HAR §17-1736-12. REPEALED

[R 09/30/13] §17-1736-13 Application for provider participation. (a) Any provider who wishes to provide care, goods, or services to receive reimbursement from the Hawaii medical assistance program, shall apply in writing to the med-QUEST division of DHS. The provider shall, at the request of the DHS med-QUEST administrator, supply all information requested concerning the provider's education and qualifications as a provider, financial status of the provider's practice, background history of the provider, and if the provider is required to maintain a license, the status of that license. The DHS med-QUEST administrator shall, in the administrator's sound discretion, have the right to approve or deny any application for certification as a provider under the Hawaii medical assistance program. If a provider is denied certification by the DHS med-QUEST administrator, the provider may request a fair hearing as provided by section 17-1736-33. Application forms to request certified provider status shall be furnished by the DHS med-QUEST administration. (b) Except for providers exempted in subsections (c) and (d), all providers participating or applying to participate in Hawaii's medical assistance program shall have a current and valid written agreement or contract on file with DHS. Failure to maintain such a contract shall constitute grounds for suspension, termination, or withholding payment of claims submitted under the Hawaii medical assistance program until a UNOFFICIAL 1736-6 current and valid written agreement is signed and on file with DHS. (c) A provider outside of the State of Hawaii who furnishes goods and services authorized to be provided under the Hawaii medical assistance program to eligible Hawaii residents visiting in that state and urgently requiring care and services shall be exempt from the certification requirement so long as that provider is properly licensed to provide health care services in accordance with the laws of the provider's home state, and the provider is certified by Medicaid in the provider's home state to furnish the health care services actually rendered. (d) Provider outside of the State of Hawaii who satisfy the requirements of subsection (c) also furnish services not available in Hawaii to eligible Hawaii residents as long as that provider obtains prior oral or written authorization from the DHS med-QUEST division's medical consultant prior to providing the goods, care, and services that the provider deems necessary. The medical consultant granting the prior authorization shall immediately reduce the substance of the authorization into writing and mail a copy to the out-of-state provider. (e) Pharmacy providers who are the exclusive suppliers of prescribed drugs and supplies to a long term care facility shall apply for a separate provider agreement and provider number for each facility served as described in subsection (a). [Eff 08/01/94; am 03/30/96; am 02/10/97 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§431.51, 447.15) §17-1736-14 Approval or denial of provider application and notification. (a) DHS, upon finding that a provider applicant meets the requirements for participation in the medicaid program, shall promptly notify the person or entity in writing of the department's approval of the provider's application. The department shall arrange with its fiscal agent to issue to the new provider: (1) A provider code number and instructions regarding the use of that number; (2) A provider manual complete with all letter updates; and (3) Notification of federal and state penalties for fraud. UNOFFICIAL 1736-7 (b) The department shall promptly notify any applicant in writing who does not meet all the requirements for participation. The notice shall state the reasons for the department's denial of the application. The notice shall inform the provider of the provider's right to a fair hearing. The department's fair hearing procedure as provided in subchapter 3 shall be utilized if a hearing is requested. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§431.51, 455.22) §17-1736-15 Requirements for participation in the program by providers. (a) Except for payments authorized to out-of-state providers in emergency situations and to Qualified Medicare Beneficiaries (QMB) only providers, or as authorized under section 17-1736-13, payments under the medical assistance program for goods, care, and services shall be made only to providers approved by DHS to participate in the Hawaii medical assistance program. (b) An individual, institution, or organization shall meet all of the following requirements in order to become and retain eligibility as a provider under the medical assistance program: (1) The provider shall be licensed or approved as follows: (A) The provider, if an individual, shall be licensed to practice the provider's profession in accord with state law. Permits, temporary licenses, provisional licenses, expired or unrenewed licenses, or any form of license or permit which requires supervision of the licensee shall not serve to qualify the licensee as an approved provider of service under the Hawaii medical assistance program; (B) The provider, if a medical or health related institution, shall be certified by the state department of health under applicable public health rules of the state and standards of the federal government. The following shall apply regarding Medicare certification for participation in Medicaid: (i) Hospitals are required to be Medicare certified; (ii) Facilities that provide SNF UNOFFICIAL 1736-8 services are required to be Medicare certified; (iii) Facilities that provide SNF and ICF services, but are not Medicare certified, may participate as an ICF; and (iv) Facilities that provide ICF services only are unable to obtain Medicare certification, therefore, participation as an ICF is allowed. (C) The provider of any other health care services shall comply with standards and all licensure, certification and other requirements as applicable; (2) The provider shall comply with the non-discrimination provisions of Title VI of the Civil Rights Act of l964 (42 U.S.C. §2000d) by not discriminating against program beneficiaries on the basis of race, color, national origin, or mental or physical handicap; and (3) The provider shall accept Medicaid’s established rates of payments whether based on DHS's fee schedule, negotiated rate, reasonable cost reimbursement, or other adopted rates, whichever is applicable, as payment in full for goods, care, or services furnished. The provider shall not require any participation in payment by the Medicaid recipient for goods, care, or services furnished by the provider. The provider shall not demand or receive any additional payment from any Medicaid recipient with the exception of the department's proviso for cost sharing of medical care costs. [Eff 08/01/94; am 02/07/05 ] (Auth: HRS §346-14) (Imp: HRS §346-59; 42 C.F.R. §§440.40, 442.12, 442.101, 447.15, 482.1, 483.1; Pub. L. No. 100-360 §301) §17-1736-16 Provider requirements regarding advance directives. (a) Hospitals, hospices, nursing homes, health maintenance organizations, and other health care facilities that receive funds from medicare or medicaid are required by law (Pub. L. No. 101-508 and chapter 327D, HRS) to have in place a mechanism for advising patients of their legal rights and options for UNOFFICIAL 1736-9 refusing or accepting treatment if they are or become incapacitated. (b) Providers must offer written information as well as summaries of pertinent institutional policies to all adult patients regarding their rights under State laws to accept or refuse treatment and to make advance directives. (1) An advance directive is a document that is written in advance of an incapacitating illness that state a patient's choices about treatment, or name someone to make such choices, if the patient becomes unable to make decisions. (2) Through advance directives such as living wills and durable powers of attorney for health care, patients will be able to make legally valid decisions about their future medical treatment. (3) The patient's medical record must be documented to indicate whether the patient has an advance directive. (c) Institutions may not discriminate against or condition care provided to a patient on the basis of whether the patient has, or has not, executed an advance directive. (d) Institutions must provide (individually or with others) education to staff and community regarding issues associated with advance directives. [Eff 08/01/94 ] (Auth: HRS §346-14, 42 U.S.C. §1396 a(w)) (Imp: HRS §327D) §17-1736-17 Record keeping requirements for providers. (a) In order to determine the correct amount of medicaid program payments due to any provider, and to protect the medicaid program from fraud and abuse, the DHS's representative, agent, investigative and recovery service, the fiscal agent, and the medicaid fraud control unit of the attorney general's office shall have the right to examine, inspect, copy, and if necessary, seize all records of a provider pertaining to medicaid patients which are necessary to fully disclose the type and extent of health care services or supplies provided to eligible medicaid recipients. The provider, for a period of three calendar years, shall maintain thorough records of medicaid patients, including but not limited to the following: UNOFFICIAL 1736-10 (1) Billings and account ledgers; (2) Records of patient appointments; (3) Patient history forms, medical records, diagnosis, and orders prescribed and treatment plans; (4) Records of requests for and results of tests and examinations ordered or furnished; (5) Records of prescriptions, medications, assistive devices, or appliances prescribed, ordered, or furnished; and (6) All records which are necessary to justify the amount of claims for payment which are determined by cost reimbursement or a similar basis, including billing documents showing the cost of services or supplies provided to the recipient. (b) A provider shall make these records available to any duly authorized DHS representative or agent, including the DHS investigative and recovery service, a representative of the fiscal agent, and any representative of the medicaid fraud control unit. These records shall be made available at the provider's place of business during normal business hours or upon agreement of the provider and appropriate representatives of the state at any other mutually convenient time or place. (c) In addition to those records required to be maintained in accordance with subsection (b), institutional providers shall also make available to the agencies specified in subsection (b) records of receipts and disbursements of patient trust funds by the provider, including ledger accounts reflecting credits, debits and balances for each recipient. (d) The records described in subsections (a) and (b) shall be maintained for a period not less than three calendar years. For purposes of this section, a record shall not be counted as three calendar years old until the last entry made in that record is three years old. (e) All records obtained by the state agency, the investigative and recovery service, the fiscal agent or the medicaid fraud control unit, pursuant to this section, shall be maintained in safe keeping and may be used for auditing, scientific examination and writing analysis, photocopying, or testing in any other way, so long as that test does not significantly alter, damage, or destroy the record taken. Records which are not undergoing examination or testing as defined in this UNOFFICIAL 1736-11 subsection and are not intended to be used as evidence in a judicial or administrative hearing by the State shall be immediately returned to the provider. (f) Cost report files of an institutional provider shall contain the following information: (1) Reimbursable cost; (2) Cost finding schedules; and (3) Other financial and statistical data to support reimbursable cost, including: (A) Employment records; (B) Work shift and schedules; and (C) Payroll records of all institutional personnel, owners, and corporate officers. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-40) §17-1736-18 Confidential communications and disclosure requirements for physician and psychologist providers. (a) There is no privilege under this section in any administrative proceeding where the: (1) Competency; (2) Practitioner's license; (3) Provider status; or (4) Practice; of the physician is an issue, including fair hearing criminal cases involving fraud, or civil cases involving over-payment under the medicaid program. However, the identifying data of a patient whose records are admitted into evidence at an administrative hearing shall be kept confidential among the parties to the hearing unless waived by the patient. The administrative agency, board, or commission may close its proceedings to the public to protect a patient's confidentiality. (b) The DHS director may require providers of health care goods and services, including physicians and psychotherapists, to seek written authorization from the med-QUEST administration to provide care, goods, or services to medicaid patients. A provider's request for authorization shall include: (1) The patient's name; (2) A diagnosis of the patient's psychiatric, physical, or psychological condition; (3) Whether or not the patient can work, either part-time or full-time; (4) The number of times the patient has seen the provider over a given prior period; UNOFFICIAL 1736-12 (5) The number of future visits the doctor anticipates needing in order to properly treat the patient; (6) Information on whether the patient is working and if so, whether on a full-time or part- time basis; and (7) Any other information requested by the med- QUEST division which properly relates to the patient's present or prior condition or appropriate care to be rendered to the patient. (c) For purposes of this section, confidential communication shall consist only of the statements made between a physician or psychologist and a patient during a therapy session. The provider's diagnosis, finding, and treatment plan shall not be considered confidential communications. (d) Whenever a provider refuses to disclose unprivileged information to the med-QUEST division, then payment of claims for which the information is lacking may, at the discretion of the director, be denied, or if payment is already made, recovery may be initiated by the department. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §431.10) §17-1736-19 Disclosure by providers and their fiscal agents of information concerning provider's ownership and control. (a) Providers shall disclose to the med-QUEST division the following information upon request: (1) The name and address of each person with an ownership or controlling interest in the provider; (2) The name, address, and ownership or controlling interest which the provider may have in any other entity which also has certification as a provider under the Hawaii medical assistance program or the medicare program; (3) The name of any business, either in the State or elsewhere, whether incorporated or not, in which the provider has a financial or management interest and which is itself a supplier of medical goods, care, or services to any provider certified under the medical assistance program; UNOFFICIAL 1736-13 (4) The name of any business either in the State or elsewhere, whether incorporated or not, in which a blood relative of an individual provider has a financial or management interest and which is itself a supplier of medical goods, care, or services to any provider certified under the medical assistance program; (5) The name of any blood relatives or in-laws of an individual provider who have a financial or management interest in any business concern which is itself a supplier of medical goods, care, or services to any provider certified under the Hawaii medical assistance program; and (6) The name of any blood relative or in-laws of an individual provider who is also a provider certified under the medical assistance program. (b) The provider shall upon discovery of any information required by subsection (a), immediately notify the med-QUEST division in writing of the information required to be provided. (c) If the DHS director, as a result of any of the information provided pursuant to subsection (a), determines in the director's sound discretion that a conflict of interest exists based upon a relationship revealed by a provider pursuant to the requirements of subsection (a), then the DHS director may withdraw certification of the provider until the relationship which creates the conflict of interest is terminated. (d) Failure by any provider to reveal the existence of any relationship specified in subsection (a) shall be grounds for suspension or termination of that provider's certification under the medical assistance program. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.104) §17-1736-20 Provider requirements prior to certification. (a) Prior to certification as a provider under the medical assistance program, a provider must submit to the department full and complete information about: (1) The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the twelve UNOFFICIAL 1736-14 month period ending on the date that certification is requested; and (2) Any significant business transactions between the provider and any supplier of services or goods wholly owned, or between the provider and any subcontractor during the five year period ending on the date of the request for certification. (b) The information required by subsection (a) must be provided within thirty-five days of the date of any request by the secretary of DHHS or the medicaid agency of the State. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.105) §17-1736-21 Disclosure by providers of information on persons convicted of crimes. (a) The provider shall disclose to DHS the identity of any person who has an ownership or controlling interest in the provider, or who is an agent, managing employee, or employee of the provider and who has been convicted of a criminal offense relating to that person's involvement in the medical assistance program, medicare, or any Title XX service program since the start of those programs. (b) DHS shall notify DHHS immediately of any disclosures made pursuant to subsection (a). (c) DHS may refuse to enter into or renew an agreement with a provider if a person with ownership or controlling interest in that provider, or an agent or managing employee of that provider is a person who has been convicted of a criminal offense relating to the person's involvement in a program established under the medical assistance program, medicare, or any Title XX program. (d) DHS may refuse to enter into or may terminate a provider agreement if the full and accurate disclosure requirements under this section are not met by the provider. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.106) §17-1736-22 Cause for suspension or termination of providers. DHS may suspend or terminate a provider from the medical assistance program based upon any one or combination of reasons established in section 17-1736-33(c). [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.l3) UNOFFICIAL 1736-15