Current through September 17, 2024
003.01
PROVIDER ELIGILIBITY. To be eligible to participate in
Title XIX (Medicaid) and Title XXI Children's Health Insurance Program (CHIP),
the provider must meet the general standards for all providers in 471 Nebraska
Administrative Code (NAC) Chapters 1, 2, and 3, if appropriate, and the
standards for participation for each provider type included within:
(A) Each provider specific chapter of Title
471 NAC;
(B) Title 480 NAC for Home
and Community-Based Waiver Services;
(C) Title 403 and 404 NAC for Community-Based
Services for Individuals with Developmental Disabilities; and
(D) Title 482 NAC for Managed Care
Services.
003.02
PROVIDER ENROLLMENT. The Department will not cover
services rendered, ordered, or referred by a provider, or pay a provider for
services, when that provider is not enrolled with Medicaid in accordance with
471 NAC 2. Each provider business location where services are rendered must be
enrolled.
003.02(A)
PROVIDER
SCREENING. The Department will, at a minimum, screen all providers
as provided in 42 Code of Federal Regulations (CFR) Part 455, Subpart E. In
accordance with
42 CFR
455.452, the Department may enact additional
or more stringent screening methods which will be included within either the
NAC or Nebraska state law. The Department will deny or terminate the enrollment
of any provider that fails to comply with or meet all applicable screening
requirements.
003.02(A)(i)
SITE
VISITS. A provider must permit the Centers for Medicare and
Medicaid Services (CMS) and the Department to conduct unannounced onsite
inspections of any and all provider locations. The Department may deny or
terminate the enrollment of a provider who fails to permit a site visit. The
Department may also deny or terminate a provider if, based on the site visit,
the Department determines the provider location does not match the service
provider agreement or does not meet the standards for participation.
003.02(A)(ii)
CATEGORICAL RISK
LEVELS. All provider types are categorized into one of three risk
levels based on a determination by the Centers for Medicare and Medicaid
Services (CMS) and the state Medicaid agency of the risk of fraud, waste, and
abuse. The risk level of a provider will be raised to high risk, regardless of
their provider type risk level, when payments are suspended based on a credible
allegation of fraud, the provider has an existing Medicaid overpayment, or the
provider has been excluded by the Office of the Inspector General or any
state's Medicaid program within the last 10 years. Provider types are subject
to screening requirements based on their applicable risk level.
003.02(A)(ii)(1)
LOW
RISK. Low risk screening includes.
003.02(A)(ii)(1)(a)
LICENSE. Verification that the provider's applicable
license(s) is not expired and has no current limitations.
003.02(A)(ii)(1)(b)
DATABASES. Pre- and post-enrollment database checks to
confirm the identity and participation eligibility of the provider, owners, and
managing employees.
003.02(A)(ii)(2)
MODERATE
RISK. Moderate risk screening includes all components of low risk
screening as well as pre- and post-enrollment site visit.
003.02(A)(ii)(3)
HIGH
RISK. High risk screening includes all components of low and
moderate risk screening as well as fingerprint based criminal background checks
of the provider or any person who owns five percent or more direct or indirect
ownership interest in the providers.
003.02(A)(iii)
CRIMINAL
BACKGROUND CHECKS. As a condition of enrollment, providers must
consent to criminal background checks including fingerprinting when required to
do so under State law or by risk level determined for that category of
provider. Failure to consent to criminal background checks will result in the
denial or termination of the service provider agreement.
003.02(A)(iv)
FINGERPRINT
SUBMISSION. Any high risk provider, or any person with a five
percent or more ownership interest in a high risk provider, must submit a set
of fingerprints, in a form and manner determined by the State Medicaid agency,
within 30 days upon request from the Centers for Medicare and Medicaid Services
(CMS) or the State Medicaid agency. Failure of the provider or owner, as
applicable, to meet this requirement will result in the denial or termination
of the service provider agreement.
003.02(B)
SERVICE PROVIDER
AGREEMENTS. Each provider must have an approved service provider
agreement with the Department. By signing the service provider agreement, a
provider agrees to comply with all provisions stated therein. A service
provider agreement is not an employment agreement or contract, and enrollment
as a Medicaid provider does not constitute employment by or with the Department
and does not guarantee referrals. Service provider agreements cannot be
transferred to any other person or entity.
003.02(B)(i)
REQUIRED
FORMS. Providers must complete, sign, and submit to the Department
the following forms as appropriate.
(1)
MC-19, "Service Provider Agreement";
(2) MLTC-62, "Nebraska Ownership/Controlling
Interest and Convictions Disclosure";
(3) All applicable addendum forms;
(4) "United States Citizenship Attestation
form"; and
(5) MS-84 "State of
Nebraska ACH/EFT Enrollment form".
Certain providers of home and community-based services must
also complete provider agreement forms as indicated in Title 480 NAC. Certain
providers of medical transportation services must also complete the service
provider agreement form as indicated in Titles 473 and 474 NAC.
The Department may require a provider to periodically
complete a new service provider agreement to update information or eligibility,
and may terminate the enrollment of a provider that fails to comply with this
requirement.
003.02(C)
APPROVAL AND
ENROLLMENT. The Department will review and screen each submitted
service provider agreement and upon approval and enrollment will assign an
effective date to the provider and a Medicaid provider number to use when
billing Medicaid.
003.02(D)
ORDERING AND REFERRING PROVIDERS. Ordering and
referring physicians or other professionals providing Medicaid services must be
enrolled providers and must include their National Provider Identifier (NPI) on
any claims for items or services ordered or referred.
003.02(E)
REACTIVATION. At the discretion of the Department,
providers who have previously been terminated or excluded may or may not be
reactivated as providers of Title XIX (Medicaid) and Title XXI Children's
Health Insurance Program (CHIP) services. At the end of a technical or
time-limited termination period, the provider may request in writing that the
Department reactivate the service provider agreement. The Medicaid Division may
approve or deny reactivation of the service provider agreement. The provider
may be reactivated conditionally with a closed-end service provider agreement
or other restrictions or requirements as deemed to be necessary by the
Department.
003.02(F)
REVALIDATION. The Department must revalidate the
enrollment of all providers at least every five years. Providers who do not
complete revalidation will not be eligible past their revalidation due
date.
003.02(G)
APPLICATION FEE. At initial enrollment, re-enrollment,
reactivation, and revalidation providers must submit to the Department an
application fee before the Department can execute a service provider agreement.
Exempt from this application fee requirement are the following.
(i) Individual physicians and non-physician
practitioners;
(ii) Providers
enrolled in or that have paid an application fee to Medicare or another State's
Medicaid or Children's Health Insurance Program (CHIP); and
(iii) Providers or categories of providers
that have received an application fee waiver from the Centers for Medicare and
Medicaid Services (CMS).
003.02(H)
TEMPORARY
MORATORIA. A moratorium imposed under this section lasts for an
initial period of six months and if necessary may be extended in six-month
increments by the Department. Notice of any moratoria issued by the Department
will be provided through a provider bulletin. The Department, in its discretion
and under mandate from the Secretary of the United States Department of Health
and Human Services enforces temporary moratoria under either of the following
conditions.
(i) The Department must impose
temporary moratoria on the enrollment of new providers or provider types that
pose an increased risk to the Medicaid program as identified by the Secretary
of the United States Department of Health and Human Services unless the
Department determines that a temporary moratorium would adversely affect access
to medical assistance; and
(ii) The
Department may impose temporary moratoria or place numerical caps or other
limits on the enrollment of new providers that it and the Secretary of the
United States Department of Health and Human Services have identified as having
significant potential for fraud, waste, or abuse unless the Department
determines that such action would adversely affect access to medical
assistance.
003.03
STANDARDS FOR
PARTICIPATION. Providers must meet the following minimum
requirements:
(1) Accept the philosophy of
service provision which includes acceptance of, respect for, and a positive
attitude toward Medicaid clients and the philosophy of client
empowerment;
(2) Meet any
applicable licensure or certification requirements and maintain current
licensure or certification;
(3)
Obtain adequate information on the medical and personal needs of each client,
if applicable;
(4) Not discriminate
against any client, employee, or applicant for employment because of race, age,
color, religion, sex, handicap, or national origin, in accordance with 45 CFR
Parts 80, 84, 90, and 41 CFR Part 60;
(5) Agree to a law enforcement criminal
background check and Adult Protective Services and Child Protective Services
Central Registry checks;
(6)
Operate a drug-free workplace;
(7)
Attend training on Medicaid as deemed necessary by the Department;
(8) Provide services within the scope of
practice identified in state and federal law, and under all applicable state
and federal licensure or certification requirements; and
(9) Agree to maintain up-to-date and accurate
service provider agreement information by submitting any changes, within 35
days of the change, to the Department.
003.03(A)
PROVIDER
EMPLOYEES. Employees of providers are subject to the same
standards.
003.04
DEPARTMENT EMPLOYEES AS PROVIDERS. No employee of the
Department and its subdivisions, and Department contractors, except clinical
consultants, may serve as providers under Medicaid or as paid consultants to
enrolled providers without the express written approval of the Medicaid
Director.
003.05
PRINCIPLES OF PROVIDING MEDICAL ASSISTANCE. The amount
and type of service required is defined for each case through utilization
review. The provider will limit services to essential health care. The plan for
providing services within program guidelines through Medicaid is based on the
following principles:
(A) All plans for
medical care must provide for essential health services and for integration of
treatment with social planning to reduce economic dependency;
(B) Medical care and services must be
coordinated with health services available through existing public and private
sources;
(C) Medical care and
services must be provided as economically as is consistent with accepted
standards of medical care and fair compensation to providers;
(D) Medical care and services must be within
the licensure of the provider giving the care or service; and
(E) The client must be allowed, within these
limitations, to exercise free choice in the selection of a qualified
provider.
003.06
PROVIDER MATERIALS. The provider is responsible for
understanding and complying with all applicable regulations and ensuring that
employees, consultants, and contractors are informed about all applicable
regulations, including:
(A) 471 NAC 1, 2, and
3;
(B) Each service specific
chapter in Title 403, 404, 471 and 480 NAC that is applicable to services
rendered by the provider, and instructions for forms and electronic
transactions.
003.07
PROVIDER BULLETINS. The provider must comply with the
information in each provider bulletin when conducting enrollment activities,
rendering services and submitting claims for payment.
003.08
ELECTRONIC INFORMATION
EXCHANGE. Any entity that exchanges standard electronic
transactions with the Department must have an approved trading partner
agreement with the Department.
003.09
VERIFICATION OF LAWFUL
PRESENCE. Individual providers enrolling as a solo practitioner
must attest to:
(A) United States
citizenship; or
(B) Status as a
qualified alien under the Federal Immigration and Nationality Act, including
disclosure of the alien number and official immigration documents as needed to
verify status and work authorization.
