PURPOSE: This rule implements federal regulatory requirements promulgated by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services at 76 Fed. Reg. 5862 (February 2, 2011), 42 CFR Parts 455 and 457, establishing the bases on which enrollment, revalidation, and establishment of a new practice location may be approved, limited, or denied.

1. (1) Missouri Medicaid Audit Compliance (MMAC) shall terminate the provider’s enrollment or deny enrollment—

   1. (A) Where the provider or any person with a five percent (5%) or greater direct or indirect ownership interest in 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 or person 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;
   2. (B) Where the provider or any person with a five percent (5%) or greater direct or indirect ownership interest in the provider has been convicted of a criminal offense related to that person’s 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;
   3. (C) Of any provider that is terminated on or after January 1, 2011, 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 USC 1320a-7;
   4. (D) If 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;
   5. (E) If the provider, or any person with a five percent (5%) or greater direct or indirect ownership interest in the provider, fails to submit sets of fingerprints in a form and manner to be determined by MMAC within thirty

2. (30) days of a request by 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; and

   1. (F) If 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.

3. (2) MMAC may terminate the provider’s enrollment or deny enrollment if CMS or MMAC—

   1. (A) Determines that the provider has falsified any information provided on the application; or
   2. (B) Cannot verify the identity of any provider applicant.
4. (3) Except to the extent inconsistent with this rule, the requirements of 13 CSR 70-3.020 and 13 CSR 70-3.030 remain in force, including any provisions regarding denial of applications and termination, until those provisions are rescinded.
5. (4) 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.

AUTHORITY: sections 208.159 and 660.017, RSMo 2000.* Original rule filed Dec. 12, 2013, effective July 30, 2014. *Original authority: 208.159, RSMo 1979 and 660.017, RSMo 1993, amended 1995.