Service Providers

PURPOSE: This rule establishes the responsibilities of service providers and outlines the framework of who is eligible to provide care; this includes hospitals and clinics, as well as individual providers of care. (1) Provider Specifications. (A) Eligible children may be approved for hospitalization by contractual agreement in treatment centers. 1. Treatment centers shall have a pediatric unit which meets the requirements of 19 CSR 30-20.021(4)(F)1.–7. 2. Treatment centers shall have open heart surgical facilities and facilities for cardiac catheterization. 3. Treatment centers shall have the capacity for dealing appropriately with neurosurgical conditions requiring emergency services. 4. Treatment centers shall have the capacity for dealing appropriately with all pediatric surgical procedures. 5. Treatment centers shall have the capacity to be designated as pediatric trauma centers. 6. Treatment centers shall have the capacity to provide pediatric specialty outpatient clinics. 7. Treatment centers shall be approved by the Joint Commission on the Accreditation of Hospitals (JCAH) or the American Osteopathic Association (AOA). (B) Special condition centers (SCC) include pediatric rehabilitation units, burn units, orthopedic units, dental units, plastic surgery units and otolaryngologic units and other pediatric facilities which do not have the full capacity of a treatment center, but have the capacity to provide limited or specialized services for Crippled Children’s Service (CCS)-eligible clients. 1. SCCs shall be limited in number, based on geographic and demographic considerations of any given part of Missouri. 2. Eligible children may be approved for hospitalization or outpatient care by contractual agreement for those specific conditions for which the SCCs provide services. 3. Emergency hospital admissions shall be handled as required by 19 CSR 401.020(2)(D). In the event that the SCC is not able to provide adequate hospitalization, the patient shall be stabilized and subsequently transferred to a treatment center which is more fully equipped to deal with the emergency. 4. SCCs shall be approved by JCAH or AOA. (C) CCS-approved physicians shall be certified by or eligible for certification by a specialty or subspecialty practice board recognized by and affiliated with the American Medical Association (AMA) or the AOA. Chiropractors shall be certified by or eligible for certification by a specialty or subspecialty practice board recognized by and affiliated with the Council of Chiropractic Education, the American Chiropractic Association or the International Chiropractic Association. Physicians or chiropractors who are boardeligible shall have two (2) years from the time they are approved to obtain board certification before being discontinued from the CCS list of approved physicians or chiropractors. For certain conditions, the physician or chiropractor is expected to act as an integral part of an interdisciplinary team of physicians or chiropractors and other health professionals to deal with the medical aspects of the condition. These conditions include spina bifida, cleft lip and palate, severe and extensive burns, spinal cord injuries and head trauma with loss of consciousness for more than twenty-four (24) hours. Services shall be provided or supervised by a CCS-approved physician or chiropractor who is a specialist in the condition for which the child is CCSapproved. (D) Therapists include speech therapists, physical therapists and occupational therapists. 1. Therapy must be approved in advance by CCS. When therapy is recommended by the attending physician or interdisciplinary team, CCS authorization is necessary for therapy services not covered by another agency. 2. Therapy services are provided by a CCS-approved therapist. 3. Therapy personnel shall be licensed by their respective boards in Missouri. (E) General dental services are not approved by CCS, except as specified in 19 CSR 40-1.020(2)(C). Specialized dental services are approved for cleft lip and palate and gengevectomy for patients receiving dilantin therapy. CCS-approved specialty dentists must be board-certified or board-eligible and licensed to practice in their specialty areas under section 332.171, RSMo 1986. Dentists who are board-eligible shall have two (2) years from the time they are approved to obtain board certification before being discontinued from the CCS list of approved dentists. (F) Appliances, prostheses and equipment that are approved by CCS are provided by contractual agreement with direct service vendors; approved repairs and replacements are also provided by contractual agreement with direct service vendors. Appliances, prostheses and equipment authorized by CCS include artificial limbs, artificial stock eyes, braces, catheterization supplies, communication devices, dental appliances within orthondontic and prosthodontic limitations, ear molds, hearing aids, ostomy supplies and feeding tubes, respirator equipment, shoes for specific diagnostic criteria, tracheostomy tubes and supplies, wheelchairs, walkers, ambulatory aids and universal cuffs and splints. (G) Outpatient x-ray and laboratory services are authorized if they are directly related to the medical condition the client has been enrolled under. They may be requested by the patient’s attending physician, chiropractor, dentist or interdisciplinary team. Whenever possible, they should be included in the client’s individual care plan (ICP). (H) All outpatient drugs, supplies and equipment costing more than three hundred dollars ($300) must be pre-authorized by CCS. Medication, nutritional formulas and supplies necessary for the treatment of a disease or condition may be provided. (I) Payment for medical services shall be limited to those services available in Mis- souri, except when a client develops specialized needs which cannot be treated in Missouri and must be referred out-of-state. (2) Any person or facility wishing to provide health care for CCS shall complete a provider application. CCS shall notify providers of application approval and make contractual agreements with facilities approved to provide health care. (A) Approved providers shall agree to accept as payments in full, the amounts established by CCS. 1. If a provider receives payment from a source other than CCS which is equal to or exceeds the amount of the program fee schedule for the authorized services rendered, the provider may not seek any additional amount from either the client or the program. 2. Approved providers shall submit bills on forms prescribed by CCS and within the billing time limits negotiated between CCS and its providers. Unless the provider receives a waiver of the time limit from the program administrator or designee, failure to comply with time limits may result in denial of the claim. (B) Approved providers shall submit to the case manager legible and complete medical or chiropractic reports for each service or set of related services authorized by CCS. Failure to submit medical reports may result in termination of provider agreement. 1. Medical reports submitted to CCS are the property of CCS. CCS shall not release the reports except under the following circumstances: A. Reports shall be given to other providers when necessary to assure continuity of treatment or provision of services to the client, if the client consents to the release; and B. Reports shall be used by CCS as necessary to collect for services paid for by CCS from liable third parties. 2. For a client to receive and continue receiving services, the client’s CCS-approved physician or chiropractor shall initiate a proposal for services to be incorporated into the ICP. (C) CCS shall reimburse for diagnostic evaluations or treatment services only if a prior written authorization has been provided. 1. Emergency authorization of reimbursement for treatment service(s) shall be provided by CCS in situations which are determined by the CCS program administrator or designee to have the potential for irrevocable damage, injury or long-term consequences if treatment is not provided immediately. In these instances, CCS shall be notified by the attending physician or hospital within seventy-two (72) hours after admission to a CCS-approved hospital. Eligibility for further authorization shall be determined according to criteria in 19 CSR 401.020(2)(D). 2. Purchase of services related to psychosocial disturbances are excluded, except when attributable to a medical condition for which the client is enrolled. Requests for these services are subject to review by the program administrator or designee. 3. Purchase of services related to educational activities or educational disabilities are excluded. 4. Out-of-state providers are subject to the same fee schedule, time limitations, standards and requirements as in-state providers. AUTHORITY: sections 192.005.2, 201.060, 201.100 and 201.120, RSMo 1986.* This rule was previously filed as 13 CSR 50-160.070. Emergency rule filed Dec. 12, 1984, effective Dec. 22, 1984, expired April 20, 1985. Original rule filed Dec. 12, 1984, effective April 11, 1985. Amended: Filed June 2, 1987, effective Aug. 13, 1987. Amended: Filed Jan. 18, 1989, effective April 27, 1989. *Original authority: 192.005, RSMo 1985; 201.060, RSMo 1959; 201.100, RSMo 1959 and 201.120, RSMo 1959.