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.