Denial or Limitations of Applying Provider

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 bases on which enrollment, revalidation, and establishment of a new practice location may be approved, limited, or denied. (1) Missouri Medicaid Audit Compliance (MMAC) may terminate the provider’s enrollment or deny enrollment— (A) Where the provider did not submit timely and accurate information or did not cooperate with screening methods required under applicable statutes and regulations unless the provider cures the failure to comply with this subsection within thirty (30) days of MMAC’s notice that it intends to terminate the provider or deny enrollment; (B) Where the provider or any person with an ownership or control interest has been convicted of or pled guilty to a criminal offense, including any suspended imposition of sentence, any suspended execution of sentence, or any period of probation or parole, related to their involvement with the Medicare, Medicaid, or Title XXI program in the last ten (10) years, unless MMAC determines that denial or termination of enrollment is not in the best interests of the MO HealthNet Program and MMAC documents that determination in writing; (C) Where the provider or any person with an ownership or control interest has been convicted of or pled guilty to a misdemeanor or felony charge, including any suspended imposition of sentence, any suspended execution of sentence, or any period of probation or parole relating to: 1. Endangering the welfare of a child; 2. Abusing or neglecting a resident, patient, or client; 3. Misappropriating funds or property belonging to a resident, patient, or client; or 4. Falsifying documentation verifying delivery of services to a personal care assistance services consumer; (D) Where the provider or any person with an ownership or control interest has been placed on the Family Care Safety Registry as mandated by sections 210.900–210.936, RSMo; or been placed on the Missouri Sex Offender Registry as mandated by sections 589.400–589.425 and 43.650, RSMo; (E) Where the provider is terminated under Title XVIII of the Social Security Act or under the Medicaid Program or Children’s Health Insurance Program (CHIP) of any other state unless MMAC determines that the termination was not for cause, which may include, but is not limited to, fraud, integrity, or quality. Termination or denial of enrollment will not be required if MMAC determines it would not be in the best interests of the MO HealthNet Program and MMAC receives a waiver from the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services pursuant to 42 U.S.C. 1320a-7; (F) Where the provider or a person with an ownership or control interest or who is an agent or managing employee of the provider fails to submit timely or accurate information, unless MMAC determines that termination or denial of enrollment is not in the best interests of the MO HealthNet Program, and MMAC documents that determination in writing; (G) Where the provider, or any person with ownership or control interest, fails to submit fingerprints in a form and manner to be determined by MMAC within thirty (30) days of a request by Centers for Medicare and Medicaid Services (CMS) or MMAC, unless MMAC determines that termination or denial of enrollment is not in the best interests of the MO HealthNet Program, and MMAC documents that determination in writing; (H) Where the provider fails to permit access to provider locations for any site visits under 13 CSR 65-2.020, unless MMAC determines that termination or denial of enrollment is not in the best interests of the MO HealthNet Program, and MMAC documents that determination in writing; (I) Where the provider fails to complete an application for provider direct deposit as required by 13 CSR 70-3.140; (J) Where the provider or a person with an ownership or control interest submitted false information to MMAC; or (K) Where the identity of any provider or person with an ownership or control interest cannot be verified. (2) Denial of enrollment shall preclude any provider or person from submitting claims for payment, either personally or through claims submitted by any clinic, group, corporation, affiliate, partner, or any other association to the single state agency or its fiscal agents for any services or supplies delivered under the MO HealthNet program whose enrollment as a MO HealthNet provider has been denied. Any claims submitted by a nonprovider through any clinic, group, corporation, affiliate, partner, or any other association and paid shall constitute overpayments. (3) No clinic, group, corporation, partnership, affiliate, or other association may submit claims for payment to the MO HealthNet Division or its fiscal agent for any services or supplies provided by a provider or person within each association who has been denied enrollment in the MO HealthNet program. Any claims for payment submitted and paid under these circumstances shall constitute overpayments. (4) Except to the extent inconsistent with this rule, the requirements of 13 CSR 70-3.030 remain in force, including any provisions regarding denial of applications and termination, until those provisions are rescinded. (5) 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. 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.