PURPOSE: This rule establishes the basis on which providers and vendors of health care services under the MO HealthNet program may be admitted to or denied enrollment in the program and lists the grounds upon which enrollment may be denied.

1. (1) The following definitions will be used in administering this rule:

   1. (A) Affiliates—Persons having an overt, covert, or conspiratorial relationship so that any one of them directly or indirectly controls or has the power to control another;
   2. (B) Applying provider—Any person who has submitted a provider enrollment application or request for enrollment in the MO HealthNet program;
   3. (C) Closed-end provider agreement—An agreement that is for a specific period of time not to exceed twelve (12) months and that must be renewed in order for the provider to continue to participate in the MO HealthNet program;
   4. (D) Fiscal agent—An organization under contract to the state MO HealthNet agency for providing services in the administration of the MO HealthNet program;
   5. (E) Limited provider agreement—The granting of MO HealthNet enrollment to an applying provider by the single state agency upon the condition that the applying provider perform services, deliver supplies, or otherwise participate in the program only in adherence to or subject to specially set out conditions agreed to by the applying provider prior to enrollment;
   6. (F) Medicaid agency or the agency—The single state agency administering or supervising the administration of a state Medicaid plan;
   7. (G) Open-end provider agreement—An agreement that has no specific termination date and continues in force as long as it is agreeable to both parties;
   8. (H) Participation—The ability and authority to provide services or merchandise to eligible MO HealthNet participants and to receive payment from the MO HealthNet program for the services or merchandise;
   9. (I) Provider—Any person having an effective, valid, and current written provider enrollment application and application for provider direct deposit with the MO Health- Net agency for the purpose of providing services to eligible participants and obtaining reimbursement excluding, for the purposes of this rule only, all persons receiving reimbursement in their capacity as owners or operators of a licensed nursing home;
   10. (J) Provider enrollment application—A signed writing utilizing forms specified by the single state agency, containing all applicable information requested and submitted by a provider of medical assistance services for the purpose of enrolling in the MO HealthNet program;
   11. (K) Person—Any natural person, partnership, corporation, not-for-profit corporation, professional corporation, or other business entity;
   12. (L) Termination from participation—The ending of participation in the Medicaid program; and
   13. (M) Application for provider direct deposit—A signed writing utilizing forms specified by the single state agency containing all applicable information requested and submitted by a provider of medical assistance services for the purpose of having MO HealthNet checks automatically deposited to an authorized bank account.

2. (2) Duties of the Single State Agency.

   1. (A) Upon receiving a provider enrollment application and application for provider direct deposit, the single state agency shall record receipt of the applications and conduct whatever lawful investigation which, in the discretion of the MO HealthNet agency, is necessary to verify, supplement, or change the information contained in the application.
   2. (B) If, in the discretion of the MO Health- Net agency, further information is needed from the applying provider to verify or supplement a provider enrollment application or application for direct deposit, the MO HealthNet agency shall immediately make a clear and precise request to the provider for the information and inform the prospective provider whether or not the applications will be withheld pending receipt of the requested information.
   3. (C) The single state agency, within ninety
3. (90) calendar days after receiving an application, shall complete its investigation and determine whether to deny or allow enrollment of the applying provider. The MO HealthNet agency’s decision shall be made known to the applying provider within ninety-five (95) calendar days after the application was received by the agency. A denial of enrollment shall be made known to an applying provider giving the reason(s) for the denial in writing. The written notice of denial 13 CSR 70-3

will be effective upon the date it is mailed by the single state agency to the address entered on the application by the provider.

1. (D) In the event that the applications cannot be fully investigated by the single state agency within ninety (90) days of receipt, the MO HealthNet agency, upon written notice to the applying provider, may extend the time for conducting the investigation for a period not to exceed one hundred twenty (120) calendar days from the date of receipt of the applications by the MO HealthNet agency. The MO HealthNet agency must send the notice of delay to the applying provider within sixty (60) calendar days from the time the application in question was received.

1. (3) The single state agency, at its discretion, may deny or limit an applying provider’s enrollment and participation in the MO HealthNet program for any one (1) of the following reasons:

   1. (A) A false representation or omission of any material fact or information required or requested by the single state agency pursuant to an applying provider making application to enroll. This shall include material facts or omissions about previous Medicaid participation in Missouri or any other state of the United States;
   2. (B) Previous or current involuntary surrender, removal, termination, suspension, ineligibility, or otherwise involuntary disqualification of the applying provider’s Medicaid participation in Missouri or any other state of the United States;
   3. (C) Previous or current involuntary surrender, removal, termination, suspension, or otherwise involuntary disqualification from participation in Medicare;
   4. (D) Previous or current involuntary surrender, removal, termination, suspension, ineligibility, or otherwise involuntary disqualification from participation in another governmental or private medical insurance program. This includes, but is not limited to, programs such as Workers’ Compensation and Special Health Needs. For the purposes of subsections (3)(B)–(D), involuntary surrender, removal, termination, suspension, ineligibility, or other involuntary disqualification shall include withdrawal from medical assistance or medical insurance program participation arising from or as a result of any adverse action by a government agency, licensing authority, or criminal prosecution authority of Missouri or any other state or the federal government including Medicare;
   5. (E) Regardless of changes in control or ownership, the existence of any amount due the single state agency which is the result of an overpayment under the MO HealthNet program of which the applying provider or former owner, regardless of when the services were rendered, has had notice. Any amount due which is the subject of a plan of restitution shall not be considered in applying this section unless the applying provider is in default of the plan of restitution in which case enrollment may be denied or limited;
   6. (F) Previous or current conviction of any crime relating to the applying provider’s professional, business, or past participation in Medicaid, Medicare, or any other public or private medical insurance program;
   7. (G) Any civil or criminal fraud against the MO HealthNet program or any other public or private medical insurance program;
   8. (H) Any termination, removal, suspension, revocation, denial or consented surrender, or other involuntary disqualification of any license, permit, certificate, or registration related to the applying provider’s business or profession in Missouri or any other state of the United States. Any such license, permit, certificate, or registration which has been denied or lost by the provider for reasons not related to matters of professional competence in the practice of the applying provider’s profession, upon proof of reinstatement, shall not be considered by the agency in its decision to enroll the applying providers unless the conduct is harmful or dangerous to the mental or physical health of a patient;
   9. (I) Any false representation or omission of a material fact in making application for any license, permit, certificate, or registration related to the applying provider’s profession or business in Missouri or any other state of the United States;
   10. (J) Any previous failure to correct deficiencies in provider operation after receiving written notice of the deficiencies from the single state agency;
   11. (K) Any previous violation of any regulation or statute relating to the applying provider’s participation in the MO HealthNet program;
   12. (L) Failure to supply further information to the single state agency after receiving a written request for further information pursuant to a provider enrollment application or application for provider direct deposit;
   13. (M) Failure to affix a proper signature to a provider enrollment application, application for provider direct deposit, or any other enrollment forms. Submission of any application bearing a signature that conceals the involvement in the provider’s operation of a person who would otherwise be ineligible for Medicaid participation shall be grounds for denial of enrollment by the single state agency. Otherwise, the single state agency shall give the applying provider an opportunity to provide a proper signature and, after that, consider the application as if the proper signature was originally affixed;

   14. (N) A previous or current conviction or a plea of 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. 1. Endangering the welfare of a child;
       2. 2. Abusing or neglecting a resident,

patient, or client;

1. 3. Misappropriating funds or property

belonging to a resident, patient, or client; or

1. 4. Falsifying documentation verifying

delivery of services to a personal care assistance services consumer;

1. (O) Placement on the “Family Care Safety Registry” as mandated by sections 210.900– 210.936, RSMo;
2. (P) Placement on the “Missouri Sex Offender Registry” as mandated by sections 589.400–589.425 and 43.650, RSMo; or
3. (Q) Failure to complete an application for provider direct deposit as required by 13 CSR 70-3.140.

1. (4) After investigation and review of the applying provider’s provider enrollment application and application for provider direct deposit and consideration of all the information, facts, and circumstances relevant to the applications, including, but not limited to, a review of the applying provider’s affiliates, the single state agency, at its discretion, in the best interest of the MO HealthNet program, will make one (1) of the following determinations:

   1. (A) Enroll the applying provider in an open-ended provider agreement;
   2. (B) Deny or limit the application of an applying provider based on the abuse, fraud, or deficiencies of an affiliate, provided that each decision to deny or limit is based on a case-by-case evaluation, taking into consideration all relevant facts and circumstances known to the single state agency. The program abuse, fraud, regulatory violation, or deficiencies of a past or present affiliate of an applying provider may be imputed to the applying provider where the conduct of a past or present affiliate was accomplished with the knowledge or approval of the applying provider; or
   3. (C) Deny or limit the applying provider’s enrollment for one (1) or more of the reasons in subsections (3)(A)–(Q).
2. (5) Denial of enrollment shall preclude any 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. (6) No clinic, group, corporation, partnership, affiliate, or other association may submit claims for payment to the single state agency or its fiscal agent for any services or supplies provided by a 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. (7) The provider shall advise the single state agency, in writing, on enrollment forms specified by the single state agency, of any changes affecting the provider’s enrollment records within ninety (90) days of the change, with the exception of change of ownership or control of any provider which must be reported within thirty (30) days. The Provider Enrollment Unit within the division is responsible for determining whether a current MO HealthNet provider record shall be updated or a new MO HealthNet provider record is created. A new MO HealthNet provider record is not created for any changes, including, but not limited to, change of ownership, change of operator, tax identification change, merger, bankruptcy, name change, address change, payment address change, Medicare number change, National Provider Identifier (NPI) change, or facilities/offices that have been closed and reopened at the same or different locations. This includes replacement facilities, whether they are at the same location or a different location, and whether the Medicare number is retained or if a new Medicare number is issued. If a new provider record is created in error due to change information being withheld at the time of application, the new MO HealthNet provider record shall be made inactive, the existing provider record will be made active, the existing provider record shall be updated, and the provider may be subject to sanction. The division shall issue payments to the entity identified in the current MO HealthNet provider enrollment application. Regardless of changes in control or ownership, the division shall recover from the entity identified in the current MO HealthNet provider enrollment application liabilities, sanctions, and penalties pertaining to the MO HealthNet program, and Procedure of General Applicability

regardless of when the services were rendered.

1. (8) MO HealthNet provider identifiers are contingent upon the applying provider receiving a favorable determination of compliance with Civil Rights requirements from the Office of Civil Rights (OCR). If OCR approval is not obtained and maintained, any reimbursement received shall be recouped.
2. (9) The provider is responsible for all services provided and all claims filed using her/his MO HealthNet provider identifier regardless to whom the reimbursement is paid and regardless of whom in her/his employ or services produced or submitted the MO HealthNet claim, or both. The provider is responsible for submitting proper diagnosis codes, procedure codes, and billing codes. When the length of time actually spent providing a service (begin and end time) is required to be documented, the provider is responsible for documenting such length of time by documenting the starting clock time and the end clock time, except for services as specified pursuant to 13 CSR 70- 91.010(4)(A), Personal Care Program, regardless to whom the reimbursement is paid and regardless of whom in the provider’s employ or services produced or submitted the MO HealthNet claim.
3. (10) MO HealthNet provider identifiers shall not be released to any non-governmental entity, except the enrolled provider, by the MO HealthNet Division or its agents.
4. (11) MO HealthNet reimbursement shall not be made for any services performed by an individual not enrolled as a MO HealthNet provider, except for those services performed by the employee of the enrolled provider who is acting within their scope of practice and under the direct supervision of the enrolled provider. For example, an enrolled psychology or therapy provider may only bill for services that they actually perform. Psychology, therapy, and psychiatric services reimbursed through the physician program do not allow billing for supervised services.
5. (12) A provider that receives payment or makes payment of five (5) million dollars or more in a federal fiscal year under the MO HealthNet program must annually attest that the provider complies with the provisions of section 6032 of the federal Deficit Reduction Act of 2005. If a provider furnishes items or services at more than a single location or under more than one (1) contractual or other payment arrangement, the provisions apply to that provider if the aggregate payments total five (5) million dollars or more. A provider meeting this dollar threshold and having more than one (1) federal tax identification number shall provide the single state agency written notification of each associated federal tax identification number, each associated provider name, and each associated MO HealthNet provider identifier by September 30 of each year. The provider’s annual attestation must be made by March 1 of each year. The provider must provide a copy of the attestation within thirty (30) days upon the request of the single state agency. Any provider that claims an exemption from the provisions of section 6032 of the federal Deficit Reduction Act of 2005 must provide proof of such exemption within thirty (30) days upon the request of the single state agency.

AUTHORITY: sections 208.159, 208.164, and 210.924, RSMo 2000 and sections 208.153 and 208.201, RSMo Supp. 2009.* This rule was previously filed as 13 CSR 40- 81.165. Original rule filed June 14, 1982, effective Sept. 11, 1982. Amended: Filed July 30, 2002, effective Feb. 28, 2003. Amended: Filed April 29, 2005, effective Oct. 30, 2005. Amended: Filed Nov. 1, 2005, effective June 30, 2006. Amended: Filed March 30, 2007, effective Oct. 30, 2007. Amended: Filed June 1, 2010, effective Dec. 30, 2010. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007; 208.159, RSMo 1979; 208.164, RSMo 1982, amended 1995; 208.201, RSMo 1987, amended 2007; and 210.924, RSMo 1999.