Current through Register Vol. 49, No. 18, September 16, 2024
(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.
