chapter 22 – medical assistance eligibility

 

subchapter 22A – identifying information

 

10A NCAC 22A .0101       SCOPE

The Division of Medical Assistance shall administer and supervise the administration of medical services under Title XIX of the Social Security Act, commonly referred to as Medicaid.  A fiscal agent, under contract to the Department of Health and Human Services, shall process claims for medical services, and conduct utilization control activities.  Payment of claims shall be made to the providers.  Notwithstanding any other rules in this Chapter, no services shall be covered for which funds have not been allocated by the General Assembly.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

10A NCAC 22A .0102       reserved for future codification

 

 

subchapter 22B – provider issues

 

section .0100 - general

 

10A NCAC 22B .0101       INSTITUTIONAL HEALTH SERVICES

No provider may be enrolled in the Medicaid Program to provide any new institutional health service for which a Certificate of Need is required under G.S. 131E, Article 9 without first obtaining a Certificate of Need and meeting the conditions imposed by it.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54;

Eff. March 1, 1993;

Recodified from 10 NCAC 26B .0124 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0125 Eff. April 1, 1994;

Recodified from 10 NCAC 26B .0126 Eff. January 1, 1998.

10A NCAC 22B .0102       COORDINATION WITH TITLE XVIII

The entire range of benefits under Part B of Title XVIII to Medicare ‑‑ eligible persons shall be provided through a buy‑in agreement with the Secretary of Health and Human Services.  This agreement shall cover all persons eligible under the state's approved Title XIX plan.

 

History Note:        Authority G.S. 108A‑25(b);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. June 1, 1988.

 

10a NCAC 22B .0103       INSTITUTIONAL STANDARDS

Institutions must meet standards prescribed for participation in Titles XVIII and XIX.  These standards are specified by state licensing law and by federal statutes and regulations, and are kept on file in the state agency and available on request.

 

History Note:        Authority G.S. 108A‑25(b); 131‑E; 42 C.F.R. 440.10; 42 C.F.R. 442, Subparts (D)(E);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977.

 

10A NCAC 22B .0104       TIME LIMITATION

(a)  To receive payment, claims must be filed either:

(1)           Within 365 days of the date of service for services other than inpatient hospital, home health or nursing home services; or

(2)           Within 365 days of the date of discharge for inpatient hospital services and the last date of service in the month for home health and nursing home services not to exceed the limitations as specified in 42 C.F.R. 447.45; or

(3)           Within 180 days of the Medicare or other third party payment, or within 180 days of final denial, when the date of the third party payment or denial exceeds the filing limits in Subparagraphs (1) or (2) of this Rule, if it can be shown that:

(A)          A claim was filed with a prospective third-party payor within the filing limits in Subparagraph (1) or (2) of this Rule; and

(B)          There was a possibility of receiving payment from the third party payor with whom the claim was filed; and

(C)          Bona fide and timely efforts were pursued to achieve either payment or final denial of the third-party claim.

(b)  Providers must file requests for payment adjustments or requests for reconsideration of a denied claim no later than 18 months after the date of payment or denial of a claim.

(c)  The time limitation specified in Paragraph (a) of this Rule may be waived by the Division of Medical Assistance when a correction of an administrative error in determining eligibility, application of court order or hearing decision grants eligibility with less than 60 days for providers to submit claims for eligible dates of service, provided the claim is received for processing within 180 days after the date the county department of social services approves the eligibility.

(d)  In cases where claims or adjustments were not filed within the time limitations specified in Paragraphs (a) and (b) of this Rule, and the provider shows failure to do so was beyond his control, he may request a reconsideration review by the Director of the Division of Medical Assistance.  The Director of Medical Assistance is the final authority for reconsideration reviews.  If the provider wishes to contest this decision, he may do so by filing a petition for a contested case hearing in conformance with G.S. 150B-23.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 447.45;

Eff. February 1, 1976;

Amended Eff. October 1, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. June 1, 1993; June 1, 1988; November 1, 1986; July 1, 1985.

 

10A NCAC 22B .0105       OVERUTILIZER IDENTIFICATION

Overutilizers of Medicaid services, as defined in 10A NCAC 22F .0701, will be identified by a unique annotation of the Medicaid identification card.

 

History Note:        Authority G.S. 108A‑25(b);

Eff. January 1, 1978;

Amended Eff. May 1, 1990; October 4, 1979.

 

Section .0200 ‑ MANUALS AND FORMS

 

10A NCAC 22B .0201       MANUALS

Manuals and bulletins explaining Medicaid procedures are available through the private contractor mentioned in 10A NCAC 22A .0101.

 

History Note:        Authority G.S. 108A‑25(b);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22B .0202       FORMS

All forms are available through the private contractor mentioned in 10A NCAC 22A .0101.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 143B‑10;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

 

 

subchapter 22C – amount: duration: and scope of assistance

 

10A NCAC 22C .0101       COST SHARING

Deductibles, coinsurance, or co‑payments within the limits established by federal law or regulation under SSA 1902(a)(ar) and SSA 1916 which is adopted by reference pursuant to N.C.G.S. 150B‑14(a)(2)(c), shall be imposed with respect to care or services provided to the categorically or medically needy.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 34 C.F.R. 447.50;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990.

10A NCAC 22C .0102       MEDICALLY NEEDY

(a)  Each item of care and service listed in Section 1905(a)(1) to (5) of the Social Security Act shall be provided for persons classified medically needy.

(b)  Care and services made available to the medically needy shall be equal in amount, duration, and scope for medically needy persons.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 440.220; 42 C.F.R. 440.240;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977.

 

10A NCAC 22C .0103       CATEGORICALLY NEEDY

Care and services made available to the categorically needy shall, in amount, duration, and scope, be equal to or greater than those made available to the medically needy.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 440.210;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977.

 

10A NCAC 22C .0104       HEALTH INSURING ORGANIZATIONS

 

History Note:        Authority G.S. 108A‑25(b); 34 C.F.R. 434.14;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 22D – recipient issues

 

10A ncac 22D .0101       CO‑PAYMENT

(a)  Co‑payment Requirements.  The following requirements are imposed on all Medicaid recipients for the following services:

(1)           Outpatient Hospital Services.  Co‑payment shall be charged at the rate of three dollars ($3.00) per outpatient visit.

(2)           Chiropractic Services.  Co‑payment shall be charged at the rate of one dollar ($1.00) per chiropractic visit.

(3)           Podiatric Services.  Co‑payment shall be charged at the rate of one dollar ($1.00) per podiatric visit.

(4)           Optometric Services.  Co‑payment shall be charged at the rate of two dollars ($2.00) per optometric visit.

(5)           Optical Supplies and Services.  Co‑payment shall be charged at the rate of two dollars ($2.00) per item.  Co‑payment for repair of eyeglasses and other optical supplies will be charged at the rate of two dollars ($2.00) per repair exceeding five dollars ($5.00).

(6)           Prescribed Drugs.  Co-payment shall be charged at the rate of one dollar ($1.00) per dispensing for Generic drugs and three dollars ($3.00) for dispensing for Brand Name drugs, including refills.

(7)           Dental Services.  Co‑payment shall be charged at the rate of three dollars ($3.00) per visit, or if more than one visit is required but the service is billed under one procedure code with one date of service, then only one co‑payment shall be collected.  Full and partial dentures are examples of when more than one visit is required but the service is billed under one procedure code.

(8)           Physicians.  Co-payment will be charged at the rate of three dollars ($3.00) per visit.

(b)  Co‑payment Exemptions.  No co‑payment shall be charged for the following services:

(1)           EPSDT related services;

(2)           Family Planning Services;

(3)           Services in state owned mental hospitals;

(4)           Services covered by both Medicare and Medicaid;

(5)           Services to persons under age 21;

(6)           Services related to pregnancy;

(7)           Services provided to residents of ICF, ICF‑MR, SNF, Mental Hospitals; and

(8)           Hospital emergency room services.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.230(d);

Tax Equity and Fiscal Responsibility Act of 1982, Subtitle B; Section 95 of Chapter 689, 1991 Session Laws;

Eff. January 1, 1984;

Temporary Amendment Eff. August 15, 1991 For a Period of 180 Days to Expire on February 15, 1992;

Amended Eff. February 1, 1992;

Temporary Amendment Eff. September 15, 1992 For a Period of 180 Days or Until the Permanent Rule Becomes Effective, Whichever is Sooner;

Amended Eff. February 1, 1993;

Temporary Amendment Eff. January 1, 2002;

Amended Eff. April 1, 2003.

 

 

SUBCHAPTER 22E ‑ COOPERATIVE AGREEMENTS

 

10A NCAC 22E .0101       department of ENVIRONMENT AND NATURAL RESOURCES

 

History Note:        Authority G.S. 108A‑25(b); 143B‑10;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. August 1, 1990;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22E .0102       VOCATIONAL REHABILITATION

The cooperative agreements between the Divisions of Medical Assistance and Vocational Rehabilitation, Department of Health and Human Services, shall commit the Divisions to their responsibilities with regard to social services and medical services.

 

History Note:        Authority G.S. 108A‑25(b); 143B‑10; 143B‑138;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. August 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22E .0103       MENTAL HEALTH, DEVELOP/DISABILITIES/SUBSTANCE ABUSE SVCS

The cooperative agreements between the Divisions of Medical Assistance and Mental Health, Developmental Disabilities and Substance Abuse Services, Department of Health and Human Services, shall commit the Divisions to their responsibilities with regard to social services.

 

History Note:        Authority G.S. 108A‑25(b); 143B‑10; 143B‑138;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. August 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22E .0104       FACILITY SERVICES

10A NCAC 22E .0105       BLUE CROSS AND BLUE SHIELD

 

History Note:        Authority G.S. 108A‑25(b); 143B‑10;

Eff. November 1, 1977;

Amended Eff. August 1, 1990;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

 

 

SUBCHAPTER 22F ‑ PROGRAM INTEGRITY

 

SECTION .0100 ‑ GENERAL

 

10A NCAC 22F .0101        SCOPE

This Subchapter shall provide methods and procedures to ensure the integrity of the Medicaid program.  Nothing in these procedures is intended, nor shall be construed, to grant any provider any right to participate in the Medicaid program not granted by federal law or regulations.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. 455.1;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990; May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

10a NCAC 22F .0102        ORGANIZATION

The North Carolina Department of Health and Human Services, Division of Medical Assistance shall perform the duties required by this Subchapter.  The Department or Division may enter into contracts with other persons for the purpose of performing these duties.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 455;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22F .0103        FUNCTIONS

(a)  The Division shall develop, implement and maintain methods and procedures for preventing, detecting, investigating, reviewing, hearing, referring, reporting, and disposing of cases involving fraud, abuse, error, overutilization or the use of medically unnecessary or medically inappropriate services.

(b)  The Division shall institute methods and procedures to:

(1)           receive and process complaints and allegations of provider and recipient aberrant practices;

(2)           perform preliminary and full investigations to collect facts, data, and information;

(3)           analyze and evaluate data and information to establish facts and conclusions concerning provider and recipient practices;

(4)           make administrative decisions affecting providers, including but not limited to suspension from the Medicaid program;

(5)           recoup improperly paid claims;

(6)           establish remedial measures including but not limited to monitoring programs;

(7)           conduct administrative review or, when legally necessary, hearings except as provided in Subparagraph (b)(8) of this Rule;

(8)           refer for provider peer review those cases involving questions of professional practice.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. 455, Subpart A;

Eff. May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22F .0104        PREVENTION

(a)  Provider Education.  The Division may at its discretion, or shall upon the request of a provider, conduct on‑site educational visits to assist a provider in complying with requirements of the Medicaid Program.

(b)  Provider Manuals.  The Division will prepare and furnish each provider with a provider manual containing at least the following information:

(1)           amount, duration, and scope of assistance;

(2)           participation standards;

(3)           penalties;

(4)           reimbursement rules;

(5)           claims filing instructions.

(c)  Prepayment Claims Review.  The Division will check eligibility, duplicate payments, third party liability, and unauthorized or uncovered services by means of prepayment review, computer edits and audits, and other appropriate methods of review.

(d)  Prior Approval.  The Division shall require prior approval for certain specified covered services as set forth in the State Plan.

(e)  Claim Forms.  The Division's provider claim forms shall include the following requirements for provider participation and payment.  These requirements shall be binding upon the Division and the providers:

(1)           Medicaid payment constitutes payment in full.

(2)           Charges to Medicaid recipients for the same items and services shall not be higher than for private paying patients.

(3)           The provider shall keep all records as necessary to support the services claimed for reimbursement.

(4)           The provider shall fully disclose the contents of his Medicaid financial and medical records to the Division and its agents.

(5)           Medicaid reimbursement shall only be made for medically necessary care and services.

(6)           The Division may suspend or terminate a provider for violations of Medicaid laws, regulations, policies, or guidelines.

(f)  Pharmacy and Institutional Provider Agreements.  All institutional and pharmacy providers shall be required to execute a written participation agreement as a condition for participating in the N.C. State Medical Assistance Program.

(g)  The Recipient Management LOCK‑IN System.  The Department of Health and Human Services, Division of Medical Assistance, will establish a lock‑in system to control recipient overutilization of provider services.  A lock‑in system restricts an overutilizing recipient to the use of one physician and one pharmacy, of the recipient's choice, provided the recipient's physician can refer the recipient to other physicians as medically necessary.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. Part 455;

Eff. May 1, 1984.

 

10a NCAC 22F .0105        DETECTION

(a)  The Division will accept, investigate and where good reason to do so exists, refer for prosecution, allegations or complaints of provider or recipient fraud, abuse, overutilization, error or aberrant practices.

(b)  The Division will conduct post‑payment reviews and audits of a statistically significant sampling of provider claims.

(c)  The Division will compare provider and recipient practices to establish statistical models of normal provider or recipient practices.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. Part 455;

Eff. May 1, 1984.

 

10a NCAC 22F .0106        CONFIDENTIALITY

All investigations by the North Carolina Division of Medical Assistance concerning allegations of provider fraud, abuse, over‑utilization, or inadequate quality of care shall be confidential, and the information contained in the files of such investigations shall be confidential, except as permitted by State or Federal law or regulation.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. May 1, 1990.

 

10a NCAC 22F .0107        RECORD RETENTION

All Title XIX providers shall keep and maintain all Medicaid financial, medical, or other records necessary to fully disclose the nature and extent of services furnished to Medicaid recipients and claimed for reimbursement.  These records shall be retained for a period of not less than five years from the date of service, unless a longer retention period is required by applicable federal or state law, regulations or agreements.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑63; 108A‑64; 42 C.F.R. Part 455;

Eff. April 1, 1988.

 

SECTION .0200 ‑ PROVIDER FRAUD AND PHYSICAL ABUSE OF RECIPIENTS

 

10A NCAC 22F .0201        DEFINITION OF PROVIDER FRAUD

(a)  Provider fraud is defined as provided by N.C.G.S. 108A‑63, which is adopted by reference pursuant to N.C.G.S. 150B‑14(a)(2)(c).

(b)  "Provider" shall include any person who furnishes goods or services under this Rule and any other person acting as an employee, representative or agent of such person.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 143B‑10; 42 U.S.C. 1396(b) et seq.; 42 C.F.R. Part 455;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990; May 1, 1984.

 

10a NCAC 22F .0202        INVESTIGATION

(a)  The Division will publish methods and procedures for the control of provider fraud, abuse, error, and overutilization.

(b)  There shall be a preliminary investigation of all complaints received or aberrant practices detected, until it is determined:

(1)           whether there are sufficient findings to warrant a full investigation;

(2)           whether there is sufficient evidence to warrant referring the case for civil and/or criminal fraud action;

(3)           whether there is insufficient evidence to support the allegation(s) and the case may be closed.

(c)  There shall be a full investigation if the preliminary findings support the conclusion of possible fraud until:

(1)           the case is referred to the appropriate law enforcement agency;

(2)           the case is found to be one of program abuse subject to administrative action;

(3)           the case is closed for insufficient evidence of fraud or abuse; or

(4)           the provider is found not to have abused or defrauded the program.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 42 U.S.C. 1396(b) et seq.; 42 C.F.R. Part 455;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984.

 

10a NCAC 22F .0203        REFERRAL TO LAW ENFORCEMENT AGENCY

The Division shall refer all cases of reasonably suspected provider fraud or physical abuse of recipients to the State Medicaid Fraud Control Unit.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; P.L. 95‑142; 42 C.F.R. 455.14; 42 C.F.R. 455.15;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984.

 

SECTION .0300 ‑ PROVIDER ABUSE

 

10 NCAC 22f .0301           DEFINITION OF PROVIDER ABUSE

Provider abuse includes any incidents, services, or practices inconsistent with accepted fiscal or medical practices which cause financial loss to the Medicaid program or its beneficiaries, or which are not reasonable or which are not necessary including, for example, the following:

(1)           Overutilization of medical and health care and services.

(2)           Separate billing for care and services that are:

(a)           part of an all‑inclusive procedure,

(b)           included in the daily per‑diem rate.

(3)           Billing for care and services that are provided by an unauthorized or unlicensed person.

(4)           Failure to provide and maintain within accepted medical standards for the community:

(a)           proper quality of care,

(b)           appropriate care and services, or

(c)           medically necessary care and services.

(5)           Breach of the terms and conditions of participation agreements, or a failure to comply with requirements of certification, or failure to comply with the provisions of the claim form.

The foregoing examples do not restrict the meaning of the general definition.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 42 C.F.R. 455, Subpart C;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984.

 

10A NCAC 22F .0302        INVESTIGATION

(a)  Abusive practices shall be investigated according to the provisions of Rule .0202 of this Subchapter.

(b)  A Provider Summary Report shall be prepared by the investigative unit furnishing the full investigative findings of fact, conclusions, and recommendations.

(c)  The Division shall review the findings, conclusions, and recommendations and make a tentative decision for disposition of the case from among the following administrative actions:

(1)           To place provider on probation with terms and conditions for continued participation in the program.

(2)           To recover in full any improper provider payments.

(3)           To negotiate a financial settlement with the provider.

(4)           To impose remedial measures to include a monitoring program of the provider's Medicaid practice terminating with a "follow‑up" review to ensure corrective measures have been introduced.

(5)           To issue a warning letter notifying the provider that he must not continue his aberrant practices or he will be subject to further division actions.

(6)           To recommend suspension or termination.

(d)  The tentative decision shall be subject to the review procedures described in Section .0400 of this Subchapter.

(e)  If the investigative findings show that the provider is not licensed or certified as required by federal and state law, then the provider cannot participate in the North Carolina State Medical Assistance Program (Medicaid).

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 455.14; 42 C.F.R. 455.15;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. July 1, 1988; May 1, 1984.

 

section .0400 – agency reconsideration review

 

10A NCAC 22F .0401        PURPOSE

These Rules specify the policies and procedures for hospital and physician requests for reconsideration of retrospective denials of acute hospital days determined not to be necessary by the Division of Medical Assistance.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 456;

Eff. December 1, 1982;

Transferred and Recodified from 10 NCAC 26I .0201 Eff. July 1, 1995;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22F .0402        RECONSIDERATION REVIEW FOR PROGRAM ABUSE

(a)  Upon notification of a tentative decision the provider will be offered, in writing, by certified mail, the opportunity for a reconsideration of the tentative decision and the reasons therefor.

(b)  The provider will be instructed to submit to the Division in writing his request for a Reconsideration Review within fifteen working days from the date of receipt of the notice.  Failure to request a Reconsideration Review in the specified time shall result in the implementation of the tentative decision as the Division's final decision.

(c)  If requested, the Reconsideration Review shall be scheduled within twenty calendar days from receipt of the request.  The provider will be notified in writing to appear at a specified day, time and place.  The provider may be accompanied by legal counsel if he so desires.

(d)  The purpose of the Reconsideration Review includes:

(1)           Clarification, formulation, and simplification of issues;

(2)           Exchange and full disclosure of information and materials;

(3)           Review of the investigative findings;

(4)           Resolution of matters in controversy;

(5)           Consideration of mitigating and extenuating circumstances;

(6)           Reconsideration of the administrative measures to be imposed;

(7)           Reconsideration of the restitution of overpayments.

(e)  The Reconsideration Review decision will be sent to the provider in writing by certified mail within five working days following the date of review.  It will state the schedule for implementing the administrative measures and/or recoupment plan, if applicable, and it will state that if the Reconsideration Review decision is not acceptable to the provider, he may request a contested case hearing in accordance with the provisions found at 10A NCAC 01.  Pursuant to G.S. 150B‑23(f), the provider shall have 60 days from receipt of the Reconsideration Review decision to request a contested case hearing.  Unless the request is received within the time provided, the Reconsideration Review decision shall become the Division's final decision.  In processing the contested case request, the Director of the Division of Medical Assistance shall serve as the secretary's designee and shall be responsible for making the final agency decision.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑22; 42 C.F.R. Part 455;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

ARRC Objection October 22, 1987;

Amended Eff. November 1, 1988; March 1, 1988; May 1, 1984.

 

10A NCAC 22F .0403        PROCESS

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 456;

Eff. December 1, 1982;

Amended Eff. January 1, 1988; January 1, 1986;

Transferred and Recodified from 10 NCAC 26I .0202 Eff. July 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

SECTION .0500 ‑ PEER REVIEW

 

10A NCAC 22F .0501        GENERAL

10A NCAC 22F .0502        PEER REVIEW ESTABLISHED

10A NCAC 22F .0503        CHOICE OF PROCEDURES

10A NCAC 22F .0504        COMPOSITION OF PEER REVIEW BOARD

10A NCAC 22F .0505        NOTICE OF PEER REVIEW

 

History Note:        Authority G.S. 108A‑25(b); 150B‑11; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990; January 1, 1987; January 1, 1986; May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22F .0506        VENUE

10A NCAC 22F .0507        DOCUMENTATION

10A NCAC 22F .0508        PEER REVIEW PROCEDURES

10A NCAC 22F .0509        DISQUALIFICATION OF BOARD MEMBERS

10A NCAC 22F .0510        FAILURE OF PROVIDER TO ATTEND THE REVIEW

 

History Note:        Authority G.S. 108A‑25(b); 150B‑11; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Amended Eff. May 1, 1990; September 1, 1988; January 1, 1987;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

section .0600 – administrative sanctions and recoupment

 

10A NCAC 22F .0601        RECOUPMENT

(a)  The Medicaid Agency will seek full restitution of any and all improper payments made to providers by the Medicaid Program.  Recovery may be by lump sum payment, by a negotiated payment schedule not to exceed one year or by withholding from the provider's pending claims the total or a portion of the recoupment amount.

(b)  A provider may argue all or a part of a recoupment imposed by the Medicaid Agency by requesting a Reconsideration Review of the investigative findings and, thereafter, an Executive Decision.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. February 1, 1982;

Amended Eff. May 1, 1984.

 

10A NCAC 22F .0602        ADMINISTRATIVE SANCTIONS AND REMEDIAL MEASURES

(a)  The following types of sanctions may be imposed, singly or in combination, by the Medicaid Agency in instances of program abuse by providers:

(1)           Warning letters for those instances of abuse that can be satisfactorily settled by issuing a warning to cease the specific abuse. The letter will state that any further violations will result in administrative or legal action initiated by the Medicaid Agency.

(2)           Suspension of a provider from further participation in the Medicaid Program for a specified period of time, provided the appropriate findings have been made and provided that this action does not deprive recipients of access to reasonable service of adequate quality.

(3)           Termination of a provider from further participation in the Medicaid Program, provided the appropriate findings have been made and provided that this action does not deprive recipients of access to reasonable services of adequate quality.

(4)           Probation whereby a provider's participation is closely monitored for a specified period of time not to exceed one year.  At the termination of the probation period the Medicaid Agency will conduct a follow-up review of the provider's Medicaid practice to ensure compliance with the Medicaid rules.  Notwithstanding his probation, a probationary provider's participation, like that of all providers, is terminable at will.

(5)           Remedial Measures to include:

(A)          placing the provider on "flag" status whereby his claims are remanded for manual review;

(B)          establishing a monitoring program not to exceed one year whereby the provider must comply with pre-established conditions of participation to allow review and evaluation of his Medicaid practice, i.e., quality of care.

(b)  The following factors are illustrative of those to be considered in determining the kind and extent of administrative sanctions to be imposed:

(1)           seriousness of the offense;

(2)           extent of violations found;

(3)           history or prior violations;

(4)           prior imposition of sanctions;

(5)           period of time provider practiced violations;

(6)           provider willingness to obey program rules;

(7)           recommendations by the investigative staff or Peer Review Committees; and

(8)           effect on health care delivery in the area.

When a provider has been administratively sanctioned, the Division shall notify the appropriate professional society, board of licensure, State Attorney General's Office, federal and state agencies, and appropriate county departments of social services of the findings made and the sanctions imposed.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. December 1, 1995; May 1, 1990.

 

10A NCAC 22F .0603        PROVIDER LOCK-OUT

(a)  The Division may restrict the provider, through suspension or otherwise, from participating in the Medicaid program, provided that:

(1)           Before imposing any restrictions, the Division will give the provider notice and opportunity for review in accordance with procedures established by the Division.

(2)           The Division shows, before so restricting a provider, that in a significant number of proportion of cases, the provider has:

(A)          provided care, services, and items at a frequency or amount not medically necessary, as determined in accordance with utilization guidelines established by the Division; or

(B)          provided care, service, and items of a quality that does not meet professionally recognized standards of health care.

(3)           The Division will assure that recipients do not lose reasonable access to services of adequate quality as a result of such restrictions.

(4)           The Division will give general notice to the public of the restriction, its basis, and its duration.

(b)  Suspension or termination from participation of any provider shall preclude such provider from submitting claims for payment to the state agency.  No claims may be submitted by or through any clinic, group, corporation, or other association for any services or supplies provided by a person within such organization who has been suspended or terminated from participation in the Medicaid program, except for those services or supplies provided prior to the suspension or termination effective date.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. December 1, 1995.

 

10A NCAC 22F .0604        WITHHOLDING OF MEDICAID PAYMENTS

(a)  The Medicaid Agency shall withhold Medicaid payments in accordance with the provisions of 42 CFR 455.23 which is hereby incorporated by reference including subsequent amendments and editions.  A copy of 42 CFR 455.23 is available for inspection and may be obtained from the Division of Medical Assistance at a cost of twenty cents ($.20) a page.

(b)  The Medicaid Agency shall withhold Medicaid payments in whole or in part to ensure recovery of overpayments, or to implement the penalty provision of the Patient's Bill of Rights.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. December 1, 1995.

 

10A NCAC 22F .0605        TERMINATION

All provider contracts with the North Carolina State Medicaid Agency are terminable at will.  Nothing in these Regulations creates in the provider a property right or liberty right in continued participation in the Medicaid program.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984.

 

10A NCAC 22F .0606        TECHNIQUE FOR PROJECTING MEDICAID OVERPAYMENTS

(a)  The Medicaid agency will seek restitution of overpayments made to providers by the Medicaid program.

(b)  The agency may use a Disproportionate Stratified Random Sampling Technique in establishing provider overpayments.

(c)  This technique is an extrapolation of a statistical sampling of claims used to determine the total overpayment for recoupment.

(d)  The provider may challenge the validity of the findings in the SAMPLE itself in accordance with the provisions found at 10A NCAC 22F .0402.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑63; 42 C.F.R. Part 455;

Eff. October 1, 1987;

Temporary Amendment Eff. November 8, 1996;

Amended Eff. August 1, 1998.

 

SECTION .0700 – recipient fraud and abuse

 

10A NCAC 22F .0701        DEFINITION OF FRAUD AND ABUSE

(a)  For purposes of this Section the word "person" includes any natural person, association, consortium, corporation, body politic, partnership, or other group, entity or organization.

(b)  Abuse.  The type of abuse to which the Medicaid program is extremely vulnerable is recipient overutilization of medical and health care services for which he or she is eligible.  A recipient may be regarded as overutilizing the program care and services if he or she has been furnished covered items or services at a frequency or amount not medically necessary, as determined in accordance with utilization guidelines established by the State, and the services were furnished at the request of the recipient.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455;

42 C.F.R. Part 456;

Eff. May 1, 1984;

Amended Eff. May 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10a NCAC 22F .0702        GENERAL

The Division will establish a statewide program for the prevention, detection, investigation, referral, prosecution, recoupment of overpayments, and reporting of fraud, abuse, and overutilization due to recipient aberrant practices.  The program will be supervised by the Division and administered by the county departments of social services.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455;

42 C.F.R. Part 456;

Eff. May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22F .0703        WARNING NOTIFICATION

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22F .0704        RECIPIENT MANAGEMENT LOCK‑IN SYSTEM

(a)  The Division shall have methods and procedures for the control of recipient overutilization of Medicaid benefits.  These methods and procedures shall include Lock‑In of a recipient, shown to be an overutilizer, to specified providers of health care and services.

(b)  Prior to implementing Lock‑In the following steps shall be taken:

(1)           Recipient's utilization pattern will be documented as inappropriate;

(2)           Recipient will be notified that the State is imposing a Lock‑In procedure;

(3)           Recipient will be offered the opportunity to select a provider;

(4)           In the event the recipient fails to select a provider, a provider will be selected for him by the Division of Medical Assistance;

(5)           Recipient will receive an eligibility card indicating the selected providers.

(c)  Recipient utilization patterns will be reviewed periodically to determine if changes have occurred.  If the utilization pattern has been corrected, the Lock‑In status will be ended; if the utilization pattern remains aberrant, Lock‑In status will be continued.

(d)  Division may Lock‑In a recipient provided:

(1)           The recipient is given notice and an opportunity for a hearing before imposing restriction, pursuant to state statutes governing appeals by public assistance recipients.

(2)           The Division assures that the recipient has reasonable access to Medicaid care and services of adequate quality.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 108A‑79; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984.

 

10A NCAC 22F .0705        OVERUTILIZATION SURVEILLANCE (SUR INDICATOR)

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22F .0706        RECOUPMENT OF OVERPAYMENTS

The Division will ensure that:

(1)           counties recover any and all recipient responsible overpayments as a debt to the participating governments;

(2)           counties accept payments from each recipient and give the recipient a receipt for each transaction;

(3)           counties keep a separate accounting for Medicaid repayments on each recipient;

(4)           repayments are forwarded to the Division of Medical Assistance utilizing the DMA 7050 form.  This must be done at least on a monthly basis;

(5)           the usual adjustments to federal, state, and county funds are made by the state;

(6)           Medical Assistance overpayments are not recouped through check reduction;

(7)           payments received from recipients with overpayments involving more than one program will be prorated so that the Medicaid program will receive its fair share of each payment.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984.

 

10A NCAC 22F .0707        REPORTS AND REVIEWS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

 

 

SUBCHAPTER 22g – REIMBURSEMENT PLANS

 

SECTION .0100 – REIMBURSEMENT FOR NURSING FACILITY SERVICES

 

10A NCAC 22G .0101       REIMBURSEMENT PRINCIPLES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Amended Eff. March 22, 1978;

Emergency Amendment [(a), (b), (c), (g), (m), (o), (p), (q)] Eff. April 1, 1978 for a Period of 120 Days to Expire on July 30, 1978;

Emergency Amendment [(a), (b), (c), (g), (m), (o), (p), (q)] Expired Eff. July 30, 1978;

Amended Eff. August 1, 1982;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Amended Eff. April 1, 1992; October 1, 1991; January 28, 1985;

Temporary Amendment Eff. June 26, 2003;

Temporary Amendment Expired April 27, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22G .0102       RATE SETTING METHODS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 29 C.F.R. 1910, Subpart Z; 42 C.F.R. 447, Subpart C; S.L. 1991, c. 689, s. 95;

Eff. January 1, 1978;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Temporary Amendment Eff. October 1, 1991 for a Period of 180 Days to Expire on March 31, 1992;

Amended Eff. April 1, 1992;

Temporary Amendment Eff. July 1, 1992 for a Period of 180 Days to Expire on December 31, 1992;

Amended Eff. May 1, 1995; February 1, 1993; January 1, 1993;

Temporary Amendment Eff. January 22, 1998;

Amended Eff. April 1, 1999;

Temporary Amendment Eff. November 9, 2001;

Temporary Amendment Expired August 30, 2002;

Amended Eff. April 1, 2003;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0103       REASONABLE AND NON‑ALLOWABLE COSTS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Amended Eff. January 4, 1993; October 1, 1991; November 1, 1988; January 28, 1985;

Temporary Amendment Eff. August 3, 2004;

Amended January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22G .0104       COST REPORTING: AUDITING

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Amended Eff. March 22, 1978;

Emergency Amendment [(a), (h)] Eff. April 1, 1978 for a period of 120 days to expire on July 30, 1978;

Emergency Amendment [(a), (h)] Expired Eff. July 30, 1978;

Temporary Amendment Eff. October 1, 1984 for a period of 120 days to expire on January 28, 1985;

Amended Eff. August 1, 1998; June 1, 1995; January 4, 1993; October 1, 1991; December 1, 1988;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0105       case-mix index calculation

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S. L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Amended Eff. March 25, 1980;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Amended Eff. March 1, 1994; April 1, 1988; January 28, 1985;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0106       RECONSIDERATION REVIEWS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1978;

Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Amended Eff. January 4, 1993; November 1, 1991; May 1, 1990; June 1, 1989;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. February 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22G .0107       PAYMENT ASSURANCE

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; Section 95 of Chapter 689, 1991 Session Laws; 42 C.F.R. 447, Subpart C;

Temporary Rule Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Eff. January 28, 1985;

Amended Eff. December 1, 1988;

Temporary Amendment Eff. August 1, 1991 For a Period of 180 Days to Expire on January 31, 1992;

Amended Eff. February 1, 1992; October 1, 1991;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0108       REIMBURSEMENT METHODS FOR STATE‑OPERATED FACILITIES

(a)  A NC Division of Health Service Regulation certified State‑operated nursing facility shall be reimbursed for the reasonable costs that are necessary to efficiently meet the needs of its patients and to comply with federal and state laws and regulations.  The costs shall be determined in accordance with Rules .0103 and .0104 of this Section, except that annual cost reports shall be required for the fiscal year beginning on July 1 and ending on the following June 30 and must be submitted to the Division of Medical Assistance within 150 days after their fiscal year end.  Payments shall be suspended if reports are not filed.  The Division of Medical Assistance shall extend the deadline for filing the report if the Division determines good cause.  "Good cause" is an action uncontrollable by the provider.  The Medicare principles for the reimbursement of skilled nursing facilities shall be utilized for the cost principles that are not specifically addressed in this Section.

(b)  A per diem rate based on the providers estimated annual cost divided by patient days shall be used to make interim payments.  A desk audit and a tentative settlement shall be performed on each annual cost report to determine the amount of Medicaid reasonable cost and the amount of interim payments received by the provider.

(c)  Any payments in excess of costs shall be refunded to the Division. Any costs in excess of payments shall be paid to the provider.  An annual field audit shall be performed by a qualified independent auditor to determine the final settlement amounts.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1992;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005.

 

10A NCAC 22G .0109       PROVIDER ASSESSMENT

(a)  In accordance with 42 USC 1396b(w) and 42 CFR, Part 433, Subpart B; and consistent with the CMS Federal Waiver approved April 5, 2004 with an effective date of October 1, 2003 including subsequent amendments and revisions, a monthly nursing facility assessment based on all occupied nursing facility bed days of service is imposed on all nursing bed days in licensed nursing facilities, except:

(1)           Any nursing facility bed day of service provided by a Continuing Care Retirement Community (CCRC), as defined by GS 58-64 and licensed by the North Carolina Department of Insurance;

(2)           Any nursing facility bed day of service paid for under the Medicare program established under Title XVIII of the Social Security Act.

A copy of the Waiver may be obtained by contacting the Division of Medical Assistance, 2501 Mail Service Center, Raleigh, North Carolina 27699-2501, (919) 857-4016.

(b)  Effective October 1, 2003, the assessment is payable monthly and due to the Department of Health and Human Services or designee of the Department within 15 days of the last day of the reporting month. Facilities shall submit payment and an account of all actual patient days during the month. Failure to provide accurate and timely reporting of days and payment of assessment shall result in a 10% reduction in facility rates for Medicaid participating facilities and recoupment per the Department Cash Management Plan.

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 2003-284, Sec. 10.28; CMS Waiver approved April 5, 2004; 42 CFR Part 433, Subpart B;

Temporary Adoption Eff. August 3, 2004;

Eff. January 1, 2005.

 

10A NCAC 22G .0110       DEFINITIONS

"Public nursing facility", as used in 10A NCAC 22G, means any nursing facility that is:

(1)           Owned or operated by the State or any department or instrumentality of the State or by county, city, hospital district, or hospital authority; or

(2)           Is operated by a nonprofit corporation or association, a majority of whose board of directors or trustees are appointed by the State or any department or instrumentality of the State or by the governing body of a county, city, hospital district, or hospital authority; or

(3)           Is operated by a hospital that is a "public hospital" under G.S. 159-39(a); or

(4)           Is operated by a hospital that has verified its status by certifying State, local, hospital district or authority governmental control on the most recent version of the Form CMS 1514; or

(5)           Is a facility to which the State or any department or instrumentality of the State or a city or a county makes current appropriations (other than appropriations for the cost of medical care to prisoners or indigents).

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 159-39(a);

Temporary Adoption Eff. August 3, 2004;

Eff. January 1, 2005;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

section .0200 – hospital inpatient reimbursement plan

 

10A NCAC 22G .0201       REIMBURSEMENT PRINCIPLES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0202       DRG RATE SETTING METHODOLOGY

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. March 1, 1995;

Temporary Amendment Eff. January 22, 1998;

Amended Eff. April 1, 1999;

Temporary Amendment Eff. November 9, 2001;

Temporary Amendment Expired August 30, 2002;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A ncac 22G .0203       EXCEPTIONS TO DRG REIMBURSEMENT

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55(c); 42 C.F.R. 447, Subpart C; 42 C.F.R. 447.321;

Eff. February 1, 1995;

Temporary Amendment Eff. September 15, 1995, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. January 1, 1996;

Temporary Amendment Eff. September 25, 1996;

Temporary Amendment Eff. September 30, 1997;

Temporary Amendment Expired July 31, 1998;

Temporary Amendment Eff. September 16, 1998;

Temporary Amendment Expired June 13, 1999;

Temporary Amendment Eff. September 22, 1999;

Temporary Amendment Expired July 11, 2000;

Temporary Amendment Eff. June 13, 2001; September 21, 2000;

Temporary Amendment Eff. May 15, 2002;

Amended Eff. April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0204       DISPROPORTIONATE SHARE HOSPITALS (DSH)

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Amended Eff. July 1, 1995;

Temporary Amendment Eff. September 15, 1995, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Temporary Amendment Eff. September 29, 1995, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. January 1, 1996;

Temporary Amendment Eff. September 16, 1998; September 30, 1997; April 15, 1997; September 25, 1996;

Temporary Amendment Expired on June 13, 1999;

Temporary Amendment Eff. September 22, 1999;

Temporary Amendment Expired on July 11, 2000;

Temporary Amendment Eff. May 15, 2002; June 1, 2001; December 10, 2001; September 21, 2000;

Amended Eff. August 1, 2004; April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0205       OUT OF STATE HOSPITALS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A ncac 22G .0206       SPECIAL SITUATION

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447 Subpart C;

Eff. February 1, 1995;

Temporary Amendment Eff. December 10, 2001;

Temporary Amendment Expired September 29, 2002;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0207       COST REPORTING AND AUDITS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0208       ADMINISTRATIVE RECONSIDERATION REVIEWS

Reconsideration reviews of rate determinations shall be processed in accordance with the provisions of 10A NCAC 22J.  Requests for reconsideration reviews shall be submitted to the Division of Medical Assistance within 60 days after rate notification, unless unexpected conditions causing intense financial hardship arise, in which case a reconsideration review may be considered at any time.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995.

 

10A NCAC 22G .0209       BILLING STANDARDS

10A NCAC 22G .0210       PAYMENT OF MEDICARE PART A DEDUCTIBLES

10A NCAC 22G .0211       PAYMENT ASSURANCES

10A NCAC 22G .0212       PROVIDER PARTICIPATION

10A NCAC 22G .0213       PAYMENT IN FULL

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

SECTION .0300 ‑ ICF‑MR PROSPECTIVE RATE PLAN

 

10A NCAC 22G .0301       PAYMENT FOR SERVS‑PROSPECTIVE REIMBURSEMENT PLAN ICF‑MR FACILITIES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1982;

Temporary Amendment Eff. July 8, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. November 1, 1993;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0302       REPORTING REQUIREMENTS

 

History Note:        Temporary Amendment Eff. July 8, 1993, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner.

Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 447, Subpart C;

Eff. January 1, 1982;

Amended Eff. August 1, 1995; November 1, 1993; May 1, 1990; April 1, 1988;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0303       REQUIREMENTS FOR FINANCIAL RECORDS

 

History Note:        Temporary Amendment Eff. July 8, 1993, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Temporary Amendment Eff. July 1, 1992 for a period of 180 days to expire on

December 31, 1992;

Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. Part 447, Subpart C;

Eff. January 1, 1982;

Amended Eff. November 1, 1993; January 4, 1993; January 1, 1993; December 1, 1989;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0304       RATE SETTING METHOD FOR NON-STATE FACILITIES

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. Part 447, Subpart C;

Eff. December 1, 1984;

Amended Eff. March 1, 1988; January 1, 1987;

Temporary Amendment Eff. July 8, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. August 1, 1995; November 1, 1993;

Temporary Amendment Eff. September 8, 1999; August 7, 1998;

Amended Eff. March 19, 2001; August 1, 2000;

Temporary Amendment Eff. December 10, 2001;

Temporary Amendment Expired September 29, 2002;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0305       ALLOWABLE COSTS

10A NCAC 22G .0306       PAYMENT ASSURANCE

10A NCAC 22G .0307       REIMBURSEMENT METHODS FOR STATE‑OPERATED FACILITIES

10A NCAC 22G .0308       RATE APPEALS

10A NCAC 22G .0309       AUDITS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C;

Temporary Adoption Eff. July 8, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Eff. November 1, 1993;

Amended Eff. August 1, 1995;

Temporary Amendment Eff. June 26, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

section .0400 - PROVIDER FEE SCHEDULES

 

10A ncac 22G .0401       PHYSICIAN’S FEE SCHEDULE

 

History Note:        Authority G.S. 108A-25(b);

Eff. October 1, 1982;

Amended Eff. July 1, 1997; July 1, 1995; January 4, 1993; June 1, 1990; December 1, 1988;

Temporary Amendment Eff. July 22, 1998; January 22, 1998;

Amended Eff. April 1, 1999;

Temporary Amendment Eff. January 1, 2000 (This temporary amendment amends and replaces a permanent rulemaking originally proposed to be effective August 2000);

Amended Eff. March 19, 2001;

Temporary Amendment Eff. September 10, 2001;

Temporary Amendment Expired June 28, 2002;

Amended Eff. April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A ncac 22G .0402       OTHER SERVICES PERFORMED BY PHYSICIANS AND OTHER PRACTITIONERS

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. January 4, 1993;

Temporary Amendment Eff. March 7, 2002;

Temporary Amendment Expired December 27, 2002;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A;

 

section .0500 – reimbursement for services

 

10a NCAC 22G .0501       CLINIC SERVICES

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. February 1, 1984;

Temporary Amendment Eff. November 9, 2001;

Temporary Amendment Expired August 30, 2002;

Amended Eff. April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22G .0502       MENTAL HEALTH CLINIC SERVICES

Reimbursement for mental health clinic services will be made based on a fee schedule as developed by the Division of Medical Assistance.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. February 1, 1984.

 

10A NCAC 22G .0503       INPATIENT HOSPITAL: INAPPROPRIATE LEVEL OF CARE

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 447.253; S.L. 1985, c. 479, s. 86;

Eff. May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0504       HEALTH MAINTENANCE ORGANIZATIONS AND PREPAID HEALTH PLANS

Reimbursement to Health Maintenance Organizations and Prepaid Health Plans for services rendered will be paid as a monthly capitation fee developed by the Division of Medical Assistance.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. Part 434;

Eff. August 1, 1984;

Amended Eff. February 1, 1985.

 

10A ncac 22G .0505       PERSONAL CARE SERVICES

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 131D-4.1; 131D-4.2; S.L. 1995 c. 507, s. 23.10; 42 C.F.R. 440.170(f);

Eff. January 1, 1986;

Temporary Amendment Eff. April 22, 1996; January 9, 1997;

Amended Eff. August 1, 1998;

Temporary Amendment Eff. January 1, 2000;

Temporary Amendment Expired on October 28, 2000;

Temporary Amendment Eff. July 1, 2002;

Amended Eff. August 1, 2002;

Temporary Amendment Eff. January 13, 2003;

Amended Eff. August 1, 2004;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0506       INDEPENDENT LABORATORY SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; P.L. 93‑369; P.L. 99‑272; 42 C.F.R. 447.10; 42 C.F.R. 447.342;

Eff. March 1, 1987;

Amended Eff. September 1, 1991;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0507       DURABLE MEDICAL EQUIPMENT AND RELATED SUPPLIES

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 447, Subpart D; 1991 S.L, s. 95, c. 689;

Eff. March 1, 1990;

Temporary Amendment Eff. August 1, 1991 for a period of 180 days to expire on

January 31, 1992;

Amended Eff. December 1, 1995; February 1, 1992;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0508       PRIVATE DUTY NURSING

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 42 C.F.R. 440.80;

Eff. January 1, 1994;

Temporary Amendment Eff. December 20, 2002; July 1, 2002;

Temporary Amendment Expired November 28, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0509       REIMBURSEMENT PRINCIPLES, HEARING AIDS/ACCESSORIES/BATTERIES

(a)  Payment for hearing aids and accessories, earmolds, repairs, loaner and rental aids are reimbursed at invoice cost.

(b)  Payment for fitting and dispensing services is based on the lower of:

(1)           The provider's actual (submitted) charge, or

(2)           A fixed reimbursement fee based on estimated average statewide fees.  The estimated average statewide fees are determined based on surveys of actual fees charged by providers in the State.

(c)  Payment for batteries used with hearing aids are limited to six claims per year per recipient.  Each claim is reimbursed at the lower of:

(1)           The provider's actual (submitted) charge, or

(2)           A maximum payment amount per claim based on estimates of average usual and customary retail charges as determined based on surveys of retail prices of batteries for hearing aids.

(d)  A dispensing fee for batteries is not allowed.

 

History Note:        Authority G.S. 108A-25(b); 108A-54;

Eff. January 4, 1993;

Recodified from 10 NCAC 26H .0509 Eff. January 1, 1994.

 

10A NCAC 22G .0510       CASE MANAGEMENT SERVICES

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 1915 (g) of the Social Security Act;

Eff. April 1, 1994;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

SECTION .0600 ‑ HOME HEALTH PROSPECTIVE REIMBURSEMENT

 

10A NCAC 22G .0601       REIMBURSEMENT PRINCIPLES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Amended Eff. October 1, 1992;

Temporary Amendment Eff. August 1, 1991 for a period of 180 days to expire on

January 31, 1992;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22G .0602       REIMBURSEMENT METHODS

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c.479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Amended Eff. October 1, 1992; May 1, 1990;

Temporary Amendment Eff. October 4, 1996;

Amended Eff. April 1, 1997;

Temporary Amendment Eff. July 25, 1997;

Amended Eff. August 1, 1998;

Temporary Amendment Eff. November 9, 2001;

Temporary Amendment Expired August 30, 2002;

Amended Eff. April 1, 2003;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0603       APPEALS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985. c. 479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0604       COST REPORTING AND AUDITING

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22G .0605       PAYMENT ASSURANCES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S. L. 1985, c. 479, s. 86; 42 C.F.R. 440.70;

Eff. October 1, 1987;

Amended Eff. October 1, 1992; May 1, 1990;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

 

 

SUBCHAPTER 22h ‑ APPEALS PROCEDURES

 

SECTION .0100 ‑ RECIPIENT/APPLICANT APPEAL REVIEW PROCEDURES FOR DENIAL, TERMINATION, SUSPENSION, OR REDUCTION OF PRIOR APPROVAL REQUESTS FOR MEDICAID COVERED MEDICAL SERVICES OR FOR OTHER MEDICAID COVERED MEDICAL SERVICES

 

10A NCAC 22H .0101       PURPOSE AND SCOPE

(a)  The purpose of the rules in this Section is to specify the policies and procedures to provide for recipient/applicant or his/her representative requests for an informal appeal of decisions changing a Medicaid recipient/applicant's level of care, denial, termination, suspension, or reduction of prior approval requests for Medicaid covered medical services or for other Medicaid covered medical services.  These policies and procedures do not apply to provider requests for Reconsideration Review of DMA provider post payment review decisions set out in 10A NCAC 22F.

(b)  The rules in this Section apply to decisions made by the Division of Medical Assistance "(DMA)", a Medical Review Independent Professional Review Team "(MR/IPR)", a Prior Approval Unit "(PAU)", other Agencies, or other entities acting as agents of this State agency.

(c)  The decision making body as set out in Paragraph (b) of this Rule shall, within two working days, notify the recipient/applicant in writing of the decision and the following:

(1)           the effective date of the decision denying, terminating, reducing, or suspending a service;

(2)           the reasons for the agency decision;

(3)           the specific regulations that support, or the change in Federal or State law that requires the decision;

(4)           the date Medicaid payment will cease, if applicable; at least 11 days after the date of the notification letter;

(5)           the opportunity for informal and formal appeal of this decision and procedures for requesting such an appeal; and

(6)           the fact that, if appealed, payment for the currently certified level of care or approved service will continue for an eligible Medicaid recipient pending appeal.

 

Editor's Note:  Thomas R. West, Administrative Law Judge with the Office of Administrative Hearings, declared Rule 10 NCAC 26I .0101(codified as 10A NCAC 22H .0101 effective July 1, 2003) void as applied in Linda Allred, Petitioner v. North Carolina Department of Human Resources, Division of Medical Assistance, Respondent (90 DHR 0940).

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 431; 42 C.F.R. 456;

Eff. April 13, 1979;

Amended Eff. May 1, 1990; November 1, 1983; October 4, 1979;

RRC objection due to lack of Authority and ambiguity Eff. October 18, 1995;

Amended Eff. December 11, 1995.

10A NCAC 22H .0102       REQUESTS FOR FORMAL AND INFORMAL APPEALS

There are two levels of appeals that may be utilized when the recipient/applicant or his/her representative is dissatisfied with a decision concerning level of care or denial, suspension, reduction, or termination of service, or prior approval.  These levels are informal and formal appeals.

(1)           Informal.  The recipient/applicant or his/her representative may request an informal Reconsideration Review by the Division of Medical Assistance (DMA) Hearing Unit.

(2)           Formal.  Formal appeals are conducted by the Office of Administrative Hearings (OAH) under G.S. 150B, and the rules promulgated by the Office of Administrative Hearings.

 

Editor's Note:   Thomas R. West, Administrative Law Judge with the Office of Administrative Hearings, declared Rule 10 NCAC 26I .0102 (codified as 10A NCAC 22H .0102 effective July 1, 2003) void as applied in Linda Allred, Petitioner v. North Carolina Department of Human Resources, Division of Medical Assistance, Respondent (90 DHR 0940).

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 431; 42 C.F.R. 456;

Eff. April 13, 1979;

Amended Eff. December 1, 1995; May 1, 1990; November 1, 1983; October 4, 1979.

 

10A NCAC 22H .0103       TIME LIMITS ON REQUESTS FOR RECIPIENT/APPLICANT INFORMAL APPEALS

The recipient/applicant or his/her representative may appeal a decision made by DMA, MR/IPR, PAU, or other State agency, or entities.  The request for an informal appeal must be made in writing and received by the DMA Hearing Unit by mail, facsimile, or hand delivery within 11 days from the date on the notification letter of suspension, reduction, termination, or denial of service.  If the eleventh day falls on a Saturday, Sunday or legal holiday, then the period during which an informal appeal may be requested shall run until the end of the next day which is not a Saturday, Sunday or legal holiday.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 456;

Eff. April 13, 1979;

Amended Eff. May 1, 1990; October 4, 1979;

RRC objection due to lack of Authority and ambiguity Eff. October 18, 1995;

Amended Eff. December 11, 1995.

 

10A NCAC 22H .0104       PAYMENT PENDING APPEALS

(a)  If no informal appeal is requested, payment shall continue for the existing level of care or approved service(s) rendered until the required change (action) date stated in the notification or until the recipient moves from that level of care or discontinues approved service(s), whichever comes first.

(b)  If an informal appeal is requested in accordance with Rule .0103 of this Section, Medicaid payment for that level of care or approved service(s) shall continue until the informal appeal process is completed.

(c)  If a formal appeal is requested in accordance with Rule .0102(b) of this Section, Medicaid payment for that level of care or approved service(s) shall continue until the formal appeal process is completed.

(d)  If the formal appeal decision upholds the original decision by DMA, MR/IPR, PAU, other State Agency or entity, DMA may institute recovery procedures against the applicant or recipient to recoup the cost of any services furnished resulting from the formal appeal process.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 431;

Eff. April 13, 1979;

Amended Eff. December 1, 1995; October 4, 1979.

 

10A NCAC 22H .0105       DISMISSAL OF APPEAL

(a)  Scheduled informal appeals may be dismissed if applicant/recipient or his/her representative withdraws the request in writing.

(b)  If applicant/recipient or his/her representative fails to appear at a scheduled informal appeal without good cause, the review will still be held.  Good cause is defined as circumstances beyond the control of the applicant/recipient or his/her representative.

(c)  If, at any time during the informal appeal process, the recipient's medical condition worsens and the patient is properly re‑certified or approved for the existing or a higher level of care or service, the informal appeal shall be concluded in favor of the recipient.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431;

Eff. April 13, 1979;

Amended Eff. December 1, 1995; May 1, 1990.

 

SECTION .0200 - HEARINGS: TRANSFER AND DISCHARGES

 

10A NCAC 22H .0201       DEFINITIONS

The following definitions shall apply throughout this Subchapter:

(1)           "Division" means the North Carolina Division of Medical Assistance of the Department of Health and Human Services.

(2)           "Hearing Officer" means the person designated to preside over hearings between a resident and a nursing facility provider regarding transfers and discharges.

(3)           "Hearing Unit" means the Chief Hearing Officer and his staff in the Division of Medical Assistance, Department of Health and Human Services.

(4)           "Notice of Transfer and Discharge form" means the form developed by the Division.

(5)           "Request for Hearing" means a clear expression, in writing by the resident or family member or legal representative of the resident, that the resident wants to appeal the facility's decision to transfer or discharge.

(6)           The "Request for Hearing form" means the form developed by the Division.

 

History Note:        Authority G.S. 108A-25(b); 42 USCS 1396r(e)(3), (f)(3); 42 C.F.R. 483.5; 42 C.F.R. 483.12; 42 C.F.R. 483.202; 42 C.F.R. 483.206;

Eff. April 1, 1994;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22H .0202       TRANSFER AND DISCHARGE REQUIREMENTS

(a)  A resident and, if known, a family member or legal representative of the resident, shall be notified in writing of a facility's decision to transfer or discharge the resident.  The Notice of Transfer or Discharge form shall be used by a facility when giving notice of a transfer or discharge.

(b)  Failure to complete the Notice of Transfer or Discharge form shall result in the notice of the transfer or discharge being ineffective.

(c)  The resident shall be handed the Notice of Transfer or Discharge form on the same day that it is dated.

(d)  A copy of the notice of Transfer or Discharge form shall be mailed to the family member or legal representative on the same day that it is dated.

(e)  The facility shall provide a Request for Hearing Form to the resident and family member or legal representative simultaneously with the Notice of Transfer or Discharge form.

 

History Note:        Authority G.S. 108A-25(b); 42 USCS 1396r(e)(3), (f)(3); 42 C.F.R. 483.5; 42 C.F.R. 483.12; 42 C.F.R. 483.202; 42 C.F.R. 483.206;

Eff. April 1, 1994.

 

10A NCAC 22H .0203       INITIATING A HEARING

(a)  In order to initiate an appeal of a facility's intent to transfer or discharge, a resident or family member or legal representative shall submit a written request for a hearing to the Hearing Unit.  The request for hearing must be received by the Hearing Unit within 11 calendar days from the date of the facility's notice of transfer or discharge.  If the eleventh day falls on a Saturday, Sunday or legal holiday, then the period during which an appeal may be requested shall run until the end of the next day which is not a Saturday, Sunday or legal holiday.

(b)  The request for hearing shall be submitted to the Hearing Unit by mail, or facsimile, or hand delivery.

 

History Note:        Authority G.S. 108A-25(b); 42 USCS 1396r(e)(3), (f)(3); 42 C.F.R. 483.12;

Eff. April 1, 1994.

 

10A NCAC 22H .0204       HEARING PROCEDURES

(a)  Upon timely receipt of a request for a hearing, the Hearing Unit shall promptly notify the facility of the request.

(b)  The parties shall be notified by certified mail of the date, time and place of the hearing.  If the hearing is to be conducted in person, it shall be held in Raleigh, North Carolina.

(c)  At least five working days prior to the hearing, the facility administrator shall make available to the resident all documents and records to be used at the hearing.  The facility administrator shall forward identical information to the Hearing Unit, to be received at least five working days prior to the hearing.

(d)  The hearing officer may grant continuances.

(e)  The hearing officer may dismiss a request for hearing if the resident or family member or legal representative of the resident fails to appear at a scheduled hearing.

(f)  The hearing officer may proceed to conduct a scheduled hearing if a facility representative fails to appear at a scheduled hearing.

(g)  The Rules of Civil Procedures as contained in G.S. 1A-1 and the General Rules of Practice for the Superior and District Courts as authorized by G.S. 7A-34 and found in the Rules Volume of the North Carolina General Statutes shall not apply in any hearings held by a Division Hearing Officer unless another specific statute or rule provides otherwise.  Division hearings are not hearings within the meaning of G.S. 150B and shall not be governed by the provisions of that Chapter unless otherwise stated in these Rules.  Parties may be represented by counsel or other representative at the hearing.

 

History Note:        Authority G.S. 108A-25(b); 42 USCS 1396r(e)(3), (f)(3); 42 C.F.R. 483.12;

Eff April 1, 1994.

 

10A NCAC 22H .0205       HEARING OFFICER'S FINAL DECISION

The Hearing Officer's final decision shall uphold or reverse the facility's decision.  Copies of the final decision shall be mailed via certified mail to the parties.

 

History Note:        Authority G.S. 108A-25(b); 42 USCS 1396r(e)(3), (f)(3); 42 C.F.R. 483.12;

Eff. April 1, 1994.

 

SECTION .0300 ‑ PASARR HEARINGS

 

10A NCAC 22H .0301       DEFINITIONS

(a)  "Division" means the North Carolina Division of Medical Assistance of the Department of Health and Human Services.

(b)  "Hearing Officer" means the person designated to preside over hearings regarding Preadmission Screening and Annual Resident Review (PASARR) determinations.

(c)  "Hearing Unit" means the Chief Hearing Officer and his staff in the Division of Medical Assistance, Department of Health and Human Services.

(d)  "Preadmission Screening and Annual Resident Review (PASARR) Notice of Determination" means the form developed by the Division.

(e)  "Request for Hearing" means a clear expression, in writing, by the evaluated individual or family member or legal representative of the evaluated individual, that the evaluated individual wants to appeal the PASARR determination.

(f)  The "Request for Hearing" form means the form developed by the Division.

(g)  The "North Carolina PASARR Psychiatric/Mental Retardation/Dual Psychiatric and MR/RC Evaluation" forms means the forms developed by the Division.

 

History Note:        Authority G.S. 108A‑25(b); 42 U.S.C.S. 1395i‑3(e)(3), (f)(3); 1396r(e)(3), (e)(7)(F), (f)(3); 42 C.F.R. 483.5; 42 C.F.R. 483.12; 42 C.F.R. 483.200; 42 C.F.R. 483.204; 42 C.F.R. 483.206;

Eff. October 1, 1994;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22H .0302       PASARR REQUIREMENTS

(a)  The evaluated individual and family member or legal representative shall be notified in writing of the Division of MH/DD/SAS' PASARR determination under the provisions of 42 CFR 483.130(k) which is incorporated by reference with subsequent changes or amendments.  A copy of 42 CFR 483.130(k) can be obtained from the Division of Medical Assistance at a cost of twenty cents ($0.20) per copy.

(b)  The PASARR Notice of Determination form shall be used by Division of MH/DD/SAS when giving notice of a PASARR determination under provisions of 42 CFR 483.130(l)(1‑4) which is incorporated by reference with subsequent changes or amendments.  A copy of 42 CFR 483.130(l)(1‑4) can be obtained from the Division of Medical Assistance at a cost of twenty cents ($0.20) per copy.

(c)  The Division of MH/DD/SAS shall provide a Request for Hearing form, pertinent Evaluation form, and PASARR Notice of Determination to the evaluated individual and legal representative under provisions of 42 CFR 483.128(1) which is incorporated by reference with subsequent changes or amendments.  A copy of 42 CFR 483.128(1) can be obtained from the Division of Medical Assistance at a cost of twenty cents ($0.20) per copy.

 

History Note:        Authority G.S. 108A‑25(b); 42 U.S.C.S. 1395i‑3(e)(3), (f)(3); 1396r(e)(3), (e)(7)(F), (f)(3); 42 C.F.R. 483.5; 42 C.F.R. 483.12; 42 C.F.R. 483.128; 42 C.F.R. 483.130; 42 C.F.R. 483.200; 42 C.F.R. 483.204; 42 C.F.R. 483.206;

Eff. October 1, 1994.

 

10A NCAC 22H .0303       INITIATING A HEARING

(a)  In order to initiate an appeal of a PASARR determination, the evaluated individual or family member or legal representative shall submit a written request for a hearing to the Hearing Unit.  The request for hearing must be received by the Hearing Unit within 11 calendar days from the date of the PASARR Notice of Determination.  If the 11th day falls on a Saturday, Sunday, or legal holiday, then the period during which an appeal may be requested shall run until the end of the next day which is not a Saturday, Sunday, or legal holiday.

(b)  The request for hearing shall be submitted to the Hearing Unit by mail, facsimile, or hand delivery.

 

History Note:        Authority G.S. 108A‑25(b); 42 U.S.C.S. 1395i ‑ 3(e)(3) and ‑ (f)(3); 1396r(e)(3), (e)(7)(F), and (f)(3); 42 C.F.R. 431.200; 42 C.F.R. 483.5; 42 C.F.R. 483.12; 42 C.F.R. 483.200; 42 C.F.R. 483.204; 42 C.F.R. 483.206;

Eff. October 1, 1994.

 

10A NCAC 22H .0304       HEARING PROCEDURES

(a)  Upon timely receipt of a request for a hearing, the Hearing Unit shall notify the Division of MH/DD/SAS of the request.

(b)  The parties shall be notified by certified mail of the date, time and place of the hearing.  If the hearing is to be conducted in person, it shall be held in Raleigh, North Carolina.

(c)  The Division of MH/DD/SAS shall mail all documents and records to be used at the hearing to the person requesting the hearing by certified mail and forward identical information to the Hearing Unit, to be received at least five working days prior to the hearing.

(d)  The hearing officer may grant continuances.

(e)  The hearing officer may dismiss a request for a hearing if the evaluated individual or legal representative fails to appear at a scheduled hearing.

(f)  The hearing officer may proceed to conduct a scheduled hearing if the Division of MH/DD/SAS fails to appear at a scheduled hearing.

(g)  The Rules of Civil Procedure as contained in G.S. 1A‑1 and the General Rules of Practice for the Superior and District Courts as authorized by G.S. 7A‑34 and found in the Rules Volume of the North Carolina General Statutes shall not apply in any hearings held by the Division Hearing Officer unless another specific statute or other rule provides otherwise.  Division hearings are not contested case hearings within the meaning of G.S. 150B and shall not be governed by the provisions of that chapter unless otherwise stated in these Rules.  The hearing officer may use the North Carolina Rules of Evidence for guidance in conducting hearings.  Parties may be represented by counsel or other representative at the hearing.

 

History Note:        Authority G.S. 108A‑25(b); 42 U.S.C.S. 1395i‑3(e)(3), (e)(7)(F), (f)(3); 42 U.S.C.S. 1396r(e)(3), (f)(3); 42 C.F.R. 431.200; 42 C.F.R. 483.200; 42 C.F.R. 483.204; 42 C.F.R. 483.206;

Eff. October 1, 1994.

 

10A NCAC 22H .0305       HEARING OFFICER'S FINAL DECISION

The Hearing Officer's final decision shall uphold or reverse the Division of MH/DD/SAS' decision.  Copies of the final decision shall be mailed via certified mail to the parties.

 

History Note:        Authority G.S. 108A‑25(b); 42 U.S.C.S. 1395i‑3(e)(3), (e)(7)(F), (f)(3); 42 U.S.C.S. 1396r(e)(3), (f)(3); 42 C.F.R. 431.200; 42 C.F.R. 483.200; 42 C.F.R. 483.204; 42 C.F.R. 483.206;

Eff. October 1, 1994.

 

 

 

SUBCHAPTER 22I ‑ TITLE XIX REIMBURSEMENT AND administrative REVIEW PROCESS

 

SECTION .0100 ‑ AUDIT REVIEW PROCESS

 

10A NCAC 22I .0101         AUDIT TO BE CONDUCTED

An audit of a provider may be conducted by the Division of Medical Assistance, or by an auditing firm subcontracted by them.

 

History Note:        Authority G.S. 108A‑25(b);

Eff. September 24, 1980;

Amended Eff. May 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

10A NCAC 22I .0102         EXIT CONFERENCE

At the conclusion of the audit, the provider may request an exit conference which shall be held by personnel of the unit conducting the audit, to discuss the audit findings with the provider.

 

History Note:        Authority G.S. 108A‑25(b);

Eff. September 24, 1980.

 

10A NCAC 22I .0103         NOTICE OF PROGRAM REIMBURSEMENT

Based on the audit findings the Division of Medical Assistance will issue to the provider a Notice of Program Reimbursement which shall state the amount of reimbursement, if any, payable to the Division of Medical Assistance or payable to the provider.

 

History Note:        Authority G.S. 108A‑25(b);

Eff. September 24, 1980;

Amended Eff. January 1, 1988;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22I .0104         RECONSIDERATION REVIEW

Following receipt of the Notice of Program Reimbursement, a provider may file a request for a reconsideration review with the Division of Medical Assistance, in accordance with 10A NCAC 22J.

 

History Note:        Authority G.S. 108A‑25(b);

Eff. September 24, 1980;

Amended Eff. January 1, 1988.

 

 

 

SUBCHAPTER 22j ‑ TITLE XIX APPEALS PROCEDURES

 

10A NCAC 22J .0101        PURPOSE AND SCOPE

The purpose of these regulations is to specify the rights of providers to appeal reimbursement rates, payment denials, disallowances, payment adjustments and cost settlement disallowances and adjustments.  Provider appeals for program integrity action are specified in 10A NCAC 22F.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b);

Eff. January 1, 1988;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

10A NCAC 22J .0102        PETITION FOR RECONSIDERATION REVIEW

(a)  A provider may request a reconsideration review within 30 calendar days from receipt of final notification of payment, payment denial, disallowances, payment adjustment, notice of program reimbursement and adjustments and within 60 calendar days from receipt of notice of an institutional reimbursement rate.  Final notification of payment, payment denial, disallowances and payment adjustment means that all administrative actions necessary to have a claim paid correctly have been taken by the provider and DMA or the fiscal agent has issued a final adjudication.  If no request is received within the respective 30 or 60 day periods, the state agency's action shall become final.

(b)  A request for reconsideration review must be in writing and signed by the provider and contain the provider's name, address and telephone number.  It must state the specific dissatisfaction with DMA's action and should be mailed to:  Appeals, Division of Medical Assistance at the Division's current address.

(c)  The provider may appoint another individual to represent him.  A written statement setting forth the name, address and telephone number of the representative so designated shall be sent to the above address.  The representative may exercise any and all rights given the provider in the review process.  Notice of meeting dates, requests for information, hearing decisions, etc. will be sent to the authorized representative.  Copies of such documents will be sent to the petitioner only if a written request is made.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b);

Eff. January 1, 1988.

 

10A NCAC 22J .0103        RECONSIDERATION REVIEW PROCESS

(a)  Upon receipt of a timely request for a reconsideration review, the Deputy Director shall appoint a reviewer or panel to conduct the review.  DMA will arrange with the provider a time and date of the hearing.  The provider must reduce his arguments to writing and submit them to DMA no later than 14 calendar days prior to the review.  Failure to submit written arguments within this time frame shall be grounds for dismissal of the reconsideration, unless the Division within the 14 calendar day period agrees to a delay.

(b)  The provider will be entitled to a personal review meeting unless the provider agrees to a review of documents only or a discussion by telephone.

(c)  Following the review, DMA shall, within 30 calendar days or such additional time thereafter as specified in writing during the 30 day period, render a decision in writing and send it by certified mail to the provider or his representative.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b);

Eff. January 1, 1988;

Pursuant to G.S. 150B-33(b)(9), Administrative Law Judge Augustus B. Elkins, II declared this rule void as applied in Psychiatric Solutions, Inc., d/b/a/ Holly Hill Hospital v. Division of Medical Assistance, North Carolina Department of Health and Human Services (02 DHR 1499).

 

10A NCAC 22J .0104        PETITION FOR A CONTESTED CASE HEARING

If the provider disagrees with the reconsideration review decision he may request a contested case hearing in accordance with 10A NCAC 01.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b);

Eff. January 1, 1988.

 

10a NCAC 22J .0105        PAYMENT STATUS

Once a final overpayment or final erroneous payment is determined by DMA to exist, action will be taken immediately to recover such overpayment or erroneous payment.  If the provider's appeal is successful, repayment will be made to the provider.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b)(d)(2);

Eff. January 1, 1988.

 

10A NCAC 22J .0106        PROVIDER BILLING OF PATIENTS WHO ARE MEDICAID RECIPIENTS

(a)  A provider may refuse to accept a patient as a Medicaid patient and bill the patient as a private pay patient only if the provider informs the patient that the provider will not bill Medicaid for any services but will charge the patient for all services provided. 

(b)  Acceptance of a patient as a Medicaid patient by a provider includes, but is not limited to, entering the patient's Medicaid number or card into any sort of patient record or general record-keeping system, obtaining other proof of Medicaid eligibility, or filing a Medicaid claim for services provided to a patient.  A patient, or a patient's representative, must request acceptance as a Medicaid patient by:

(1)           presenting the patient's Medicaid card or presenting a Medicaid number either orally or in writing; or

(2)           stating either orally or in writing that the patient has Medicaid coverage; or

(3)           requesting acceptance of Medicaid upon approval of a pending application or a review of continuing eligibility.

(c)  Providers may bill a patient accepted as a Medicaid patient only in the following situations:

(1)           for allowable deductibles, co-insurance, or co-payments as specified in 10A NCAC 22C .0102; or

(2)           before the service is provided the provider has informed the patient that the patient may be billed for a service that is not one covered by Medicaid regardless of the type of provider or is beyond the limits on Medicaid services as specified under 10A NCAC 22B, 10A NCAC 22C, and 10A NCAC 22D; or

(3)           the patient is 65 years of age or older and is enrolled in the Medicare program at the time services are received but has failed to supply a Medicare number as proof of coverage; or

(4)           the patient is no longer eligible for Medicaid as defined in 10A NCAC 21B.

(d)  When a provider files a Medicaid claim for services provided to a Medicaid patient, the provider shall not bill the Medicaid patient for Medicaid services for which it receives no reimbursement from Medicaid when:

(1)           the provider failed to follow program regulations; or

(2)           the agency denied the claim on the basis of a lack of medical necessity; or

(3)           the provider is attempting to bill the Medicaid patient beyond the situations stated in Paragraph (c) of this Rule.

(e)  A provider who accepts a patient as a Medicaid patient shall agree to accept Medicaid payment plus any authorized deductible, co-insurance, co-payment and third party payment as payment in full for all Medicaid covered services provided, except that a provider may not deny services to any Medicaid patient on account of the individual's inability to pay a deductible, co-insurance or co-payment amount as specified in 10A NCAC 22C .0102.  An individual's inability to pay shall not eliminate his or her liability for the cost sharing charge.  Notwithstanding anything contained in this Paragraph, a provider may actively pursue recovery of third party funds that are primary to Medicaid.

(f)  When a provider accepts a private patient, bills the private patient personally for Medicaid services covered under Medicaid for Medicaid recipients, and the patient is later found to be retroactively eligible for Medicaid, the provider may file for reimbursement with Medicaid. Upon receipt of Medicaid reimbursement, the provider shall refund to the patient all money paid by the patient for the services covered by Medicaid with the exception of any third party payments or cost sharing amounts as described in 10A NCAC 22C .0102.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 C.F.R. 447.15;

Eff. January 1, 1988;

Amended Eff. February 1, 1996; October 1, 1994.

 

 

 

SUBCHAPTER 22k ‑ QUALIFIED PROVIDERS

 

10A NCAC 22k .0101       DEFINITION

A provider qualified to make presumptive determinations of Medicaid eligibility for pregnant women must meet the conditions required by the Social Security Act as amended by P.L. 99‑509 and sign a written agreement with the Division of Medical Assistance (DMA).

 

History Note:        Authority G.S. 108A‑25(b); 1987 Session Laws, c. 738; P.L. 99‑509;

Eff. June 1, 1988.

10A NCAC 22K .0102       AGREEMENT

(a)  The provider must agree to participate in training offered by the Division of Medical Assistance (DMA) or its agents and to make presumptive eligibility determinations based on the procedures and guidelines issued by the DMA.

(b)  The DMA may terminate the provider's agreement and authority to make presumptive determinations if the provider fails to make required referrals within five days or fails to follow procedures and guidelines resulting in eligibility denials for a majority of the provider's referrals.

(c)  Termination of the agreement will occur 30 calendar days following notification when termination is initiated by the DMA.

 

History Note:        Authority G.S. 108A‑25(b); 1987 Session Laws, c. 738; P.L. 99‑509;

Eff. June 1, 1988.

 

10A NCAC 22K .0103       PRESUMPTIVE DETERMINATIONS

(a)  Presumptive determinations of eligibility shall apply only to pregnant women whose family income does not exceed the federal poverty guidelines as revised annually.

(b)  Only one presumptive determination of eligibility during a single pregnancy may be made by the same qualified provider.

(c)  A presumptive determination of eligibility may be made by a different qualified provider if the provider has no knowledge of a prior determination.

 

History Note:        Authority G.S. 108A‑25(b); 1987 Session Laws, c. 738; P.L. 99‑509;

Eff. June 1, 1988.

 

 

 

SUBCHAPTER 22l ‑ MANAGED CARE AND PREPAID PLANS

 

SECTION .0100 ‑ MANAGED CARE

 

10A NCAC 22l .0101       PROGRAM DEFINITION

Carolina ACCESS will contract with primary care physicians in participating counties to deliver and coordinate the health care of certain categories of Medicaid recipients.

 

History Note:        Authority G.S. 108A‑25(b); Section 93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

10a NCAC 22L .0102       COORDINATION FEE

In addition to normal Medicaid payments, the Division of Medical Assistance has the authority to pay participating physicians a monthly coordination fee for providing or coordinating the health care services of enrollees who have selected them as their primary care physician.

 

History Note:        Authority G.S. 108A‑25(b); Section 93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992.

 

10A NCAC 22L .0103       ACCESS TO CARE

Carolina ACCESS enrollees are eligible to receive all health care services that all Medicaid recipients are eligible for.  They receive their services through their primary care physician who either provides or coordinates their health care.  The Division of Medical Assistance has the authority to deny payment for covered services that are not authorized by the primary care physician.

 

History Note:        Authority G.S. 108A‑25(b); Section 93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992.

 

10A NCAC 22L .0104       ENROLLMENT

All Medicaid recipients in participating counties who are eligible for Carolina ACCESS shall enroll in Carolina ACCESS.  Medicaid recipients eligible for Carolina ACCESS include AFDC, AFDC-related, MIC, Aged, Blind and Disabled categories, unless exempt due to institutional placement.  Institutional placement includes nursing home, mental institutions and domiciliary care.  Medicaid recipients who are Medicaid Pregnant Women, foster children or who are also on Medicare, have the option to enroll in Carolina ACCESS.

 

History Note:        Authority G.S. 108A‑25(b); Section 93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992.

 

10A NCAC 22l .0105       EMERGENCY ROOM CARE

 

History Note:        Authority G.S. 108A‑25(b); Section 93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

SECTION .0200 ‑ PREPAID PLANS

 

10A NCAC 22L .0201       PROGRAM DEFINITION

The Division of Medical Assistance (DMA) may contract with Federally qualified Health Maintenance Organizations (HMOs) and State licensed and certified HMOs to provide and coordinate medical services for Medicaid eligibles.  Prior to DMA awarding a contract to an HMO, the HMO must submit an application in which it demonstrates its ability to meet all contract specifications.

 

History Note:        Authority G.S. 108A-25(b);

Eff. August 3, 1992;

Amended Eff. April 1, 1999;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22L .0202       ENROLLMENT

 

History Note:        Authority G.S. 108A-25(b);

Eff. August 3, 1992;

Amended Eff. April 1, 1999;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22L .0203       ACCESS TO CARE

(a)  In-plan and out-of-plan services shall be listed in the contract between the HMO and DMA.  The HMO shall pay for all in-plan services when provided in accordance with the HMO's policies and procedures.  DMA shall pay for all out-of-plan services provided in accordance with Medicaid policies and procedures.  The Division of Medical Assistance has the authority to deny payment for in-plan services not provided nor authorized by the HMO.

(b)  HMO members shall receive all in-plan services from their HMO or its subcontractors except:

(1)           emergency medical services as defined in 42 U.S.C. 1932(b)(2)(B) and (C), which could not be provided by the HMO because the time to reach the in-plan provider capable of providing such services would have meant risk of serious damage or injury to the member's health;

(2)           Medicaid-covered family planning services and supplies;

(3)           services provided by a public health department for the screening, diagnosis, counseling, or treatment of sexually transmitted diseases, tuberculosis or HIV; and

(4)           services for which the HMO has referred the member to an out-of-plan provider.

(c)  The HMO shall make payment for in-plan services in Paragraph (b), of this Rule, in an amount agreed upon by the provider and the HMO.  In the absence of such an agreement, payment shall be made in the amount of the Medicaid allowable fee.

 

History Note:        Authority G.S. 108A-25(b);

Eff. August 3, 1992;

Amended Eff. April 1, 1999.

 

 

 

SUBCHAPTER 22M ‑ DRUG USE REVIEW (DUR)

 

SECTION .0100 ‑ DRUG USE REVIEW BOARD

 

10A NCAC 22M .0101      ESTABLISHMENT (transferred to 10A NCAC 25K .0301)

10A NCAC 22M .0102      MEMBERSHIPS (transferred to 10A NCAc 25K .0302)

 

10A NCAC 22M .0103      CHAIRMEN (Transferred to 10A NCAC 25K .0303)

 

10A NCAC 22M .0104      ACTIVITIES (transferred to 10A NCAC 25K .0304)

 

SECTION .0200 - PROSPECTIVE DRUG REVIEW

 

10A NCAC 22M .0201      PATIENT COUNSELING (Transferred to 10A NCAC 25K .0401)

 

SECTION .0300 - RETROSPECTIVE DRUG USE REVIEW

 

10A NCAC 22M .0301      RETROSPECTIVE DRUG USE REVIEW (DUR) (Transferred to 10A NCAC 25K .0501)

 

10a NCAC 22M .0302      SCREENING AND PATTERN ANALYSIS (Transferred to 10A NCAC 25K .0502)

 

10A NCAC 22M .0303      INTERVENTIONS (Transferred to 10A NCAC 25K .0503)

 

10A NCAC 22M .0304      COMPLIANCE MONITORING (Transferred to 10A NCAc 25K .0504)

 

 

 

SUBCHAPTER 22N – PROVIDER ENROLLMENT

 

SECTION .0100 – GENERAL

 

10A NCAC 22N .0101       DEFINITIONS

For the purpose of this Subchapter, a "provider" is any individual, facility or entity that applies to furnish services to authorized Medicaid recipients and bill Medicaid directly for reimbursement.  The term "provider" also includes suppliers of medical equipment and supplies.

 

History Note:        Authority G.S. 108A-54; 143B-139.1;

Eff. July 1, 2004;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

10A NCAC 22N .0102       SIGNED AGREEMENTS

Each provider shall sign a participation contract agreement with the Division of Medical Assistance and shall not be reimbursed for services rendered prior to the effective date of the participation agreement.

 

History Note:        Authority G.S. 108A-54; 143B-139.1;

Eff. July 1, 2004.

 

SECTION .0200 - ENTITIES LICENSED UNDER NCGS 122C OR NCGS 131D

 

10A NCAC 22N .0201       DEFINITIONS

As used in this Section, the term "owner" means any entity or individual who is a sole or co-owner, partner or shareholder that holds an ownership or controlling interest of five percent or more of the provider entity. 

 

History Note:        Authority G.S. 108A-54; 143B-139.1;

Eff. July 1, 2004;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22N .0202       DISCLOSURE OF OWNERSHIP

Providers licensed under North Carolina G.S. 122C or G.S. 131D shall comply with the following disclosure conditions:

(1)           When applying to participate in the North Carolina Medicaid program, the provider shall supply the legal name and social security number of each individual who is an owner.

(2)           An enrolled provider shall notify the Division of Medical Assistance in writing of a change in the legal name of any owner.  The notification must be received within 30 business days following the change.

(3)           An enrolled provider shall notify the Division of Medical Assistance in writing if a new owner joins the provider.  The notification shall include the new owner's legal name and social security number.  The notification must be received no later than 30 business days following the change.

(4)           An enrolled provider shall notify the Division of Medical Assistance in writing if an owner withdraws his ownership interest in the provider.  The notification shall include the name of the departing owner and must be received no later than 30 business days following the change.

 

History Note:        Authority G.S. 108A-54; 143B-139.1;

Eff. July 1, 2004.

 

10A NCAC 22N .0203       ENROLLMENT RESTRICTIONS

(a)  The Department shall deny enrollment, including enrollment for new or additional services in accordance with G.S. 122C-23(e1) and G.S. 131D-10.3(h). They may be accessed online at

http://www.ncleg.net/statutes/generalstatutes/html/bysection/chapter_122c/gs_122c-23.html and

http://www.ncleg.net/statutes/generalstatutes/html/bysection/chapter_131d/gs_131d-10.3.html.

(b)  The Department may deny enrollment when an applicant meets any of the following conditions:

(1)           if the Department has initiated revocation or summary suspension proceedings against any facility licensed pursuant to G.S. 122C, Article 2, G.S. 131D, Articles 1 or 1A, or G.S. 110, Article 7 which was previously held by the applicant and the applicant voluntarily relinquished the license;

(2)           there is a pending appeal of a denial, revocation or summary suspension of any facility licensed pursuant to G.S. 122C, Article 2, G.S. 131D, Articles 1 or 1A, or G.S. 110, Article 7 which is owned by the applicant;

(3)           the applicant had an individual as part of their governing body or management who previously held a license which was revoked or summarily suspended under G.S. 122C, Article 2, G.S. 131D, Articles 1 or 1A, and G.S. 110, Article 7 and the rules adopted under these laws; or

(4)           the applicant is an individual who has a finding or pending investigation by the Health Care Personnel Registry in accordance with G.S. 131E -256.

(c)  When an application for enrollment of a new service is denied:

(1)           Pursuant to G.S. 150B-22, the applicant shall be given an opportunity to provide reasons why the enrollment should be granted or the matter otherwise settled;

(2)           DMA shall give the applicant written notice of the denial, the reasons for the denial and advise the applicant of the right to request a contested case hearing pursuant to G.S. 150B; and

(3)           The provider shall not provide the new service until a decision is made to enroll the provider, despite an appeal action.

(d)  If the action is reversed on appeal, the owner may re-apply for enrollment and may be approved back to the date of the denied application if all qualifications are met.

 

History Note:        Authority G.S. 108A-54; 143B-139.1;

Eff. July 1, 2004.

 

SECTION .0300 – ENTITIES PROVIDING SPECIFIED HABILITATIVE AND REHABILITATIVE SERVICES

 

10A NCAC 22N .0301       DEFINITIONS

For purposes of this Section:

(1)           Specified rehabilitative services are services as defined in 42 CFR 440.130(d), and 42 CFR 440.90. These regulations are hereby adopted by reference under G.S. 150B-21.6, including subsequent amendments and editions.  A copy of these regulations may be obtained by contacting the Government Printing Office, Superintendent of Documents, Post Office Box 37194, Pittsburgh, Pennsylvania  15250-7954 or they may be accessed online at http://www.gpoaccess.gov/cfr/retrieve/html.

(2)           Specified habilitative services are as defined in 42 CFR 440.180. This regulation is hereby adopted by reference under G.S. 150B-21.6, including subsequent amendments and editions.  A copy of this regulation may be obtained by contacting the Government Printing Office, Superintendent of Documents, Post Office Box 37194, Pittsburgh, Pennsylvania 15250-7954 or it may be accessed online at http://www.gpoaccess.gov/cfr/retrieve/html.

(3)           The term "Division" means a Division of the North Carolina Department of Health and Human Services.

(4)           The term "owner" has the same meaning as defined in 10A NCAC 22N .0201.

 

History Note:        Authority G.S. 108A-54; 143B-139.1;

Eff. July 1, 2004;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22N .0302       DISCLOSURE OF OWNERSHIP

Providers of Medicaid specified rehabilitative services defined in 10A NCAC 22N .0301 shall comply with the following disclosure conditions:

(1)           When applying to participate in the North Carolina Medicaid program, the provider shall supply the legal name and social security number of each individual who is an owner.

(2)           The provider shall notify the Division of Medical Assistance in writing of a change in the legal name of any owner.  The notification must be received within 30 business days following the change.

(3)           The enrolled provider shall notify the Division of Medical Assistance in writing if a new owner joins the provider entity.  The notification shall include the new owner's legal name and social security number.  The notification must be received no later than 30 business days following the change.

(4)           The enrolled provider shall notify the Division of Medical Assistance in writing if an owner withdraws his ownership interest.  The notification shall include the name of the departing owner and must be received no later than 30 business days following the change.

 

History Note:        Authority G.S. 108A-54; 143B-139.1;

Eff. July 1, 2004.

 

10A NCAC 22N .0303       ENROLLMENT RESTRICTIONS

(a)  The Department shall terminate a provider's participation in the Medicaid program for specified rehabilitative services and specified habilitative services as defined in 10A NCAC 22N .0301 when notified in writing that the Division responsible for approving the provider’s enrollment  has withdrawn its approval.  The termination shall become effective the date the Division of Medical Assistance is notified the approval has been withdrawn.  The provider may re-apply for enrollment if said provider receives approval from the Division responsible for approving enrollment.

(b)  The Department shall deny enrollment, including enrollment for new or additional services, to any entity applying to provide Medicaid habilitative or rehabilitative services when an owner of the applicant entity was the owner of another entity that had its approval withdrawn by the Division responsible for approving the provider's enrollment.  The restriction shall become effective the date Division of Medical Assistance is notified the approval has been withdrawn.  The provider may re-apply for enrollment if said provider subsequently receives approval from the Division responsible for approving enrollment.

 

History Note:        Authority G.S. 108A-54; 143B-139.1;

Eff. July 1, 2004.

 

 

 

SUBCHAPTER 22O ‑ MEDICAL ASSISTANCE PROVIDED

 

SECTION .0100 ‑ GENERAL

 

10A NCAC 22O .0101       HOSPITAL INPATIENT

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.10;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22O .0102       HOSPITAL OUTPATIENT (Transferred to 10A NCAC 25M .0301)

 

10A NCAC 22O .0103       HOME HEALTH SERVICES (transferred to 10a ncac 25O .0201(a))

 

10A NCAC 22O .0104       LABORATORY AND X‑RAY SERVICES (Items (1)-(3) transferred to 10A NCAC 25P .0406 and Items (4)-(5) transferred to 10A NCAC 25U .0201))

 

10A NCAC 22O .0105       EYEGLASSES AND OPTOMETRIC SERVICES (transferred to 10A NCAC 25N .0301)

 

10A NCAC 22O .0106       CHIROPRACTIC SERVICES (Transferred to 10A NCAC 25P .0403)

 

10A NCAC 22O .0107       MENTAL HEALTH CENTER SERVICES (transferred to 10A NCAC 25C .0201)

 

10A NCAC 22O .0108       INTERMEDIATE CARE FACILITIES (transferred to 10A NCAC 25D .0201(a)-(b))

 

10A NCAC 22O .0109       HEARING AID SERVICES (TRANSFERRED TO 10A NCAC 25N .0201)

 

10A NCAC 22O .0110       AMBULANCE SERVICES (transferred to 10A ncac 25w .0201)

 

10A NCAC 22O .0111       INPATIENT PSYCHIATRIC HOSPITAL SERVICES (Transferred to 10A NCAC 25C .0301)

 

10A NCAC 22O .0112       PSYCHIATRIC ADMISSION CRITERIA/MEDICAID BENEFICIARIES UNDER AGE 21

Medicaid criteria for the admission of those persons under age 21 to psychiatric hospitals or psychiatric units of general hospitals is limited herein.  To be approved for admission, the patient must meet criteria in Items (1), (2) and (3) of this Rule as follows:

(1)           Client meets criteria for one or more DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ‑‑ a manual whose purpose is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat various mental disorders) diagnoses. This manual is hereby incorporated by reference including subsequent amendments and editions.  Copies may be obtained from the American Psychiatric Association 1400 K Street, NW Washington, DC 2000 tel: 1-800-368-5777 at a cost of fifty-four dollars and ninety-five cents ($54.95) (hard cover); forty-two dollars and ninety-five cents ($42.95) (soft cover); five dollars ($5.00) s. and h.  The manual is available for inspection at the Division of Medical Assistance 1985 Umstead Dr., Raleigh, NC; and

(2)           At least one of the following criteria:

(a)           Client is presently a danger to self (e.g., engages in self‑injurious behavior, has a significant suicide potential, or is acutely manic).  This usually would be indicated by one of the following:

(i)            Client has made a suicide attempt or serious gesture (e.g., overdose, hanging, jumping from or placing self in front of moving vehicle, self‑inflicted gunshot wound), or is threatening same with likelihood of acting on the threat, and there is an absence of supervision or structure to prevent suicide of the client who has made an attempt, serious gesture or threat.

(ii)           Client manifests a significant depression, including current contemplation of suicide or suicidal ideation, and there is an absence of supervision or structure to prevent suicide.

(iii)          Client has a history of affective disorder:

(A)          with mood which has fluctuated to the manic phase, or

(B)          has destabilized due to stressors or non‑compliance with treatment.

(iv)          Client is exhibiting self‑injurious behavior (cutting on self, burning self) or is threatening same with likelihood of acting on the threat; or

(b)           Client engages in actively violent, aggressive or disruptive behavior or client exhibits homicidal ideation or other symptoms which indicate he is a probable danger to others.  This usually would be indicated by one of the following:

(i)            Client whose evaluation and treatment cannot be carried out safely or effectively in other settings due to impulsivity, impaired judgment, severe oppositionalism, running away, severely disruptive behaviors at home or school, self‑defeating and self‑endangering activities, antisocial activity, and other behaviors which may occur in the context of a dysfunctional family and may also include physical, psychological, or sexual abuse.

(ii)           Client exhibits serious aggressive, assaultive, or sadistic behavior that is harmful to others (e.g., assaults with or without weapons, provocations of fights, gross aggressive over‑reactivity to minor irritants, harming animals) or is threatening same with likelihood of acting on the threat.  This behavior should be attributable to the client's specific DSM‑IV diagnosis and can be treated only in a hospital setting; or

(c)           Acute onset of psychosis or severe thought disorganization or clinical deterioration in condition of chronic psychosis rendering the client unmanageable and unable to cooperate in treatment.  This usually would be indicated by the following:  Client has recent onset or aggravated psychotic symptoms (e.g., disorganized or illogical thinking, hallucinations, bizarre behavior, paranoia, delusions, incongruous speech, severely impaired judgment) and is resisting treatment or is in need of assessment in a safe and therapeutic setting; or

(d)           Presence of medication needs, or a medical process or condition which is life‑threatening (e.g., toxic drug level) or which requires the acute care setting for its treatment.  This usually would be indicated by one of the following:

(i)            Proposed treatments require close medical observation and monitoring to include, but not limited to, close monitoring for adverse medication effects, capacity for rapid response to adverse effects, and use of medications in clients with concomitant serious medical problems.

(ii)           Client has a severe eating disorder or substance abuse disorder which requires 24‑hour‑a‑day medical observation, supervision, and intervention.

(iii)          Client has Axis I or Axis II diagnosis, with a complicating or interacting Axis III diagnosis, the combination of which requires psychiatric hospitalization in keeping with any one of these criteria, and with the Axis III diagnosis treatable in a psychiatric setting (e.g., diabetes, malignancy, cystic fibrosis); or

(e)           Need for medication therapy or complex diagnostic evaluation where the client's level of functioning precludes cooperation with the treatment regimen, including forced administration of medication.  This usually would be indicated by one of the following:

(i)            Client whose diagnosis and clinical picture is unclear and who requires 24 hour clinical observation and assessment by a multi‑disciplinary hospital psychiatric team to establish the diagnosis and treatment recommendations.

(ii)           Client is involved in the legal system (e.g., in a detention or training school facility) and manifests psychiatric symptoms (e.g., psychosis, depression, suicide attempts or gestures) and requires a comprehensive assessment in a hospital setting to clarify the diagnosis and treatment needs; and

(3)           To meet the federal requirement at 42 CFR 441. 152, all of the following must apply:

(a)           Ambulatory care resources available in the community do not meet the treatment needs of the recipient.

(b)           Proper treatment of the recipient's psychiatric condition requires services on an inpatient basis under the direction of a physician.

(c)           The services can reasonably be expected to improve the recipient's condition or prevent further regression so that services will no longer be needed.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 441, Subpart D; 42 C.F.R. 441.151;

Eff. October 1, 1993;

Amended Eff. February 1, 1996.

 

10A NCAC 22O .0113       NC MEDICAID CRITERIA FOR CONTINUED ACUTE STAY IN AN INPATIENT PSYCHIATRIC FACILITY (Transferred to 10A NCAC 25C .0302)

 

10A NCAC 22O .0114       NORTH CAROLINA SPECIALTY HOSPITAL SERVICES (Transferred to 25M .0201(e))

 

10A NCAC 22O .0115       CLINIC SERVICES (transferred to 10A NCAC 25P .0402)

 

10a ncac 22o .0116       skilled nursing facility (transferred to 10a ncac 25m .0401(a)-(c))

 

10a NCAC 22O .0117       ABORTION (Transferred to 10A NCAC 25P .0405)

 

10A NCAC 22O .0118       PHARMACY SERVICES (transferred to 10A NCAc 25K .0201)

 

10A NCAC 22O .0119       OUT‑OF‑STATE SERVICES (transferred to 10A NCAc 25S .0201)

 

10A NCAC 22O .0120       PERSONAL CARE SERVICES (transferred to 10A NCAC 25O .0202(a)-(b))

 

10A NCAC 22O .0121       DURABLE MEDICAL EQUIPMENT

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 440.70(b)(3);

Eff. March 1, 1990;

Amended Eff. March 1, 1993;

Recodified from 10 NCAC 26B .0120 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0121 Eff. January 1, 1998;

Repealed Eff. September 1, 2005.

 

10A NCAC 22O .0122       PRIVATE DUTY NURSING (transferred to 10A NCAC 25O .0204)

 

10A NCAC 22O .0123       Case MGMT SVCS/Adults/Children AT-Risk/abuse/neglect/expoitation (transferred to 10a ncac 25f .0201)

 

10A NCAC 22O .0124       HIV CASE MANAGEMENT (Transferred to 10A NCAC 25F .0301)

 

10A NCAC 22O .0125       HOME INFUSION THERAPY (transferred to 10A NCAC 25O .0203)

 

SECTION .0200 ‑ DENTAL SERVICES

 

10A NCAC 22O .0201       DEFINITIONS (transferred to 10A NCAC 25H .0201)

 

10a NCAC 22O .0202       STANDARDS FOR PARTICIPATION (Transferred to 10A NCAC 25H .0203)

 

10a NCAC 22O .0203       ELIGIBILITY (Transferred to 10A NCAC 25H .0202)

 

10A NCAC 22O .0204       AMOUNT: DURATION: AND SCOPE OF SERVICES (Transferred to 10A NCAC 25H .0204)

 

10a NCAC 22O .0205       RESTRICTIONS AND PRIOR APPROVAL (Transferred to 10a NCAC 25H .0205)

 

10A NCAC 22O .0206       GUIDELINES ON SERVICES (Transferred to 10A NCAC 25H .0301)

 

10a NCAC 22O .0207       SPECIFIC GUIDELINES (Transferred to 10a NCAC 25H .0302)

 

10A NCAC 22O .0208       ANESTHESIA (Transferred to 10A NCAC 25H .0303)

 

10A NCAC 22O .0209       ANALGESIA (Transferred to 10A NCAC 25H .0304)

 

10A NCAC 22O .0210       DRUGS (Transferred to 10a NCAC 25H .0305)

 

10a NCAC 22O .0211       PRIOR APPROVAL (Transferred To 10A NCAC 25H .0206)

 

section .0300 – Amount, duration, and scope of assistance

 

10A NCAC 22O .0301       MEDICAL SERVICES (Transferred to 10A NCAC 25A .0201)

 

section .0400 – limitation of amount, duration, and scope of assistance

 

10A NCAC 22O .0401       INPATIENT HOSPITAL SERVICES (Paragraphs (a)-(d) Transferred to 10A NCAC 25M .0201 and paragraph (e) transferred to 10A NCAC 25P .0201))

 

10a NCAC 22O .0402       OUTPATIENT HOSPITAL SERVICES (transferred to 10A NCAC 25P .0301)

 

10A NCAC 22O .0403       SKILLED NURSING FACILITY SERVICES (transferred to 10A NCAC 25M .0401(d))

 

10A NCAC 22O .0404       PHYSICIAN SERVICES (transferred to 10A NCAC 25P .0401)

 

10A NCAC 22O .0405       PODIATRIST SERVICES (transferred to 10A NCAC 25P .0404)

 

10A NCAC 22O .0406       HOME HEALTH SERVICES (Transferred to 10A NCAC 25O .0201(b)-(e))

 

10A NCAC 22O .0407       PRESCRIBED DRUGS

 

History Note:        Authority G.S. 108A‑25(b); 143B‑10; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.120; 42 C.F.R. 440.230(d)

Eff. February 1, 1976

Amended Eff. October 1, 1977;

Readopted Eff. October 31, 1977

Amended Eff. May 1, 1990; August 1, 1983; April 1, 1982;

Repealed Eff. April 1, 2010.

 

10A NCAC 22O .0408       INTERMEDIATE CARE FACILITIES (transferred to 10A NCAC 25D .0201(c)-(j))

 

10A NCAC 22O .0409       Therapeutic Leave (Transferred to 10A NCAC 25m .0501)

 

10A ncac 22o .0410       personal care services (transferred to 10a ncac 25o .0202(c)-(e))

 

 

 

SECTION .0100 – GENERAL INFORMATION

 

10A NCAC 22P .0101        PURPOSE AND SCOPE

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

SECTION .0200 – DEFINITIONS

 

10A NCAC 22P .0201        DEFINITIONS

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

SECTION .0300 – MEDICAL SERVICE REQUIREMENTS

 

10A NCAC 22P .0301        SERVICE DELIVERY

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0302        ACCESS TO CARE

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0303        COORDINATION OF BENEFITS

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

SECTION .0400 – CERTIFICATION AND STAFFING REQUIREMENTS

 

10A NCAC 22P .0401        CERTIFICATION REQUIREMENTS

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0402        GOOD STANDING

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0403        MEDICAL DIRECTOR REQUIREMENTS

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0404        CLINICAL DIRECTOR

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0405        QUALITY MANAGEMENT DIRECTOR

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0406        TRAINING DIRECTOR

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0407        EXCEPTION PROCESS

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0408        MEDICAL SCHOOL/ TEACHING HOSPITAL EXCEPTION

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

SECTION .0500 – CERTIFICATION PROCEDURES

 

10A NCAC 22P .0501        LETTER OF ATTESTATION AND DESK REVIEW

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0502        INTERVIEW

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0503        VERIFICATION REVIEW

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0504        EXISTING CRITICAL ACCESS BEHAVIORAL HEALTH AGENCIES

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

SECTION .0600 – MONITORING, DECERTIFICATION AND APPEAL PROCEDURES

 

10A NCAC 22P .0601        MONITORING

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0602        DECERTIFICATION AND SUSPENSION

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.

 

10A NCAC 22P .0603        APPEAL PROCEDURES

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a; 42 C.F.R. 431.51; S.L. 2009-451, Section 10.58(d);

Temporary Adoption Eff. December 28, 2010;

Temporary Adoption Expired October 15, 2011.