Provider Enrollment and Application

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, establishing the basis on which providers under the MO HealthNet Program may be approved or denied as a new provider and/or as a revalidating provider, establishing the basis on which a new practice location may be approved or denied, establishing a revalidation requirement for all providers and establishing application and periodic screening requirements. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Enrollment. (A) All persons are required to enroll with MMAC as a billing or performing provider in the MO HealthNet Program if the services or items they provide will be billed to the MO HealthNet Program. (B) For any person to receive payment from the MO HealthNet Program for items or services other than out-of-state emergency services, the billing providers and the performing providers of such items or services must be enrolled providers in the MO HealthNet Program on the date the items or services are provided unless applicable rules or manuals permit enrollment as of an earlier date, up to a maximum of three hundred sixty-five (365) days prior to the actual enrollment date. (C) All claims for payment for items and services that were ordered, prescribed, or referred must contain the National Provider Identifier (NPI) of the provider who ordered, prescribed, or referred such items or services. (D) All persons enrolled as MO HealthNet providers shall abide by the policies and procedures set forth in the MO HealthNet provider manual(s) applicable to the provider’s provider type(s). The MO HealthNet provider manuals are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109 and available at http://manuals.momed.com/manuals/, August 20, 2021. This rule does not incorporate any subsequent amendments or additions. A MO HealthNet provider’s breach of any MO HealthNet provider manual may result in imposition of sanctions, including but not limited to termination. (2) Applications. (A) All applying providers shall have a valid email address and shall submit a MMAC-approved application and any supplemental forms, information, and documentation required by MMAC for the appropriate provider type for which the person is applying. (B) All information and documentation requested in the application and supplemental forms must be provided to MMAC prior to the application being approved. (C) Specific application instructions are modified as necessary for efficient and effective administration of the MO HealthNet Program as required by federal or state laws and regulations. Providers applying on or after the promulgation of this rule should refer to the appropriate MMAC application filing instructions, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, Missouri Medicaid Audit and Compliance Unit, 205 Jefferson Street, Second Floor, Jefferson City, MO 65109, at its website mmac.mo.gov, August 20, 2021. This rule does not incorporate any subsequent amendments or additions. (D) The application shall include all information required in the mandatory disclosures pursuant to section (3) of this rule. Upon submission of any application(s), supplemental form(s), information and documentation requested in the application(s) and supplemental form(s), MMAC may, at its discretion, request additional or supplemental information and documentation from the applying provider prior to considering the application and/or conducting screening pursuant to this rule in order to clarify any information previously submitted and to verify that the provider meets all applicable requirements of state or federal laws and regulations. (3) All providers, fiscal agents, managed care entities, and persons with an ownership or control interest in the provider are required to disclose as follows: (A) The following disclosures are mandatory: 1. The name and address of the applying provider and any person(s) with ownership in the provider. The address must include the provider’s primary business address, each additional practice location(s), and any corresponding PO Box addresses; 2. Dates of birth and Social Security numbers (in the case of a corporeal person); 3. Other tax identification number(s) of any person with ownership in the provider or in any subcontractor in which the provider has a five percent (5%) or more interest; 4. Whether any person with ownership in the applying provider is related to another person with ownership in the provider as a spouse, parent, child, or sibling; 5. Whether any person with ownership in any subcontractor in which the provider has a five percent (5%) or more interest is related to another person with ownership in the provider as a spouse, parent, child, or sibling; 6. The name of any other provider(s) in which an owner of the applying or enrolled provider has ownership; and 7. The name, address, date of birth, and Social Security number of any managing employee of the provider; (B) Disclosures from any provider are due at the following times, and must be updated within thirty (30) days of any changes in information required to be disclosed: 1. Upon initial enrollment, reenrollment, or revalidation; and 2. Upon request of MMAC; (C) Disclosures from fiscal agents are due at the following times: 1. Upon the fiscal agent submitting a proposal; 2. Upon request of MMAC; 3. Ninety (90) days prior to renewal or extension of a contract; and 4. Within thirty (30) days after any change in ownership of the fiscal agent; (D) Disclosures from managed care entities (managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, and health insuring organizations), except primary care case management programs, are due at the following times: 1. Upon the managed care entity submitting a proposal; 2. Upon request of MMAC; 3. Ninety (90) days prior to renewal or extension of the contract; and 4. Within thirty (30) days after any change in ownership; (E) Disclosures from Primary Care Case Management Programs (PCCM). PCCMs will comply with disclosure requirements under subsection (B) of this section; (F) All disclosures must be provided to MMAC. Disclosures not made to MMAC will be deemed non-disclosed and not in compliance with this section; and (G) Administrative action(s) for failure to provide required disclosures. 1. Any person’s failure to provide, or timely provide, disclosures pursuant to this section may result in deactivation, denial, rejection, suspension, or termination of the provider’s participation in the MO HealthNet program. If the failure is inadvertent or merely technical, MMAC may choose not to impose administrative actions if, after notice, the provider promptly corrects the failure. (4) Provider Revalidation. (A) All providers shall revalidate their enrollment with the MO HealthNet Division at least every five (5) calendar years from the effective date of the provider’s most recently executed provider agreement, in order to remain a MO HealthNet provider. For example, a provider whose initial or revalidated provider agreement was effective on March 1, 2020, is required to revalidate their enrollment no later than March 1, 2025. MMAC may request that the provider revalidate on an off-cycle revalidation period. (B) The MMAC-approved revalidation application, supplemental forms, information, and documentation requested by MMAC, along with the application fee and/or hardship waiver request, if applicable, shall be submitted no later than one hundred twenty (120) days prior to the expiration of the effective provider agreement. (C) Revalidating providers must comply with the requirements of this rule and will be subject to the screening process noted in this rule in order to have their applications for revalidation approved. (5) Application Fee. (A) An application fee, hardship waiver request, and/or an exemption reason provided in this rule must accompany every organizational provider’s application. (B) The application fee must be in the form of a cashier’s check, money order, or an electronic payment acceptable to MMAC and for the correct application fee amount in effect as of the date of receipt by MMAC. (C) Failure to submit the application fee in an acceptable form and/or for the correct amount may result in the return of the fee to the provider and rejection of the application. (D) Applying and revalidating providers must submit an application fee, determined as follows: 1. As of the effective date of this rule for calendar year 2021, five hundred ninety-nine dollars ($599.00); and 2. For calendar year 2022 and subsequent years— A. The amount of the application fee shall be the amount for the preceding year adjusted by the percentage change in the consumer price index for all urban consumers for the twelve- (12-) month period ending with June of the previous year as published by the Bureau of Labor Statistics of the United States Department of Labor. (E) If MMAC determines that a person is an organizational provider, that person is required to pay the application fee. (F) Exemptions from Application Fee. MMAC may waive the application fee under the following conditions: 1. Providers who are enrolled in and paid the application fee required by CMS for Medicare or another state’s Title XIX or Title XXI program within two (2) years of the date the application to enroll as a MO HealthNet Provider shall be exempt from paying an application fee; 2. MMAC, in consultation with other state of Missouri departments, divisions, and units, determines that imposition of the application fee would impede Missouri Medicaid participants’ access to care; 3. A provider is submitting a provider application as a result of a national or state public health emergency situation as lawfully declared by a federal or state authority; and 4. The provider is owned and operated by the state of Missouri or an agency of the state of Missouri. (G) Providers seeking an exemption from the application fee are responsible for notifying MMAC, in writing, that they qualify for exemption and for providing proof of such qualification. (6) Hardship Waiver Request. (A) Providers can request a hardship waiver of the application fee from the Centers for Medicare and Medicaid (CMS) when submitting their initial enrollment application or a revalidation application, but the request must be received by MMAC before the application will be processed by MMAC. A hardship waiver request will not be considered if it is received by MMAC after MMAC approves the application or revalidation. If CMS approves the hardship waiver, MMAC will refund the application fee to the provider. (B) A provider that requests a hardship waiver must submit a letter and supporting documentation that describes the hardship and why the hardship justifies an exception, including providing comprehensive documentation (which may include, but is not limited to, historical cost reports, recent financial statements such as balance sheets and income statements, cash flow statements, or tax returns). (C) Factors that may suggest a hardship exception is appropriate include but are not limited to the following: 1. Considerable bad debt expenses; 2. Significant amount of charity care/financial assistance furnished to patients; 3. Presence of substantive partnerships with those who furnish care to a disproportionately low-income population; 4. Whether an institutional provider receives considerable amounts of funding through disproportionate share hospital payments; or 5. 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. (D) Upon receipt of a hardship waiver request with an application, MMAC will send the request and all accompanying documentation to CMS. CMS will determine if the request should be approved. CMS will communicate its decision to the institutional provider and MMAC via letter. (7) Appeal of the Denial of a Hardship Waiver Request. A provider may file a written reconsideration request with CMS within sixty (60) calendar days from the date of the notice of initial determination. The request must be signed by the individual provider, a legal representative, or any authorized official within the entity. The procedures for submitting an appeal will be provided on the denial letter from CMS. (8) MMAC shall use the application fee to offset the costs associated with the provider screening program in its entirety. This includes but is not limited to the following: (A) Implementation and augmentation of MMAC’s provider enrollment system; and (B) Any other administrative costs related to the provider screening program, which include costs associated with processing fingerprints and conducting criminal background checks. The application fee does not cover the cost associated with capturing fingerprints and a provider may be charged additional costs for this purpose in addition to the application fee. (9) Refund of the Application Fee. (A) If an institutional provider is granted a hardship exception pursuant to this rule or if the application is rejected because it was not properly signed or is missing other information required to be provided on the application itself, and an application fee was included with the application and the hardship waiver request, the application fee shall be returned to the applying provider. (B) Once the screening process has begun, regardless whether the application goes through part or all of the screening process, the application fee is non-refundable. (10) Screening. (A) The screening requirements contained in this section apply to all applying providers and to all persons disclosed, or required to be disclosed, in the application. (B) MMAC shall conduct pre-enrollment screening and post-enrollment monthly screenings. Screenings may include the following: 1. Screening pursuant to 42 CFR sections 455.410(a) and (b), 42 CFR 455.412, 42 CFR 455.432, 42 CFR 455.436, and 42 CFR 455.452; 2. Screening to ensure that the providers meet all enrollment criteria for their provider type; 3. Announced or unannounced pre- and post-approval site visits; and 4. For screening purposes, utilization of databases and other sources of information to prevent enrollment of fictitious providers, to ensure that spurious applications are not processed, and to prevent fraud, waste, and abuse in the MO HealthNet Program. (C) The screening procedures and requirements are applicable to all enrolled or applying providers. All providers are required to revalidate their MO HealthNet enrollment(s) at least every five (5) years. (D) The following screening categories are established for MO HealthNet providers, as required by federal law and regulation for Medicare and Medicaid providers under 42 CFR section 424.518 and section 1902(kk)(1) of the Social Security Act. There are three (3) levels of screening: limited, moderate, and high. Each provider type is assigned to one (1) of these screening levels. If a provider could fit within more than one (1) screening level described in this section, the highest risk category of screening is applicable. 1. Limited Risk Category. A. The following providers pose a limited risk of fraud, waste, and abuse to the MO HealthNet Program and are subjected to limited category screening: (I) Physicians or non-physician practitioners (except as otherwise listed in another risk category) and medical groups or clinics; (II) Ambulatory surgical centers (ASCs); (III) Competitive acquisition program/Part B vendors; (IV) End-stage renal disease (ESRD) facilities; (V) Federally qualified health centers (FQHCs); (VI) Histocompatibility laboratories; (VII) Home infusion therapy suppliers; (VIII) Hospitals, including critical access hospitals (CAHs); (IX) Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act; (X) Mammography screening centers; (XI) Mass immunization roster billers; (XII) Opioid treatment programs (if 42 CFR 424.67(b)(3)(ii) applies); (XIII) Organ procurement organizations (OPOs); (XIV) Pharmacies; (XV) Radiation therapy centers (RTCs); (XVI) Religious nonmedical health care institutions (RNHCIs); (XVII) Rural health clinics (RHCs); and (XVIII) Skilled nursing facilities (SNFs). B. The providers in the limited category are subject to the following screening requirements: (I) Verification that the applying provider, and all persons disclosed or required to be disclosed, meet all applicable federal regulations and MO HealthNet Program requirements for the provider type; (II) Verification that the applying provider, and all persons disclosed, have a valid license, operating certificate, or certification if required for the provider type, and that there are no current limitations on such licensure, operating certificate, or certification which would preclude enrollment; (III) Verification that the applying provider’s, and that of all persons disclosed, license(s) held in any other state has/have not expired and that there is/are no current limitations on such license(s) which would preclude enrollment; (IV) Confirmation of the identity of the applying provider and determination of the exclusion status of the applying provider and any person with an ownership or control interest or who is an agent or managing employee of the provider through routine checks of the following federal databases: (a) Social Security Administration’s Death Master File; (b) National Plan and Provider Enumeration System; (c) List of Excluded Individuals/Entities; (d) The Excluded Parties List System; (e) Medicare Exclusion Database; and (f) Any such other databases as the Secretary of the United States Department of Health and Human Services has prescribed as of September 30, 2021, pursuant to section 455.436 of Title 42, Code of Federal Regulations, which is incorporated by reference and made part of this rule as published by the Office of the Federal Register, 7 G Street NW, Suite A-734, Washington, DC 20401, and available at its website https://www.ecfr.gov/current/title42/chapter-IV/subchapter-C/part-455/subpart-E/section-455.436. This rule does not incorporate any subsequent amendments and additions. (V) Database check of the National Sex Offender Public Website; (VI) The information from these databases shall be used to determine eligibility of the MO HealthNet provider and for verification of the identity of the applying person, the Social Security number, the National Provider Identifier (NPI), the National Practitioner Data Bank (NPDB) licensure, and any exclusion by the Department of Health and Human Services, Office of Inspector General; and (VII) MMAC may conduct preapproval site visits prior to acceptance of an applying provider’s application. 2. Moderate Risk Category. A. The following providers pose a moderate risk of fraud, waste, and abuse to the MO HealthNet Program and are subject to moderate screening requirements: (I) Adult Day Care providers (ADCs); (II) Ambulance service suppliers; (III) Community Mental Health Centers (CMHCs); (IV) Comprehensive outpatient rehabilitation facilities (CORFs); (V) Entities established under sections 205.968-205.973, RSMo; (VI) Hospice organizations; (VII) Independent clinical laboratories (ICLs); (VIII) Independent diagnostic testing facilities (IDTFs); (IX) Non-emergency transportation providers (NEMTs); (X) Personal care providers, including providers billing under the Consumer Directed Services program; (XI) Physical therapists including physical therapy groups; (XII) Portable X-ray suppliers (PXSs); (XIII) Revalidating Diabetes Prevention Program providers (DPPs); (XIV) Revalidating durable medical equipment suppliers (DMEPOS); (XV) Revalidating home health agencies (HHAs); and (XVI) Revalidating opioid treatment programs. B. In addition to the screening requirements for the limited risk category in paragraph (10)(D)1., the providers in the moderate risk category shall be subject to site visits prior to acceptance of an applying provider’s application and are additionally subject to unannounced post-enrollment site visits. 3. High Risk Category. A. The following providers pose a high risk of fraud, waste, and abuse to the MO HealthNet Program and are subject to high risk screening requirements: (I) Newly enrolling or reenrolling home health agencies; (II) Newly enrolling or reenrolling Durable Medical Equipment, Prosthetic, Orthotic, and Supplies (DMEPOS) suppliers; (III) Newly enrolling or reenrolling DPP suppliers; and (IV) Newly enrolling or reenrolling opioid treatment programs that have not been fully and continuously certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) since October 23, 2018. B. In addition to the screening requirements for the limited and moderate risk categories in paragraphs (10)(D)1. and 2. of this rule, the providers and their owners must submit to a fingerprint-based criminal history report check of the Federal Bureau of Investigations (FBI) Integrated Automated Fingerprint Identification System— (I) A revalidating provider who has already submitted fingerprints once will not be required to submit fingerprints a second time unless required by FBI protocols; (II) Pursuant to 42 CFR section 455.434(b), the provider is responsible for the cost of supplying the fingerprints and the state and federal government will share the cost of the processing of the fingerprints and the background check; and (III) This fingerprint-based criminal history report check applies to all persons in this risk category applying to be a provider (whether as a billing or performing provider), or an individual with a five percent (5%) or greater direct or indirect ownership interest in such provider, or a managing employee. (E) MMAC must adjust the categorical risk level from “limited” or “moderate” to “high” when any of the following occurs: 1. MMAC imposes a payment suspension on a provider based on a credible allegation of fraud, waste, or abuse by the provider; the provider has an existing Medicaid overpayment; or the provider has been excluded by the Department of Health and Human Services, Office of Inspector General or another state’s Medicaid program within the previous ten (10) years. The upward adjustment of the provider’s categorical risk level for a payment suspension or overpayment shall continue only so long as the payment suspension or overpayment continues; or 2. MMAC or CMS in the previous six (6) months lifted a temporary moratorium for the particular provider type and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider at any time within six (6) months from the date the moratorium was lifted. (F) If a person has been screened by Medicare or by another state Medicaid agency and paid Medicare or another state Medicaid agency’s application fee, within two (2) years of the date of the application to MMAC, such person will not be subject to the screening requirements or application fee provided for by this rule except those screening requirements and application fee imposed pursuant to subsection (E) of this section. (G) Any MO HealthNet Program provider not categorized by this regulation as within the limited, moderate or high risk category shall be a considered moderate risk and screened as a moderate risk. (H) MMAC may request and consider additional information or documentation related to the eligibility criteria, if at any time during the application process it appears that the enrollment application or supporting documentation is inaccurate, incomplete, or misleading; or it appears the applying person may be ineligible to become a MO HealthNet provider. (11) The provider shall advise MMAC, in writing, on enrollment forms specified by MMAC, 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. (A) The Provider Enrollment Unit within MMAC 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. A provider may be subject to administrative action if information is withheld at the time of application that results in a new provider number being created in error. The division shall issue payments to the entity identified in the current MO HealthNet provider enrollment application. Regardless of changes in control or ownership, MMAC shall recover from the entity identified in the current MO HealthNet provider enrollment application liabilities, sanctions, and penalties pertaining to the MO HealthNet program, regardless of when the services were rendered. (12) 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. (13) The provisions of this rule are declared severable. If any provision of this rule is held invalid by a court of competent jurisdiction, the remaining provisions of this rule shall remain in full force and effect, unless otherwise determined by a court of competent jurisdiction to be invalid. (14) Except to the extent inconsistent with this rule, the requirements of 13 CSR 703.030 remain in force, including any provisions regarding denial of applications and termination, until those provisions are rescinded. AUTHORITY: sections 208.159 and 660.017, RSMo 2016.* Original rule filed Dec. 12, 2013, effective July 30, 2014. Amended: Filed May 26, 2015, effective Nov. 30, 2015. ** Emergency amendment filed March 11, 2022, effective March 30, 2022, expired Sept. 26, 2022. Amended: Filed March 11, 2022, effective Oct. 30, 2022. *Original authority: 208.159, RSMo 1979, and 660.017, RSMo 1993, amended 1995. **Pursuant to Executive Order 21-07, 13 CSR 65-2.020, section (5) and subsections (9)(B) and (9)(F) was suspended from March 19, 2020 through April 13, 2021.