Standards for Reimbursement for Providers and Other Eligible Persons

Section 1200.150  Standards for Reimbursement for Providers and Other Eligible Persons a)         In order to receive reimbursement by DSCC for covered supports and services and diagnostic services rendered to an applicant or recipient child, a provider shall: 1)         Hold a valid, appropriate license, certification, accreditation, or credentials required by the state where the covered support and service or diagnostic service is rendered; 2)         Not be excluded from participation in Medicare, Medicaid or any other federal or State healthcare program; 3)         Meet any other requirements imposed as a condition of receiving Title V funds and comply with the requirements of applicable federal and State laws and not engage in practices prohibited by those laws; 4)         Have a provider agreement on file with DSCC; 5)         Accept as payment in full the amounts paid by DSCC and not seek further payment from the LRA beyond copayments and deductibles when DSCC does not pay the copayments or deductibles; 6)         Furnish to DSCC or designee, in the form and manner requested by it, any information it requests regarding payments for covered supports and services or diagnostic services, including but not limited to dates of service, appropriate ICD diagnostic codes, current procedural terminology (CPT) codes, HCPCS National Level II codes, American Dental Association (ADA) codes, National Drug Codes (NDC) and as available, explanations of benefits from non-federally or non-State funded third party payers; 7)         Notify DSCC in writing immediately when there is a change in meeting any requirement or information previously submitted by the provider; 8)         Comply with any audits by DSCC, State or federal government in connection with the DSCC Program; and 9)         Comply with the applicable requirements of Section 1200.50. b)         DSCC shall be the payer of last resort for covered supports and services and diagnostic services. Payment shall not be made until insurance or any other third party payer has paid or rejected the claim. 1)         The provider or other person eligible to receive payment shall submit claims or invoices to any third party payers liable for payment prior to billing DSCC. 2)         DSCC is not required to pursue third party liability payments from State or federally funded healthcare programs, including but not limited to Medicaid, All Kids, CHIP or Medicare. 3)         The Director or designee may waive the DSCC third party payer status if necessary to avoid undue suffering or to preserve life and good health and if immediate payment will cause DSCC funds to be utilized in the most efficient and effective fashion, all as determined based on usual and customary medical standards. c)         Subject to all the limits on benefits contained in this Part, DSCC will pay the cost of care coordination services, covered supports and services, and diagnostic services above that reimbursed by a third party payer up to an established rate of payment.  When third party payments exceed the DSCC payment maximums, the bill shall be considered paid in full. d)         In order to be eligible for payment consideration, an initial claim or bill, or a claim or bill resubmitted following prior rejection, must be received timely by DSCC, but no later than 18 months from the date when covered supports or services or diagnostic services are provided. Failure to comply with this subsection shall result in no payment by DSCC. DSCC shall have no liability for any payment of these late claims.  Providers who fail to comply with this subsection shall also not seek payment from the applicant child, recipient child, or LRA. The requirements of this subsection may be waived by the Director or designee for good cause shown. e)         The DSCC Program is not an entitlement and shall not be construed as an entitlement. DSCC shall not be liable for any benefits, including those DSCC authorized prior to the unavailability of funds. A provider's rendering of goods and services in excess of the funds available may result in no payment by DSCC. (See Section 1200.10(a)(4).)  For recipient children, the Director or designee shall establish maximum dollar amounts for payment of covered supports and services and diagnostic services per State fiscal year (July 1 through June 30). The maximum dollar amount for each recipient child shall be based on how many recipient children receiving financial assistance are in the program and the amount of State and federal annual appropriations available, combined with other restraints on DSCC's resources. DSCC shall inform the LRA and any provider who may be affected of the limit that may result in no payment by DSCC. (See also Section 1200.10(a)(4).) f)         DSCC may request providers to submit updated enrollment information.  Failure of a provider to submit this information within the requested time frames may result in the disenrollment of the provider from the DSCC Program. Disenrollment shall have no effect on the future eligibility of the Provider to participate and is intended only for purposes of DSCC's efficient administration. A disenrolled provider may reapply to the DSCC Program. g)         Providers and other eligible persons who fail to meet the requirements of this Section shall not be eligible for payment by DSCC for care coordination services, covered supports and services, and diagnostic services.