Service Providers

PURPOSE: This rule establishes the eligibility requirements and responsibilities of head injury service providers. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material. (1) Any person, organization or agency wishing to provide services shall apply to the Office of Head Injury Services (OHIS). Interested individuals or facilities shall meet eligibility criteria outlined in the Provider Manual published by the Missouri Department of Health, Head Injury Program, June 1993. OHIS shall notify providers of application approval or disapproval and shall make contractual agreements with facilities approved to provide services. (2) Approved providers shall agree to accept the amounts established by OHIS as payments in full. (A) If a provider receives payment from any source other than the OHIS which is equal to or exceeds the amount of the program fee schedule for the authorized services rendered, the provider shall not accept any additional amount from either the client or the program. Claims shall be submitted to any third-party payer (see 19 CSR 401.010(22)) before submitting a claim to the OHIS. (B) Approved providers shall submit bills on forms prescribed by the OHIS and within the billing time limits stated in the Provider Manual. Unless the provider receives a waiver of the time limit from the program administrator or designee, failure to comply with the time limits may result in denial of the claim. (C) The OHIS shall reimburse for services only if a prior written authorization request has been approved. That request completed by the provider shall include a plan of care and assurance that the client/family participated in the plan and agree. (3) Sanctions shall be imposed by the OHIS against a provider for any one (1) or more of the following reasons: (A) The provider knowingly and willfully makes or causes to be made any false statement or misrepresentation of a material fact by presenting or causing to be presented for payment under OHIS any false or fraudulent claim of services or merchandise; submits or causes to be submitted false information for the purpose of obtaining compensation greater than that for which the provider is legally entitled; submits or causes to be submitted false information for the purpose of meeting prior approval status; or submits a false or fraudulent application for provider status; (B) The provider fails to provide and maintain quality services which meet professionally recognized standards of care; (C) The provider violates the terms of the provider agreement; (D) The provider is convicted of a criminal offense relating to performance of a provider agreement with the state or for a negligent or abusive practice resulting in the death or injury of a client; (E) The provider fails to meet licensure or certification standards for participation as a given type of provider; (F) The provider solicits, charges or receives payments for services for which the provider has billed OHIS; (G) The provider is indicted for fraudulent billing practices or for negligent practice resulting in physical, emotional or psychological injury or death to the provider’s client; or (H) The provider fails to repay or to make arrangements for the repayment of identified overpayments or other erroneous payments. (4) One (1) or more of the following sanctions may be invoked against a provider for any violation listed in section (3) of this rule: termination from participation in OHIS; suspension from participation in OHIS; suspension or withholding of payments; or referral for investigation to the State Board of Registration for the Healing Arts or other appropriate state licensing agency. AUTHORITY: sections 199.001 and 199.003, RSMo Supp. 1991 and 199.009, RSMo Supp. 1993.* Original rule filed Feb. 2, 1994, effective July 30, 1994. *Original authority: 199.001 and 199.003, RSMo 1991 and 199.009, RSMo 1991, amended 1993. and Local Health Services and Local Health Services