Current through Register Vol. 35, No. 18, September 24, 2024
A. Any
person wishing to provide health care in the children's medical services
program must be a medicaid provider and shall operate under a provider
agreement with CMS.
B. Failure to
comply with the terms of the provider agreement may result in termination of
provider status and immediate cessation of payment for services rendered to the
client.
C. Providers must submit
legible and complete medical records for each service or set of related
services authorized by the program to the care coordinator. Failure to submit
medical reports may result in termination of the provider agreement. Medical
reports submitted to the program are the property of the program. The program
shall follow applicable federal and state laws regarding release of these
reports.
D. Providers must meet
standards of care established by appropriate licensing boards, certifying
bodies and standards as may be established by the CMS services program
manager.
E. Providers must seek and
obtain prior approval for all services other than routine primary care. Prior
approval is obtained through the client's CMS care coordinator and may require
review of the CMS medical director.
F. Providers must submit legible and complete
medical reports for each service or set of related services authorized by the
program to the service coordinator. Failure to submit medical reports may
result in termination of the provider agreement.
G. Violations: Sanctions may be imposed by
CMS against a provider for any one or more of the following reasons.
(1) Knowingly and willfully making or causing
to be made any false statement or misrepresentation of a material fact by:
(a) presenting or causing to be presented for
payment under children's medical services any false or fraudulent claim for
services or merchandise;
(b)
submitting or causing to be submitted false information for the purpose of
obtaining greater compensation than that to which the provider is legally
entitled;
(c) submitting or causing
to be submitted false information for the purpose of meeting prior approval
status; and
(d) submission of a
false or fraudulent application for provider status.
(2) Failure to disclose or make available to
the department or its authorized agent records of services provided to
children's medical services clients and records of payments for those
services.
(3) Failure to provide
and maintain quality services which meet professionally recognized standards of
care.
(4) Engaging in a course of
conduct or performing an act that is unreasonably improper or abusive of the
children's medical services program, or continuing such conduct following
notification that said conduct should cease.
(5) Breach of the terms of the provider
agreement.
(6) Over utilizing the
children's medical services program by inducing, furnishing or otherwise
causing a recipient to receive service(s) or merchandise substantially in
excess of the needs of the recipient.
(7) Rebating or accepting a fee or portion of
a fee or charge for a children's medical services patient referral.
(8) Violating any provision of state or
federal statutes or any rule or regulation promulgated pursuant
thereto.
(9) Violating any laws,
regulations, or code of ethics governing the conduct of occupations or
professions or regulated industries directly relating to children's medical
services.
(10) Conviction of a
criminal offense relating to performance of a provider agreement with the state
or for negligent or abusive practice resulting in death or injury to
patients.
(11) Failure to meet
standards required by state or federal law for participation, as a given type
of provider (e.g., licensure or certification).
(12) Soliciting, charging, or accepting
payments from recipients for services for which the provider has billed the
children's medical services program.
(13) Failure to correct deficiencies in
provider operations within time limits specified by program guidelines after
receiving written notice of these deficiencies from the human services
department.
(14) Formal reprimand
or censure by a professional association of the provider's peers for unethical
practices or malpractice.
(15)
Suspension or termination from participation in another governmental medical
program such as, but not limited to, worker's compensation, medicaid,
rehabilitation services, and medicare.
(16) Indictment for fraudulent billing
practices, or negligent practice resulting in physical, emotional or
psychological injury or death to the provider's patients.
(17) Failure to repay or make arrangements
for the repayment of identified overpayments or otherwise erroneous
payments.
H.
Sanctions: One or more of the following sanctions may be invoked against
a provider:
(1) termination from participation
in the children's medical services program;
(2) suspension of participation in the
children's medical services program;
(3) suspension or withholding of payments to
a provider;
(4) referral to peer
review;
(5) one-hundred percent
review of the provider's claims prior to payment; and
(6) referral to the appropriate state
licensing board or other appropriate authority for investigation.
I. A provider found by the
division to have committed a violation shall be given notice and an opportunity
for hearing in accordance with this rule.
