Definitions

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, defining the terms used in the rules of the Missouri Medicaid Audit and Compliance Unit. (1) Affiliates means persons having an overt, covert, or conspiratorial relationship so that any one (1) of them directly or indirectly controls or has the power to control another. (2) Agent means any person who has been delegated the authority to obligate or act on behalf of a provider. (3) Application shall include: (A) Enrollment application to become a MO HealthNet Program provider; (B) Revalidation application to remain a MO HealthNet Program provider; (C) New practice location application; (D) Provider direct deposit application; (E) Change of ownership application; (F) Hardship waiver request; or (G) Other information Missouri Medicaid Audit and Compliance (MMAC) needs, under applicable federal or state laws and regulations as they pertain to the Medicaid program, in order to enroll a MO HealthNet Program provider. (4) Application fee means a fee required to be paid by a MO HealthNet Program institutional provider at the time of— (A) Initial application; (B) Revalidation application; (C) Change of ownership application; or (D) New practice location application. (5) Applying provider means any person submitting an application as defined in section (3) above. (6) Approve/approval as to a billing provider means the billing provider has been determined to be eligible under Medicaid rules and regulations to receive a Medicaid billing number and be granted Medicaid billing privileges. (7) Approve/approval as to a performing provider means the performing provider has been determined to be eligible under Medicaid rules and regulations to receive a non-billing Medicaid number. (8) Best interests of the MO HealthNet Program shall include consideration of the following factors: (A) Ensuring reasonable access to MO HealthNet Program services; (B) Promoting health, safety, and welfare of participants; (C) The provider’s history of compliance with applicable rules and regulations related to the MO HealthNet Program; and (D) Any other factors related to MO HealthNet Program integrity. (9) Billing provider means a provider or supplier who is authorized to bill the MO HealthNet Program for items or services provided to Medicaid participants. Billing provider includes providers who are authorized to bill Medicaid for items or services provided by performing providers. (10) Closed-end provider agreement means an agreement which is for a specific period of time not to exceed twenty-four (24) months and which must be renewed in order for the provider to continue to participate in the Missouri Medicaid Program. (11) Conviction or convicted means that— (A) A judgment of conviction has been entered by a federal, state, or local court, regardless of whether an appeal from that judgment is pending; (B) A person has pled guilty to a criminal offense; or (C) A person is serving any period of probation or parole, regardless of any suspended imposition of sentence or suspended execution of sentence resulting from that offense. (12) Deactivate means that the provider’s participation in the MO HealthNet program is stopped. (13) Deny/denial means the applying provider has been determined to be ineligible under Medicaid rules and regulations to participate in the MO HealthNet program. (14) Department means the Department of Social Services or its designated divisions or units. (15) Enroll/enrollment means the process that MMAC uses to establish eligibility to participate as a provider in the MO HealthNet program. The process includes: (A) Identification of a provider and any owners; (B) Validation of the provider’s qualifications to meet program requirements; (C) Screening the provider and owners through all required federal and state databases; (D) Identification and confirmation of the provider’s practice location(s) and owner(s); and (E) Granting the provider a MO HealthNet number. (16) Enrollment application means a MMAC approved paper enrollment application or a MMAC approved electronic enrollment process. (17) Exclusion from participation in a federal health care program (e.g., Medicare and Medicaid) is a penalty imposed on a provider by the Office of Inspector General (OIG) under section 1128 or 1128A of the Social Security Act. States may also exclude providers from their Medicaid Programs under state law or pursuant to 42 CFR section 1002.2. (18) Federal health care program means a program as defined in section 1128B(f) of the Social Security Act. (19) Fiscal agent means an organization under contract to the state of Missouri for providing services related to the administration of the MO HealthNet Program. (20) Hardship means a financial condition in which paying the application fee would impose a significant financial burden on the provider, and the provider is otherwise eligible to be a MO HealthNet Program provider. Other factors which may indicate that a hardship exists include: (A) Considerable bad debt expenses incurred by the provider; (B) Considerable amount of charity care/financial assistance furnished to patients; (C) Presence of substantive partnerships (whereby clinical, financial integration are present) with those who furnish medical care to a disproportionately low-income population; (D) Whether an institutional provider receives considerable amounts of funding through disproportionate share hospital payments; or (E) Whether the provider is enrolling in a geographic area that is a presidentially declared disaster area under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. sections 51215206 (Stafford Act). (21) Hardship waiver request means a request submitted to MMAC (defined below) along with the provider application requesting that the application fee be waived due to hardship, detailing the hardship, and providing any documentation in support of the hardship waiver request. (22) Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity. (23) Limited provider agreement means an agreement with an applying provider which has been accepted as a MO HealthNet Program provider by MMAC (defined below) conditional upon the applying provider performing services, delivering supplies, or otherwise participating in the program only in adherence to, or subject to, specially set out conditions agreed to by the applying provider prior to enrollment. (24) Managed care entity means managed care organizations (MCOs), pre-paid inpatient health plans (PIHPs), pre-paid ambulatory health plans (PAHPs), primary care case management (PCCMs), and health improvement organizations (HIOs) or any similar managed care program type created by the state Medicaid agency. (25) Managing employee means an owner, member, partner, director, general manager, business manager, administrator, school district superintendent, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider, either under contract or through some other arrangement, whether or not the individual is a W–2 employee of the provider. (26) Medicaid agency or the agency means the single state agency administering or supervising the administration of the state Medicaid plan. (27) Missouri Medicaid Audit and Compliance Unit (MMAC) means the unit within the Department of Social Services that is responsible for program integrity and compliance in the Medicaid Title XIX, CHIP Title XXI, and Waiver Programs in Missouri, which includes the enrollment and auditing of MO HealthNet providers and Medicaid participants through the lock-in program. MMAC is charged with the responsibility of detecting, investigating, and preventing fraud, waste, and abuse of the Missouri Medicaid Title XIX, CHIP Title XXI, and Waiver Programs. (28) Medical assistance benefits means those benefits authorized to be provided by Chapter 208, RSMo. (29) MO HealthNet Program means programs operated pursuant to Title XIX of the Social Security Act, Title XXI of the Social Security Act, and/or waiver programs authorized by the United States Department of Health and Human Services. (30) MO HealthNet means the division within the department, pursuant to sections 208.001 and 208.201, RSMo, that administers the Medicaid Title XIX, CHIP Title XXI, and waiver programs, approves claims from MO HealthNet providers for services or merchandise provided to eligible Medicaid participants, and authorizes and disburses payment for those services or merchandise accordingly. (31) The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use NPIs in administrative and financial transactions adopted under HIPAA. (32) Network Provider means any provider, group of providers, or entity that has a network provider agreement with a MCO, or a subcontractor, and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of the state’s contract with an MCO. A network provider is not a subcontractor by virtue of the network provider agreement. (33) Open-end provider agreement means an agreement that has no specific termination date and continues in force as long as it is agreeable to both the state Medicaid agency and the enrolled provider. (34) Organizational provider is a non-corporeal provider. Individual physicians or other individually licensed practitioners are not institutional providers. Organizational provider includes, but is not limited to: (A) Ambulance service suppliers, health clinics, hospitals, pharmacies, and skilled nursing facilities; (B) Other organizational entities that bill the MO HealthNet Program on a fee-for-service basis, such as personal care agencies, nonemergency transportation providers, residential care facilities, adult day care facilities, assisted living facilities, residential treatment centers, providers billing under the Consumer Directed Services Program or entities established under sections 205.968205.973, RSMo; and (C) Any other types of non-corporeal MO HealthNet Program providers consistent with the state plan, the Waiver Program, and CHIP Title XXI. (35) Other disclosing entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under Title V, XVIII, or XX of the Act. This includes: (A) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization (meaning all MCOs) that participates in Medicare (Title XVIII); (B) Any Medicare intermediary or carrier; and (C) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under Title V or Title XX of the Act. (36) Participant means a person who is eligible to receive benefits allocated through the department as part of the MO HealthNet Program. (37) Participation means the ability and authority to provide services or merchandise to eligible MO HealthNet participants. (38) Performing provider means a provider or supplier who provides items or services to Medicaid participants, but who does not directly bill or receive payment from the MO HealthNet Program. Performing provider can also include referring, ordering, prescribing, and/or attending physicians, and non-physician practitioners. (39) Person means any corporeal person or individual; or any legal or commercial entity, including but not limited to, any partnership, corporation, not-for-profit, professional corporation, business trust, estate, trust, limited liability company, association, joint venture, governmental agency, or public corporation. (40) Person with an ownership or control interest, as defined in sections 1124 and 1124A(a) of the Social Security Act, means a person or corporation that— (A) Has an ownership interest totaling five percent (5%) or more in a disclosing entity; (B) Has an indirect ownership interest equal to five percent (5%) or more in a disclosing entity; (C) Has a combination of direct and indirect ownership interests equal to five percent (5%) or more in a disclosing entity; (D) Owns an interest of five percent (5%) or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five percent (5%) of the value of the property or assets of the disclosing entity; (E) Is an officer or director of a disclosing entity that is organized as a corporation; (F) Is a partner in a disclosing entity that is organized as a partnership; or (G) Is a managing employee. (41) Practitioner means a physician or other individual licensed under state law to practice his or her profession. (42) Provider means billing and performing providers and includes any person that enters into a contract or provider agreement with MMAC for the purpose of providing items or services to Missouri Medicaid participants. Provider includes ordering, referring, prescribing, and/or attending physicians, and non-physician practitioners. (43) Provider agreement means an agreement with MMAC which authorizes a provider to furnish items or services to eligible Missouri Medicaid participants. (44) Provider application means the MMAC approved application and supplemental forms required to be submitted for the purpose of becoming a MO HealthNet Program provider, containing information and documentation requested by MMAC. (45) Provider direct deposit means a form specified by MMAC and submitted by a provider of Medicaid Title XIX, CHIP Title XXI, or Waiver Program services for the purpose of having Missouri Medicaid checks automatically deposited to an authorized bank account. (46) Reject/rejected means that the provider’s enrollment application was not approved due to incomplete or incorrect information, failure to submit an application fee, or the applying provider is not eligible to participate in the MO HealthNet Program. (47) Revalidation means the requirement that all existing providers must go through an application process to verify their enrollment information is current, and they are still eligible to participate in the MO HealthNet Program. (48) Revalidation application means an approved MMAC revalidation application and supplemental forms which are required to be submitted by all existing providers, containing all information and documentation requested by MMAC under applicable federal or state laws and regulations, and submitted at the time revalidation is required pursuant to this rule. (49) Site visit may include any or all of the following: (A) Physical visit to, and inspection of, the premises of the provider or a beneficiary’s home if the provider has no central operational facility; (B) Obtaining photographs of the provider or the provider’s business for inclusion in the provider’s enrollment file; (C) Full documentation of observations made at the provider’s premises including such facts as: 1. The facility was vacant and free of all furniture; 2. A notice of eviction or similar documentation is posted at the facility; and 3. The premises are not occupied by the provider, but by another person; (D) A written report of the findings regarding each site visit; (E) Verification that the facility is operational, open for business, and staff is present; (F) Verification that customers are present at the facility where appropriate for the provider type; (G) Acceptance of attestation with documentation when deemed appropriate by MMAC and consistent with applicable federal or state laws and regulations; or (H) Acceptance of proof of a recent site visit under the Medicare program or other state Medicaid program when deemed appropriate by MMAC and consistent with applicable federal or state laws and regulations. (50) State plan means a document completed by the state of Missouri to tell the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) how the state will administer the MO HealthNet Program according to federal laws and regulations. (51) Subcontractor means— (A) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or (B) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement. (52) Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm). (53) Suspension from participation means a provider is not authorized to provide MO HealthNet Program services for a specified or indefinite period of time. (54) Suspension of payments means withholding of MO HealthNet Program payments otherwise due to a provider for a specified or indefinite period of time. (55) Termination means the department’s discontinuation of a provider’s participation in the MO HealthNet program. (56) Voluntary termination means that a provider submits written confirmation to MMAC of its decision to discontinue participation in the MO HealthNet Program. (57) Waiver program means programs authorized in section 1915 of the Social Security Act (or other waiver programs authorized by federal law). (58) Written notice means a notice to the address of the provider as listed in MMAC’s system, in writing, transmitted via the US mail, other public or private service for the delivery of correspondence, packages, or other things, facsimile, e-mail, or any other method/mode of transmittal that is deemed by MMAC to be an efficient, cost-effective, verifiable, and reliable method/mode of communication with the provider or applying provider. AUTHORITY: sections 208.159 and 660.017, RSMo 2016.* Original rule filed Dec. 12, 2013, effective July 30, 2014. Amended: Filed Aug. 20, 2021, effective March 30, 2022. *Original authority: 208.159, RSMo 1979, and 660.017, RSMo 1993, amended 1995.