Provider Agreements

This section applies to all providers including Family-Directed Community Supports (FDCS). (7-1-26) 01. General. All individuals or entities must enter into a written provider agreement accepted by the Department prior to receipt of any reimbursement for services. Agreements may contain any terms or conditions deemed appropriate by the Department. All provider agreements must be signed by an authorized representative who has the legal authority to bind the provider in the agreement. (7-1-26) 02. Enforcement Actions and Terminations. The Department may take any of the following actions for cause based on the conduct of the provider, or its employees or agents, or when the provider fails to comply with the provider agreement, or any applicable state or federal regulation: (7-1-26) a. Require corrective actions in IDAPA 16.05.07; (7-1-26) b. Require a corrective action plan to be submitted by the provider to address noncompliance with requirements; (7-1-26) c. Reduce, limit, or suspend payment of claims pending the submission, acceptance, or completion of a corrective action plan; (7-1-26) d. Limit or suspend provision of services to participants who have not previously established services with the provider pending the submission, acceptance, or completion of a corrective action plan; or (7-1-26) e. Terminate the provider’s agreement. (7-1-26) i. The Department may terminate provider agreements with or without cause by giving written notice to the provider as set forth in the agreement. (7-1-26) ii. Terminations without cause may result from elimination or change of programs or requirements, or the provider's inability to continue providing services due to the actions of another agency or board. Terminations without cause are not subject to contested case proceedings since the action will either affect a class of providers or will result from the discretionary act of another regulatory body. If an agreement does not provide a notice period, the period is twenty-eight (28) days. (7-1-26) iii. Terminations for cause may be appealed. (7-1-26) 03. Crossover Only Providers. Providers of professional services may enroll as crossover only providers that bill for dual eligible participants’ Medicare coinsurance and deductible. Crossover only providers act as non-billing ORPs for all other participants. (7-1-26) 04. Non-billing Ordering, Referring, and Prescribing (ORP). Providers may enroll as non-billing ORPs, provided they follow the provider application process and sign a provider agreement. Non-billing ORPs are not eligible for reimbursement and are otherwise not Medicaid providers. (7-1-26) 023. – 024. (RESERVED)