Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 4 - Provider Enrollment › Rule 23-200-4.2 - Conditions of Participation

Current through June 25, 2024
A. Providers must
				comply with the following conditions to participate in the Mississippi Medicaid
				program:
1. All providers must complete
				provider agreements and/or provider enrollment application packages per the
				requirements of the Division of Medicaid.
2. The provider must be licensed and/or
				certified by the appropriate federal and/or state authority, as
				applicable.
3. Agree to furnish
				required documentation of the provider's business transactions per
				42
				C.F.R. §
											455.105(b) to
				the Division of Medicaid or to the Department of Health & Human Services
				(HHS) within thirty-five (35) days of the date on the request.
4. Agree to abide by the requirements of the
				Affordable Care Act (ACA) concerning the following:
a) Provider Screening Procedures ( 42 C.F.R.
				§§ 455.400-470 ), based on the category of the provider type, which
				includes license verifications, database checks of eligible professionals,
				owners, managing employees, etc., fingerprinting and criminal background
				checks, and/or unscheduled or unannounced site visits based on required
				screening rules.
1) Providers with an expired
				license will be denied enrollment.
2) Providers with any current disciplinary
				limitations on their license may be denied enrollment.
3) Providers that meet any of the exclusion
				requirements according to state and/or federal law will be denied
				enrollment.
b) Provider
				Application Fees (
				42 C.F.R. §
												455.460 ).
c) Temporary Moratorium (
				42 C.F.R. §
												455.470 ).
d) Provider Termination (
				42 C.F.R. §
												455.416 ).
e) Payment Suspensions (
				42 C.F.R. §
												455.23 ).
5. The provider agrees to review, complete
				and submit a completed re-validation document as required by the policies of
				Division of Medicaid. All providers must undergo a revalidation screening
				process at least once every five years in accordance with
				42 C.F.R. §
											455.414.
6. All professional and institutional
				providers participating in the Medicaid program are required to keep records
				that fully disclose the extent of services rendered and billed under the
				program. These records must be retained for a minimum of five (5) years in
				order to comply with all federal and state regulations and laws. When there is
				a change of ownership or retirement, a provider must continue to maintain all
				Medicaid beneficiary records, unless an alternative method for maintaining the
				records has been established and approved by the Division of Medicaid. Upon
				request, providers are required to make such records available to
				representatives of the Division of Medicaid and others as provided by law in
				validation of any claims. The Division of Medicaid staff shall have immediate
				access to the provider's physical location, facilities, records, documents, and
				any other records relating to medical care and services rendered to
				beneficiaries during regular business hours. Providers must maintain records as
				indicated in Part 200 Chapter 1, Rule
				1.3: Maintenance of
				Records.
7. The provider must
				comply with the requirements of the Social Security Act and federal regulations
				concerning: (a) disclosure by providers of ownership and control information;
				and (b) disclosure of information by a provider's owners of any persons with
				convictions of criminal offenses against Medicare, Medicaid, or the Title XX
				services program. If the Division of Medicaid ascertains that a provider has
				been convicted of a felony under federal or state law for an offense that the
				Division of Medicaid determines is detrimental to the best interests of the
				program or of Medicaid beneficiaries, the Division of Medicaid may refuse to
				enter into an agreement with such provider, or may terminate or refuse to renew
				an existing agreement.
8. The
				provider must agree to accept payment for Medicaid covered services in
				accordance with the rules and regulations for reimbursement, as declared by the
				Secretary of Health and Human Services and by the state of Mississippi, and
				established under the Mississippi Medicaid program.
9. The provider must agree to accept, as
				payment in full, the amount paid by the Medicaid program for all services
				covered under the Medicaid program within the beneficiary's service limits with
				the exception of authorized deductibles, co-insurance, and co-payments. All
				services covered under the Medicaid program will be made available to the
				beneficiary. Beneficiaries will not be required to make deposits or payments on
				charges for services covered by Medicaid. A provider cannot pick and choose
				procedures for which the provider will accept Medicaid. At no time shall the
				provider be authorized to split services and require the beneficiary to pay for
				one type of service and Medicaid to pay for another. All services provided to
				Medicaid beneficiaries will be billed to Medicaid where Medicaid covers said
				services, unless some other resources, other than the beneficiary or the
				beneficiary's family, will pay for the service.
10. For most medical services rendered, the
				provider must agree to take all reasonable measures to determine the legal
				liabilities of third parties including Medicare and private health insurance to
				pay for Medicaid covered services, and if third party liability is established,
				to bill the third party before filing a Medicaid claim. Exceptions to this rule
				are outlined in Part 306 Third Party Recovery. For the purpose of this
				provision, the term "third party" includes an individual, institution,
				corporation, or public or private agency that is or may be liable to pay all or
				part of the medical costs of injury, disease or disability of a Medicaid
				beneficiary and to report any such payments as third parties on claims filed
				for Medicaid payment.
11.
				Participating providers of services under the Medicaid program, i.e.,
				physicians, dentists, hospitals, nursing facilities, pharmacies, etc., must
				comply with the requirements of Title VI of the Civil Rights Act of 1964,
				Section 504 of the Rehabilitation Act of 1973, and the Age of Discrimination
				Act of 1975. Under the terms of these Acts, a participating provider or vendor
				of services under any program using federal funds is prohibited from making a
				distinction in the provision of services to beneficiaries on the grounds of
				race, color, national origin or handicap. This includes, but is not limited to,
				distinctions made on the basis of race, color, national origin, age or handicap
				with respect to: (a) waiting rooms, (b) hours of appointment, (c) order of
				seeing patients, or (d) assignment of patients to beds, rooms or sections of a
				facility. The Division of Medicaid is responsible for routine and complaint
				investigations dealing with these two (2) Acts.
12. Participating providers are prohibited
				from making a distinction in the provision of services to Medicaid
				beneficiaries on the grounds of being Medicaid beneficiaries. This includes,
				but is not limited to, making distinctions with regard to waiting rooms, hours
				of appointment, or order of seeing patients, third party sources (pursuant to
				federal regulations), and quality of services provided, including those
				provided in a facility.
13. The
				provider must agree that claims submitted will accurately reflect both the
				nature of the service and who performed the service.
14. The provider must maintain a copy of the
				Administrative Code for Mississippi Medicaid and all revisions.
15. Participating providers must be eligible
				to participate in the Medicaid program as determined by DHHS-Office of
				Inspector General (DHHS-OIG). Certain individuals and entities are ineligible
				to participate in the Medicaid program on the basis of their exclusion as
				sanctioned by DHHS-OIG by authority contained in Sections 1128 and 1156 of the
				Social Security Act. The effect of exclusion is that no program payment will be
				made for any items or services, including administrative and management
				services, furnished, ordered or prescribed by an excluded individual or entity
				under the Medicare, Medicaid, and State Children's Health Insurance Programs
				during the period of the exclusion. Program payments will not be made to an
				entity in which an excluded person is serving as an employee, administrator,
				operator, or in any other capacity, for any services including administrative
				and management services furnished, ordered, or prescribed on or after the
				effective date of the exclusion. In addition, no payment may be made to any
				business or facility that submits bills for payment of items or services
				provided by an excluded party. The exclusion remains in effect until the
				subject is reinstated by action of the DHHS-OIG. It is the responsibility of
				each Medicaid provider to assure that no excluded person or entity is employed
				in a capacity which would allow the excluded party to order, provide,
				prescribe, or supply services or medical care for beneficiaries, or allow the
				excluded party to hold an administrative, billing, or management position
				involving services or billing for beneficiaries.
16. The provider must verify with the NET
				Broker that all non-emergency transportation (NET) services are for a Medicaid
				covered service only. The provider is only required to verify the date, time,
				beneficiary's Medicaid number, and provide confirmation that a Medicaid covered
				service will be provided at the appointment.