
Regulations, which is incorporated by reference and made part of this rule as
published by the Office of the Federal Register, 7 G Street NW, Suite A-734,
Washington, DC 20401, and available at its website
https://www.ecfr.gov/cur-rent/title-42/chapter-IV/subchapter-C/part-455/subpart-E/sec-tion-455.436.
This rule does not incorporate any subsequent amendments and
additions.
(V) Database
check of the National Sex Offender Public Website;
(VI) The information from these databases shall be
used to determine eligibility of the MO HealthNet provider and for verification
of the identity of the applying person, the Social Security number, the
National Provider Identifier (NPI), the National Practitioner Data Bank (NPDB)
licensure, and any exclusion by the Department of Health and Human Services,
Office of Inspector General; and
(VII) MMAC may conduct preapproval site visits prior
to acceptance of an applying provider's application.
2. Moderate Risk Category.
A. The following providers pose a moderate
risk of fraud, waste, and abuse to the MO HealthNet Program and are subject to
moderate screening requirements:
(I) Adult
Day Care providers (ADCs);
(II)
Ambulance service suppliers;
(III)
Community Mental Health Centers (CMHCs);
(IV) Comprehensive outpatient rehabilitation
facilities (CORFs);
(V) Entities
established under sections 205.968-205.973, RSMo;
(VI) Hospice organizations;
(VII) Independent clinical laboratories
(ICLs);
(VIII) Independent
diagnostic testing facilities (IDTFs);
(IX) Non-emergency transportation providers
(NEMTs);
(X) Personal care
providers, including providers billing under the Consumer Directed Services
program;
(XI) Physical therapists
including physical therapy groups;
(XII) Portable x-ray suppliers
(PXSs);
(XIII) Revalidating
Diabetes Prevention Program providers (DPPs);
(XIV) Revalidating durable medical equipment
suppliers (DMEPOS);
(XV)
Revalidating home health agencies (HHAs); and
(XVI) Revalidating opioid treatment
programs.
B. In addition
to the screening requirements for the limited risk category in paragraph
(10)(D)1., the providers in the moderate risk category shall be subject to site
visits prior to acceptance of an applying provider's application and are
additionally subject to unannounced post-enrollment site visits.
3. High Risk Category.
A. The following providers pose a high risk
of fraud, waste, and abuse to the MO HealthNet Program and are subject to high
risk screening requirements:
(I) Newly
enrolling or reenrolling home health agencies;
(II) Newly enrolling or reenrolling Durable
Medical Equipment, Prosthetic, Orthotic, and Supplies (DMEPOS) suppliers;
(III) Newly enrolling or
reenrolling DPP suppliers; and
(IV)
Newly enrolling or reenrolling opioid treatment programs that have not been
fully and continuously certified by the Substance Abuse and Mental Health
Services Administration (SAMHSA) since October 23, 2018.
B. In addition to the screening requirements
for the limited and moderate risk categories in paragraphs (10)(D)1. and 2. of
this rule, the providers and their owners must submit to a fingerprint-based
criminal history report check of the Federal Bureau of Investigations (FBI)
Integrated Automated Fingerprint Identification System-
(I) A revalidating provider who has already
submitted fingerprints once will not be required to submit fingerprints a
second time unless required by FBI protocols;
(II) Pursuant to
42 CFR section
455.434(b), the provider is
responsible for the cost of supplying the fingerprints and the state and
federal government will share the cost of the processing of the fingerprints
and the background check; and
(III)
This fingerprint-based criminal history report check applies to all persons in
this risk category applying to be a provider (whether as a billing or
performing provider), or an individual with a five percent (5%) or greater
direct or indirect ownership interest in such provider, or a managing
employee.
(E) MMAC must adjust the categorical risk level from
"limited" or "moderate" to "high" when any of the following occurs:
1. MMAC imposes a payment suspension on a
provider based on a credible allegation of fraud, waste, or abuse by the
provider; the provider has an existing Medicaid overpayment; or the provider
has been excluded by the Department of Health and Human Services, Office of
Inspector General or another state's Medicaid program within the previous ten
(10) years. The upward adjustment of the provider's categorical risk level for
a payment suspension or overpayment shall continue only so long as the payment
suspension or overpayment continues; or
2. MMAC or CMS in the previous six (6) months
lifted a temporary moratorium for the particular provider type and a provider
that was prevented from enrolling based on the moratorium applies for
enrollment as a provider at any time within six (6) months from the date the
moratorium was lifted.
(F) If a person has been screened by Medicare or by
another state Medicaid agency and paid Medicare or another state Medicaid
agency's application fee, within two (2) years of the date of the application
to MMAC, such person will not be subject to the screening requirements or
application fee provided for by this rule except those screening requirements
and application fee imposed pursuant to subsection (E) of this
section.
(G) Any MO HealthNet
Program provider not categorized by this regulation as within the limited,
moderate or high risk category shall be a considered moderate risk and screened
as a moderate risk.
(H) MMAC may
request and consider additional information or documentation related to the
eligibility criteria, if at any time during the application process it appears
that the enrollment application or supporting documentation is inaccurate,
incomplete, or misleading; or it appears the applying person may be ineligible
to become a MO HealthNet provider.
(11) The provider shall advise MMAC, in writing, on enrollment forms specified by MMAC, of any changes affecting the provider's enrollment records within ninety (90) days of the change, with the exception of change of ownership or control of any provider which must be reported within thirty (30) days.
(A) The
Provider Enrollment Unit within MMAC is responsible for determining whether a
current MO HealthNet provider record shall be updated or a new MO HealthNet
provider record is created. A new MO HealthNet provider record is not created
for any changes, including but not limited to change of ownership, change of
operator, tax identification change, merger, bankruptcy, name change, address
change, payment address change, Medicare number change, National Provider
Identifier (NPI) change, or facilities/offices that have been closed and
reopened at the same or different locations. This includes replacement
facilities, whether they are at the same location or a different location, and
whether the Medicare number is retained or if a new Medicare number is issued.
A provider may be subject to administrative action if information is withheld
at the time of application that results in a new provider number being created
in error. The division shall issue payments to the entity identified in the
current MO HealthNet provider enrollment application. Regardless of changes in
control or ownership, MMAC shall recover from the entity identified in the
current MO HealthNet provider enrollment application liabilities, sanctions,
and penalties pertaining to the MO HealthNet program, regardless of when the
services were rendered.
(12) MO HealthNet provider identifiers shall not be released to any non-governmental entity, except the enrolled provider, by the MO HealthNet Division or its agents.
(13) 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.
(14) 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.
Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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