Current through Register No. 40, October 3, 2024
(a)
Each provider agency who seeks to be enrolled to provide and receive
reimbursement for home and community based waiver services shall:
(1) Complete an application for enrollment
via the MMIS portal at: in order to apply to be and operate as a New Hampshire
Medicaid enrolled provider in accordance with
42 CFR
455.410 and
He-W
520.06, unless they choose to contract with an OHCDS
for pass-through billing, pursuant to
He-M
504.06;
(2) Contact the bureau to request a screening
in accordance with (b) below:
a. Following
initiation of an application in accordance with (1) above; or
b. Not less than 120 days prior to expiration
of the current enrollment period when the provider agency intends to submit an
application for re-enrollment;
(3) Meet the applicable licensing,
certification, or other requirements of the specific service they provide, such
as but not limited to, criteria required in New Hampshire RSA 151, RSA 171-A,
42 CFR
441.301, or a contract with the bureau or
OHCDS; and
(4) Have an executed
Medicaid provider participation agreement with the department in order to
obtain Medicaid agency identification numbers from the department for the
specific services for which the provider agency is enrolling.
(b) Each provider applicant shall
participate in a department screening upon enrollment and re-enrollment to
review the following:
(1) Mission and vision
statements, as applicable;
(2)
Training practices, such as but not limited to, requirements per specific
position, purchased training platforms, and continuing education hours
requirements;
(3) Service-specific
competencies, as related to developmental services defined in chapter He-M
500;
(4) Three references that
illustrate the provider applicant's ability to meet their service obligations
in accordance with their mission and vision statement;
(5) Financial indicators of fiscal integrity,
including but not limited to;
a. Financial
statements identifying current portion of long-term debt payments including
principal and interest; and
b. A
measure of total current assets available to cover the cost of current
liabilities;
(6)
Liability protections;
(7) Policies
and practices regarding restraint and seclusion;
(8) Attestation that criminal background and
appropriate registry checks were completed pursuant to
He-M
504.03(g)-(h); and
(9) Attestation that office of inspector
general checks were completed in accordance with
He-M
504.03(n).
(c) The screening in (b) above shall occur
within 90 days of application for enrollment and within 120 days for
reenrollment.
(d) A provider
applicant shall not be enrolled pursuant to (a)(4) above until the department
has completed the screening in (b) above and has communicated this to the
department's program integrity office.
(e) In addition to the reasons set forth in
He-W
520.06, the department shall deny an application for
provider agency enrollment or re-enrollment, as applicable, due to any of the
following reasons:
(1) Failure to complete the
screening required in (b) above;
(2) Any reported abuse, neglect, or
exploitation of an individual by an applicant, provider, provider agency, or
contractor, if such abuse, neglect, or exploitation is reported on the state
registry of abuse, neglect, and exploitation in accordance with
RSA
161-F:49 or
RSA
169-C:35 and the provider agency failed to
take appropriate action;
(3) A
provider agency fails to ensure that its providers, staff, and contractors meet
the training requirements in chapter He-M 500, He-M 1001, He-M 1201, or Nur
404;
(4) A provider agency,
provider, staff, or contractor has an illness or behavior that, as evidenced by
documentation obtained or the observations made by the department, would
endanger the well-being of the individuals or impair the ability of the
provider agency to comply with department rules and the provider agency failed
to take appropriate action to address and respond;
(5) A provider agency, or any of its
providers, staff, contractors, or any representative thereof, knowingly
provides materially false or misleading information to the
department;
(6) A provider agency,
or any of its providers, staff, contractors, or any representative thereof,
fails to permit or interferes with any inspection or investigation by the
department;
(7) A provider agency,
or any of its providers, staff, contractors, or representatives thereof, fails
to provide required documents to the department or entities acting on its
behalf;
(8) Federal or state laws,
regulations, or guidelines are modified in such a way that either providing the
services under the medicaid provider participation agreement is prohibited or
the department is prohibited from paying for such services from the planned
funding source; or
(9) The provider
agency, provider, or contractor no longer holds a required license,
certification, or other credential to qualify as a provider of services.
(f) Enrollment or
re-enrollment shall be denied upon the written notice by the department to the
provider agency stating the specific rule(s) with which the provider agency
does not comply.
(g) A provider
agency may request an appeal, in accordance with He-C 200, regarding a proposed
denial of enrollment or re-enrollment within 30 business days of the decision.
(h) The provider agency's
enrollment status shall be suspended until the appeal determination is
adjudicated.
(i) The denial shall
not become final until the period for requesting an appeal has expired, or, if
the provider agency requests an appeal, until such time as the administrative
appeals unit issues a decision upholding the department's decision.
(j) If the department's decision is not
upheld, the denial would be ineffective, and the provider shall continue to
provide services.
(k) Appeals shall
be submitted in writing, to the bureau administrator in care of the
department's office of client and legal services.
(l) Each enrolled provider shall:
(1) Submit claims for payment in accordance
with He-M
504.05; and
(2) Be subject to monitoring by the
department or entities acting on its behalf, in accordance with the
requirements of He-M 504.09, He-M 500, and He-M
1201.
(m) An enrolled
provider or applicant shall update MMIS and notify the department, in writing
to the bureau chief, or designee, of any material change in any status or
condition of any element on their application within 30 days of the change
occurring for changes such as, but not limited to:
(1) Business affiliation;
(2) Ownership and control
information;
(3) Federal tax
identification number;
(4) Criminal
convictions;
(5) Addition to the
bureau of elderly and adult services (BEAS) or DCYF state registries;
and
(6) The types of services that
are offered.
(n) An
enrolled provider shall notify any applicable service coordination agency if
any change results in a change to the provider agency's ability to deliver
services to an individual as outlined in that individual's service agreement
within 2 business days.
(o) An
enrolled provider or provider applicant shall notify any applicable area agency
or service coordination agency if any change impacts their status as a provider
agency within 2 business days.
(p)
An enrolled provider shall immediately notify, in writing, the department, any
applicable area agencies, any applicable service coordination agencies, and any
individuals receiving services from the provider agency, in accordance with
He-M
504.13 of their decision to terminate their status as
an enrolled provider and update the MMIS at least 90 days prior to the
termination date.
(q) Enrolled
providers terminating in accordance with (n) above shall ensure each
individual's full service file and any other pertinent documentation is
transferred to their respective service coordination agency within 2 business
days of the notification.
(r)
Documentation of services provided between the date of notice and the last date
of service provision shall be transferred to the respective service
coordination entity no more than 2 business days after the end of service
provision.
(s) Claims submitted by,
or payments made to, enrolled provider agencies who have not timely furnished
the notification of changes or have not submitted any of the items that are
required due to a change, in accordance with (n)-(q) above, shall be denied
payment or be subject to recovery.
