North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-05 - Provider Integrity › Section 75-02-05-04 - Provider responsibility

Current through Supplement No. 393, July, 2024
To assure quality medical care and services, Medicaid and
				  children's health insurance program payments may be made only to providers
				  meeting established standards. Providers who are certified for participation in
				  Medicare are eligible for participation, providing no sanction has been imposed
				  as provided for in section 75-02-05-07. Comparable standards for providers who
				  do not participate in Medicare are established by state law and appropriate
				  licensing and standard-setting authorities in the health and mental health
				  fields.
1. Payment for services under
				Medicaid and children's health insurance program is limited to those covered
				services that are medically necessary for the proper management, control, or
				treatment of an individual's medical problem and provided under the physician's
				or licensed practitioner's direction and supervision.
2. Each provider agrees to retain
				documentation to support medical services rendered for a minimum of seven years
				and, upon request, to make the documentation available to persons acting on
				behalf of the department and the United States department of health and human
				services. A provider shall provide the records at no charge.
3. A provider must accept, as payment in
				full, the amounts paid in accordance with the payment structure established by
				the department. A provider performing a procedure or service may not request or
				receive any payment, in addition to the amounts established by the department,
				from the recipient, or anyone acting on the recipient's behalf, for the same
				procedure or service. In cases where a client share has been properly
				determined by a human service zone, the provider may hold the recipient
				responsible for the client share.
4. A provider may not bill a recipient for
				services that are allowable under Medicaid or children's health insurance
				program, but not paid due to the provider's lack of adherence to Medicaid or
				children's health insurance program requirements.
5. If an enrolled Medicaid or children's
				health insurance program provider does not bill Medicaid for certain services,
				the enrolled Medicaid or children's health insurance program provider must
				notify all recipients of any limitation and secure acknowledgment, in writing.
				If the provider expressly informs the recipient, or in the case of a child, the
				recipient's parent or guardian, that provider would not accept Medicaid or
				children's health insurance program payment for certain services, the provider
				may bill the recipient as a private-pay client for the services.
6. No Medicaid or children's health insurance
				program payment will be made for original claims received by the department
				later than one hundred eighty days from the date of service. Final claim
				adjustments must be submitted within three hundred sixty-five days from the
				date of service. The department may grant a variance to extend the deadline for
				a provider to submit a final claim adjustment. A refusal to grant a variance is
				not subject to a request for review or an appeal.
7. The department will process claims within
				one hundred eighty days from the date on the Medicare explanation of benefits
				if the provider followed Medicare's timely filing policy.
8. In all joint Medicare/Medicaid cases, a
				provider must accept assignment of Medicare payment to receive payment from
				Medicaid for amounts not covered by Medicaid and children's health insurance
				program.
9. When the recipient has
				other medical insurance, all benefits available due from that other insurance
				must be applied prior to the provider accepting payment by Medicaid.
10. A provider may not offer or accept a fee,
				portion of a fee, charge, rebate, or kickback for a Medicaid or children's
				health insurance program patient referral.
11. Claims for payment and documentation must
				be submitted as required by the department or its designee.
12. A provider shall comply with all accepted
				standards of professional conduct and practice in dealing with recipients and
				the department.
13. Each provider
				shall comply with all applicable centers for Medicare and Medicaid services
				regulations.
14. Each provider
				shall comply with requests for documentation from the provider's practice, that
				may include patient information for non-Medicaid or non-children's health
				insurance program recipients, which allows department staff or its authorized
				agent to evaluate overall scheduling, patient-to-provider ratios, billing
				practices, or evaluating the feasibility of services provided per
				day.
General Authority:
NDCC 50-06-01.9,
					 50-24.1-04, 50-29-02
Law Implemented:
42 CFR
					 431.107