1.03-1Enrollment ProcessA. All providers must complete an initial enrollment application followed by subsequent enrollment applications to take place at various intervals as follows:1. Every three (3) years for providers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS);2. Every five (5) years for all other providers; and3. Upon request by the Department.B. Providers should enroll online through the Department's Health PAS portal, located at https://mainecare.maine.gov. Consistent with 42 C.F.R. § 431.107, the provider understands and agrees that an executed Provider Agreement by and between the provider and MaineCare is mandatory for participation or continued participation in the MaineCare Program. If upon request, a provider fails to timely furnish an executed Provider Agreement to MaineCare, the provider will be out of compliance. No reimbursement for claims submitted shall be paid to the provider until compliance is established.
Providers have a continuing obligation to supply the Department with complete, accurate, and updated information as required by the MBM and the Provider Agreement.
The Department may request additional information beyond the Provider Application from an applicant. The Department may require the applicant to provide documentation demonstrating the applicant's ability to provide high-quality care, services, and supplies and to be financially responsible.
All providers are required to update any changes to their NPI information or any other enrollment information within ten (10) days of the change.
1. New MaineCare Provider Agreement Required In the event of any of the following changes, the provider will be required to sign a new provider agreement. a. New enrollment application submitted;b. Subsequent enrollment application submitted;c. Reactivation application submitted.2. Requirements for Updated MaineCare Provider Agreement Under the following circumstances, the provider is required to change their MaineCare Provider Agreement (rather than sign a new provider agreement): b. Change of physical address to a service location; c. Existing service location is terminated;d. Change of provider name or "doing business as" (DBA) name. In the event that any requirement of this Chapter governing provider participation is inconsistent with the requirements of any other Chapter of the MBM, the requirements of this Chapter shall control.
C.Enrollment Fee1. A prospective or re-enrolling provider must submit the applicable application fee established in 42 CFR 424.514(d) to MaineCare prior to executing a MaineCare Provider Agreement, except for the following providers: a. Individual physicians or non-physician practitioners; and b. Providers that are enrolled in either of the following: i. Title XVIII of the Social Security Act; or ii. Another State's Title XIX or XXI plan; and c. Providers that have paid the applicable application fee to: i. A Medicare contractor; or ii. Another State Medicaid Agency. 2. Institutional providers that submit an application to establish a new practice location must submit the applicable application fee prior to executing a MaineCare Provider Agreement.3. MaineCare will reject the enrollment application from a newly-enrolling institutional provider, or an institutional provider that is applying to establish a new practice location, that is submitted without the application fee or documentation that CMS has granted the provider a hardship waiver for the application fee.4. Requests for hardship waivers must be submitted to CMS pursuant to 42 CFR 424.514.D. MaineCare does not reimburse in-state providers, including rendering providers, for services provided to members prior to enrollment approval or after a provider's enrollment has been terminated (end-dated). E. Once the enrollment application has been submitted online through the Department's Health PAS portal, notification of MaineCare's decision will be sent to providers via electronic notification or U.S. mail. The effective enrollment date is the effective date of the Provider Agreement. F. In the case of retroactive enrollment for Federally Qualified Health Centers (FQHCs), the retroactive FQHC enrollment will be effective on the date of the FQHC's Health Resources and Services Administration (HRSA) or CMS approval, not before. In the case of retroactive enrollment for Rural Health Clinics (RHC), retroactive enrollment will be effective on the date of the Medicare approval. In the case of retroactive enrollment for Indian Health Centers (IHCs), the retroactive IHC enrollment will be effective on the date of the HRSA grant. Retroactive enrollment for all other providers is subject to review and approval by the Department in accordance with 42 C.F.R. § 431.108. The provider must supply all information requested by the Department, including all reasons justifying the request for retroactive enrollment, as well as proof of any required licensure or certification for the period. A request for retroactive enrollment is subject to the Department's review and discretion and is not a guarantee of claim payment or prior authorization. The Department may grant retroactive enrollment back to the Medicare certification date, but will not grant a retroactive enrollment date that is more than three hundred and sixty-five (365) days prior to the date of the provider's MaineCare application submission.
G. The Department will pay for MaineCare covered services provided only to the following members: 1. Those who are eligible for the specific services on the date the services are actually provided, unless otherwise specified in the MBM; or 2. Those who have been granted retroactive MaineCare eligibility after services have been provided. For more information on retroactive eligibility see Section 1.04-1.H. Certain providers will be required to use rendering provider NPI in accordance with the appropriate billing instructions. For some types of new providers not previously reimbursed under MaineCare, reimbursement rates must be established before the provider may be enrolled and reimbursed for covered services. Chapter II outlines additional requirements that may apply in specific instances including state contracts, and certification of state share. Certain providers will be required to: attend provider education sessions; have prior authorization of services; and/or have one hundred (100%) percent review of claims prior to payment.
I.National Provider Identifier In order to enroll with MaineCare, providers must obtain a NPI. If a provider is not eligible for an NPI, the Provider Enrollment Health PAS portal will assign an Atypical Provider Identifier (API) to qualified providers. In addition, this system will assign three-digit identifiers to each service location enrolled by the provider.
These identifying numbers must be used in submitting all claims for payment.
J.Fingerprint-based Criminal Background Checks1. Any provider or provider applicant whose categorical risk level is high, as defined below, must consent to a fingerprint-based criminal background check (FCBC) and submit fingerprints to the Department or its vendor in the form and manner required by the Department. The provider or provider applicant and any person with a five (5) percent or greater direct or indirect ownership interest in the provider or provider applicant must submit fingerprints as directed by the Department and shall be responsible for the costs of the FCBC. The Department shall terminate or deny enrollment of a provider if the provider, provider applicant, or any person with a five (5) percent or greater direct or indirect ownership interest in the provider or provider applicant who is required to submit fingerprints:
a. Fails to submit them within thirty (30) days of the Department's request;b. Fails to submit them in the form and manner requested by the Department; or c. Has been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or CHIP programs in the last ten (10) years. The Department may rely upon a provider or provider applicant's Medicare enrollment if that provider or provider applicant is considered high risk by Medicare, has been enrolled by Medicare, has undergone an FCBC, and if the provider or provider applicant has passed or failed the FCBC.
The Department may also rely upon the results of an FCBC conducted by another state's Medicaid program if the provider or provider applicant is enrolled in the other state's Medicaid or CHIP program and has met the revalidation requirement of 42 CFR § 455.414.
2.High Categorical Riska. In accordance with 42 CFR 424.518, the following provider types have high categorical risk: i. Prospective (newly enrolling) home health agencies;ii. Prospective (newly enrolling) DME suppliers;iii. Prospective (newly enrolling) Medicare Diabetes Prevention Program suppliers; andiv. Prospective (newly enrolling) opioid treatment programs that have not been fully and continuously certified by SAMHSA since October 23, 2018.b. The categorical risk for a provider or supplier shall be adjusted to high if the following occurs: i. MaineCare has imposed a payment suspension on a provider based on credible allegations of fraud, waste or abuse within the past ten years;ii. The provider has an existing Medicaid overpayment of $1,000 or more owed to the Department which is not currently under appeal or in a payment plan;iii. The provider has been excluded by the Office of the Inspector General or another State's Medicaid program within the previous 10 years;iv. MaineCare or CMS in the previous six (6) months lifted a temporary moratorium for a particular provider or supplier type, and a provider or supplier that was prevented from enrolling based on the moratorium applies for enrollment as a MaineCare provider or supplier at any time within 6 months from the date the moratorium was lifted; or v. The provider or supplier:A. Has been excluded from Medicare by the Office of the Inspector General; B. Had billing privileges revoked by a Medicare contractor within the previous 10 years and is attempting to: 1. Enroll as a new provider or supplier; or 2. Establish billing privileges for a new service location;C. Has been terminated or is otherwise precluded from billing Medicaid;D. Has been excluded from any federal health care program; or E. Has been subject to any final adverse action within the previous ten (10) years, which includes the following: 1. A Medicare-imposed revocation of any Medicare-imposed privileges;2. Suspension or revocation of a license to provide health care by any State licensing authority;3. Revocation or suspension by an accreditation organization;4. A conviction of a Federal or State felony offense (as defined in 42 CFR § 424.535(a)(3)(i) ) within the last 10 years preceding enrollment, revalidation, or re-enrollment; or 5. An exclusion or debarment from participation in a Federal or State health care program. 1.03-2Additional Enrollment Requirements for Out-of-State ProvidersA. All out-of-state providers, with the exception of NOPRs, must be fully enrolled with MaineCare, including those providers that provide emergency services. Out-of-state providers are subject to all requirements as described in 1.03-1. Out-of-state NOPRs must follow the same enrollment requirements as in-state NOPRs.B. Out-of-state providers may enroll after services have been provided but must do so before billing for the services rendered. The Department may terminate the enrollment status of an out-of-state provider at any time there are no MaineCare members receiving authorized services from that provider.C. Out-of-state providers that only provide emergency services to MaineCare members traveling out-of-state may bill MaineCare for those services. These providers must notify the Department, or its Authorized Entity, within one business day of an emergency admission for a MaineCare member. Inpatient emergency admissions will be reviewed for medical appropriateness. Length of stay will be authorized by the Department, or its Authorized Entity, and will be based upon medical documentation supporting the member's need for services. In order to be reimbursed by MaineCare for emergency inpatient services provided, the provider must receive and submit an authorization number on the claim form submitted to the Department. For emergency services that do not result in an inpatient admission, the provider must notify the Department, or its Authorized Entity, of the treatment provided to the member, also within one (1) business day.
In cases where the provider is unable to confirm proof of MaineCare coverage (e.g., member is unconscious or the member does not have a MaineCare card readily available), the provider may exceed the one-day requirement by providing a sufficient explanation of the case.
D. Other instances in which an out-of-state provider may enroll in MaineCare include, but are not limited to the following: 1. Services and equipment provided to a member who is residing out-of-state, at the discretion of the Department, taking into account cost-effectiveness and medical necessity;2. A provider that is the sole provider of a type of cost-effective medically necessary item or service may be enrolled only for the purpose of providing that item or service with prior authorization. An example would be an out-of-state laboratory that conducts a test, or a manufacturer of a highly specialized item, not provided by any in-state provider; and 3. An out-of-state provider of services to a MaineCare member who is eligible for services as a Qualified Medicare Beneficiary (QMB) may enroll as a MaineCare provider only for the purpose of billing Medicare coinsurance and deductibles.E. The Department reserves the right to issue a request for proposals for provision of any service, pharmaceutical, supply, or piece of equipment. The resulting contract may be awarded to an out-of-state provider.F. Out-of-state providers located within fifteen (15) miles of the Maine/New Hampshire border are treated the same as Maine providers in all aspects of policy requirements, enrollment, rates of reimbursement, and payment methodologies with the exception of out-of-state hospitals, which are excluded from in-state reimbursement methodology as described in Chapter III, Section 45. MaineCare will not provide payment to any entity outside the United States. G. Maine-based providers that are providing services out-of-state are considered out-of-state providers and as such are bound by the same requirements as out-of-state providers, including prior authorization and proper licensure within the state in which services are being provided.1.03-3 Denial of Enrollment and Subsequent Enrollment ApplicationsA. MaineCare shall deny enrollment or subsequent enrollment of any individual or entity that meets any of the following conditions:1. The provider is currently excluded by MaineCare;2. The provider has been terminated on or after January 1, 2011, by Medicare or by the Medicaid program or CHIP of any other state, and remains excluded;3. The provider or any person with a five percent (5%) or greater direct or indirect ownership interest in the provider fails to submit timely and accurate information and cooperate with any screening methods required under 42 CFR PART 455, Subpart E;4. Any provider or any person with a five percent (5%) or greater direct or indirect ownership interest in the provider who has been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or title XXI program in the last 10 years;5. Any provider or a person with an ownership or control interest or who is an agent or managing employee of the provider fails to submit timely or accurate information; or 6. The provider fails to permit access to provider locations for a site visit.B. MaineCare may deny enrollment of any individual or entity that meets any of the following conditions: 1. The provider has falsified any information or omitted any material fact on the application; 2. The Department is unable to verify the identity of the provider;3. The provider has any previous suspension, exclusion or involuntary withdrawal from participation in MaineCare, Medicare, or the Medicaid program of any state;4. The provider is, has been previously, or is currently suspended, excluded, or has involuntarily withdrawn from participation in any private medical insurance program;5. The provider is in receipt of, but has not made restitution for, a MaineCare, Medicare, or other state Medicaid program's overpayment, as determined to have been made pursuant to a final decision or determination of an agency having the powers to conduct the proceeding and after an adjudicatory proceeding in which no appeal is pending or after resolution of the proceeding by stipulation or agreement; however, if a provider has entered into a plan of restitution of such overpayments, an application will not be denied solely on this factor unless the provider has defaulted in repayment; 6. The provider has made any false representation or omission of a material fact in making application in any state for any license, permit, certificate, or registration related to a profession or business;7. The provider has failed to correct deficiencies in the operation of a business or enterprise after having received written notice of the deficiencies from a state or federal licensing or auditing agency;8. The provider fails to supply further information concerning the application after receiving a written request for such further information;9. The provider submits an application which conceals an ownership or control interest of any person who would otherwise be ineligible to participate;10. The provider has been indicted for or convicted of any crime relating to the furnishing of, or billing for, medical care, services, or supplies which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals;11. The provider has a prior finding by a licensing, certifying, or professional standards board or agency of the violation of the standards or conditions relating to licensure or certification or as to the quality of services provided;12. The provider has a prior history of excessive claims or furnishing of unnecessary or substandard services and/or items, or any prior improper conduct under any private or publicly funded program or insurance policy;13. The provider demonstrates any other factor having a direct bearing on the applicant's ability to provide high-quality medical care, services or supplies to recipients of MaineCare benefits, or to be fiscally responsible to the program for care, services or supplies to be furnished under the program, including actions by persons affiliated with the applicant;14. Any other factor which may affect the effective and efficient administration of the program, including, but not limited to, the current availability of medical care, services or supplies to members, or the inability to bill appropriately for services rendered.1.03-4Notice of Denial of Application Upon completion of its review of an enrollment application, including consideration of the above factors, the Department will notify any provider applicant of the Department's denial of the application by issuing a written notice of denial to the provider or provider applicant. The notice will specify the reasons for the denial. Department denials may be appealed in accordance with this regulation.
1.03-5Claims Submittal Following Termination of Enrollment Providers that are terminated, either voluntarily or involuntarily, from MaineCare enrollment, will have one (1) year from the end date of their enrollment to submit claims for services provided during the period of active enrollment (that is, for services delivered prior to the end date of enrollment). Claims for services delivered during the period of active enrollment will not be reimbursed if the claims are submitted beyond one (1) year of the date of the service.
1.03-6Changes of Ownership, Closures, and DisenrollmentA. Providers must notify the Provider Enrollment Unit of any Change in Ownership (CHOW), closure, or intention to disenroll from the MaineCare program no less than thirty (30) days prior to the intended change, except in the case of reasonably unforeseen circumstances. Providers must take all reasonable and appropriate steps requested by the Department to transition members before the intended change and, upon request, submit a transition plan to the Department for review and approval.B. Providers undergoing a CHOW must update the change on the Health PAS portal. As part of that process, the providers will be required to complete the CHOW questionnaire and follow the online instructions for submission. Depending on the questionnaire responses, the provider may be required to submit a new application.1.03-7Automatic Disenrollment The Department will terminate the enrollment of any provider (other than NOPR providers) that has not submitted a claim within three hundred and sixty-five (365) days of enrollment. Such providers are eligible to re-enroll at any time.
1.03-8Requirements of Provider ParticipationEnrolled providers must:
A. Maintain current licenses, as applicable, and must submit copies of license renewals to the Provider Enrollment Unit to ensure continuity of services through license expiration dates. Providers that are "covered health care providers" are required to obtain an NPI from the CMS National Provider System. Providers must write their NPI and API ID number(s) and the three (3) digit service location identifier, if applicable, on the copy of their license renewals to ensure accurate data entry. License renewals or updates must be submitted to and received by the Department at least thirty (30) days prior to the date of the license expiration or change. If the provider has not received the renewed or updated license in sufficient time, the provider must submit proof of application for the license renewal or update at least thirty (30) days before the license expiration and then provide the license renewal or change with the numbers required above within ten (10) days of receipt.
B. Notify the Department whenever there is a change in any of the information that the provider previously submitted to the Department using the MaineCare Services portal at https://mainecare.maine.gov. An example would be: a change in address, or the addition or deletion of staff from the practice. This must be done within ten (10) days of each occurrence. Failure to provide complete and accurate information in a timely fashion will constitute good cause for the Department to terminate the agreement.C. Not interfere with a member's freedom of choice in seeking medical care from any institution, agency, pharmacy or person who is qualified to perform a required service and is a MaineCare provider. D. Not discourage or interfere with a MaineCare member accessing medically necessary MaineCare services for which the member is eligible.E. Allow members the freedom to reject medical care and treatment.F. Not discriminate against any member, because of race, color, sex, gender identity, sexual orientation, religious creed, ancestry, national origin, age, or physical or mental handicap or disability, or any other factor as specified in the Maine Human Rights Act, 5 M.R.S. §4551et seq., the Federal Civil Rights Act, 42 U.S.C. § 1981et seq., The Americans With Disabilities Act of 1990, 42 U.S.C. § 12101, or the Federal Rehabilitation Act, 29 U.S.C. § 504et seq. The provider will comply with 5 M.R.S. §784(2) and any and all appropriate federal and state laws and regulations regarding non-discrimination.G. Provide services and supplies to members in the same quality and mode of delivery as they are provided to the general public.H. Charge and bill MaineCare for the provision of services and supplies to members in an amount not to exceed the provider's usual and customary charges to the general public or, the contractual agreement for a member with a liable third party.I. Accept as payment in full the MaineCare rate as specified in Section 1.08-1. J. Bill only for covered services and supplies delivered. In cases where a partial unit of service is delivered, the provider may bill for the partial unit. A provider also has the option to round up a partial unit and bill for the nearest whole unit, if the partial unit of service provided is equal to or greater than eighty percent (80%) of the unit of service: e.g. providers may round 1.8 units of service up to two (2) units of service; the provider may bill 1.7 units of service provided either as 1.7 units of service if it bills the partial unit or as 1.0 unit of service if it does not. If the provider rounds up to the next unit from eighty percent (80%) or greater, the provider must document the actual units of service delivered in the member's record. Providers may bill partial units of service delivered to one or two decimal places, and providers may round partial units of service to the first or second decimal place. For example, to bill ten minutes of a 15-minute service (.667 units), providers may choose to use the first decimal place, not round, and bill .6 units; use the second decimal place, not round, and bill .66 units; round to the second decimal place and bill .67 units; or round to the first decimal place and bill .7 units. Providers shall not round up to .8 units and then round up again to bill the whole unit.
In cases where an unforeseen and uncontrollable circumstance prevents a provider from delivering a whole unit of service, the provider may round up the partial unit to the nearest whole unit if the partial unit is equal to or greater than fifty percent (50%) of the unit of service: e.g. providers may round 1.5 units of service up to two (2) units of service in the case of an unforeseen and uncontrollable circumstance; 1.4 units of service provided would be billed at either 1.4 units of service if the provider bills a partial unit or 1.0 unit of service if it does not. Unforeseen and uncontrollable circumstances may include, but are not limited to, a power outage, a fire or other event that necessitates evacuation from the place of service, or a medical emergency. If rounding up from 50% or greater, the provider must document the actual units of service provided and fully describe the unforeseen and uncontrollable circumstance in the member's record.
The procedure code for the smallest unit of service must be used. Specific provisions in any other Chapters or Sections of this Manual will supersede this rounding requirement.
K. Accept assignment of Medicare benefits for eligible MaineCare members (as set forth in Section 1.07-5).L. Use designated Health Insurance Portability and Accountability Act (HIPAA) compliant billing forms, or accepted 837 transactions, for submission of charges and follow the appropriate MaineCare billing instructions. 837 filings are transactions using the HIPAA standard format for submission of electronic claims. There are three (3) versions of the 837: the Institutional (similar to the UB-04 paper claim); the Professional (comparable to the CMS 1500 paper claim) and the Dental (comparable to the ADA paper claim).M. Maintain and retain contemporaneous financial, provider, and professional records sufficient to fully and accurately document the nature, scope and details of the health care and/or related services or products provided to each individual MaineCare member. 1. Records must be consistent with the unit of service specified in the applicable policy covering that service. Records must include, but are not limited to all required signatures, treatment plans, progress notes, discharge summaries, date and nature of services, duration of services, titles of persons providing the services, all service/product orders, verification of delivery of service/product quantity, and applicable acquisition cost invoices. Providers must make a notation in the record for each service billed. For example, if a service is billed on a per diem basis the provider must make a notation for each day billed. 2. If a service is billed on a fifteen (15) minute unit basis, a notation for each visit is sufficient.3. Records must be kept in chronological order with like information together as appropriate. For MaineCare purposes such records must be retained for a period of not less than five (5) years from the date of service or longer if necessary to meet other statutory requirements. If an audit is initiated within the required retention period, the records must be retained until the audit is completed and a settlement has been made.4. At all reasonable times during the prescribed retention period, persons duly authorized by the Department or the federal government, whether employees or contractors, shall be given the right to full access to inspect, review, or audit all medical, quality assurance documents, financial, administrative records, and other documents and reports required to be kept under federal and state laws and regulations. Those duly authorized shall also have the right to obtain copies of such records at no expense to the Department, federal or state government. The provider and any approved subcontractor shall give the Department or the Federal government complete and private access to the Provider's staff and to any resident or member for the purpose of reviewing the provider's compliance with the provider agreement, and other applicable federal and state laws and regulations, including laws and regulations governing licensing and certification.
5. MaineCare providers, all rendering providers, and any subcontractors shall make available, during regular business hours, all pertinent provider financial records, all records of the requisite insurance coverage, all records concerning the provision of health care services to MaineCare members, and all financial records of MaineCare members, to any duly authorized representative of DHHS, the Department's Authorized Entity, the Maine Attorney General's MaineCare Fraud Unit, and the Director of the United States Centers for Medicare and Medicaid Services. MaineCare providers, all rendering providers, and any subcontractors shall provide, if requested by any of the above, copies of records and documentation, including copies of consolidated financial statements of all related corporations. Failure to comply with any request to examine or receive copies of such records shall be grounds for immediate suspension from participation in the MaineCare program.6. MaineCare providers, all rendering providers, and any subcontractors will make their premises available to any of the above, for announced visits or unannounced visits, for the purpose of determining whether enrollment or continued enrollment in the MaineCare program is warranted, to investigate and prosecute fraud against the MaineCare program, to investigate complaints of abuse and neglect of MaineCare members, and as necessary for the administration of the MaineCare program. Failure to permit inspection by DHHS, the Maine Attorney General's MaineCare Fraud Unit, or the Secretary of the United States Centers for Medicare and Medicaid Services shall be grounds for immediate suspension from participation in the MaineCare program.N. Have safeguards and security measures in place that allow only authorized persons to enter information into electronic records. Passwords or other secure means of authorization must be used that will identify the individual and the date and time of entry. Such identification will be accepted as an electronic "signature." With security measures in place, limited access may be allowed for certain individuals for changes such as member demographic information. There shall be a signature of record on file. O. Maintain and retain contracts with subcontractors for a period of at least five (5) years after the expiration date of the contract. In addition, records of contractors or subcontractors shall be subject to the same record maintenance and retention rules as are all enrolled providers (refer to Section 1.03-8 M). Providers must submit within thirty-five (35) days of the Department's request, full and complete information regarding the ownership of any subcontractor with whom the provider has had business transactions totaling twenty-five thousand dollars ($25,000.00) or more, during a twelve (12) month period prior to the date of the request. Updates to ownership information will be required on an annual basis.
P. Transfer at no charge clinical records and other pertinent information to other clinicians involved in the member's case, upon request and, when necessary, with the member's signed release of information. Members may only be charged for copies of their own records if the member is requesting that the copies be given directly to them. Charges to the MaineCare member must be in a manner comparable to any charges providers may require from private pay patients. Enrolled providers must furnish to the Department or its Authorized Entity without charge, in the form and manner requested, pertinent information, including clinical, professional and financial records, regarding services for which charges are made. Where appropriate, as determined by the Department, this will include information necessary to support requests for exemption from managed care requirements and correspondence that substantiates services billed by providers. A release of information signature is not required in order to send records to the Department or its Authorized Entity.
Q. Comply with the requirements of the Department regarding faxed and e-signatures. The Department will accept e-signatures and faxed (facsimile) copies of signatures as evidence of compliance with MaineCare documentation requirements only when the original signature is subsequently forwarded to the Department within (30) calendar days of the date of service or is already on file. 1. Providers must maintain evidence of the faxed and e-signatures in the member's record;2. A faxed signature by itself without the original signature on record will not be acceptable proof of signature.R. Hold confidential, and use for authorized program purposes only, all MaineCare information regarding members. In situations where it is medically necessary for the member's well-being, information may be shared between providers. The rules of confidentiality apply to all providers involved as referenced in Section 1.03-9 of this Manual. Confidentiality requirements described in 22 M.R.S. §1711-C also apply.S. Comply with requirements of applicable federal and state law, and with the provisions of this Manual.T. Enter into a MaineCare Provider Agreement with the Department, including any necessary Riders.U. Providers, contractors and intermediaries in public, private or voluntary agencies that have Provider agreements with the Department, are obligated to: 1. Report any suspected or identified fraud or abuse by providers or members and submit supporting documentation to the Program Integrity Unit, Division of Audit;2. Furnish available information, when requested, on excluded individuals and entities requesting reinstatement into the MaineCare Program; and 3. Ensure that the provisions of 42 C.F.R. 1000, et seq., pertaining to the exclusions of individuals and entities are abided by at all times.V.Disclosure of ownership or control Provider must disclose the following information to the department upon enrollment and within thirty (30) days of any change.
1. Providers other than individual practitioners or groups of practitioners must disclose all persons with an ownership or control interest in the provider. Persons with an ownership or control interest include the following:a. Those with an ownership interest totaling five percent (5%) or more in the provider;b. Those with an indirect ownership interest equal to five percent (5%) or more in the provider;c. Those with a combination of direct and indirect ownership interest equal to five percent (5%) or more in the provider;d. Those with an interest of five percent (5%) or more in any mortgage, deed of trust note, or other obligation secured by the disclosing entity if that interest equals five percent (5%) or more of the value of the property or assets of the provider;e. Individuals who are officers or directors if the provider organization of the provider is organized as a corporation; and f. Individuals who are partners in the provider's partnership.2. Providers other than individual practitioners or groups of practitioners must disclose all corporations or other forms of business entities with an ownership or control interest in the provider. Corporations or other forms of business entities with an ownership or control interest include the following: a. Those with an ownership interest totaling five percent (5%) or more in the provider;b. Those with an indirect ownership interest equal to five percent (5%) or more in the provider;c. Those with a combination of direct and indirect ownership interest equal to five percent (5%) or more in the provider;d. Those with an interest of five percent (5%) or more in any mortgage, deed of trust note, or other obligation secured by the disclosing entity if that interest equals five percent (5%) or more of the value of the property or assets of the provider;e. Entities who are officers or directors of the provider organization if the provider is organized as a corporation; andf. Entities who are partners in the provider's partnership.3. Providers other than individual practitioners or groups of practitioners must disclose all subcontractors in which the provider has an ownership interest of five percent (5%) or more. 4. Providers other than individual practitioners or groups of practitioners must disclose any individual owners of the provider who is related to other individual owner as a spouse, parent, child, or sibling. Providers must also disclose any individual owners of the provider's subcontractor in which the provider has an ownership interest who is related to other individual owner as a spouse, parent, child, or sibling. 5. Providers other than individual practitioners or groups of practitioners must disclose any ownership or control interest in any "other disclosing entity." "Other disclosing entity" means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but if required to disclose certain ownership and control information because of participation in any program established under Title V, XVIII, or XX of the Social Security Act. This includes: a. Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII)b. Any Medicare intermediary or carrier; andc. Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under Title V or Title XX of the Social Security Act. W. Provide adequate access to medically necessary covered health care services for MaineCare members.X. Refer to the Department any evidence demonstrating fraudulent or abusive provider and/or employee practice or overuse of member services by contacting the Program Integrity Unit.Y. Abide by the provisions of 42 C.F.R. 1000, et seq., pertaining to the exclusions of individuals and entities from participation in Medicare or MaineCare and ensure that excluded individuals or entities are not employed or utilized to provide services, receive payments, or submit claims, to the MaineCare Program. Excluded provider information can be referenced at the Health and Human Services Office of Inspector General web site: http://exclusions.oig.hhs.gov and the Division of Audit, Program Integrity Unit web site: https://mainecare.maine.gov/mhpviewer.aspx?FID=MEEX. Z. Maintain accurate, auditable and sufficiently detailed financial and statistical records to substantiate cost reports, negotiated rates, by report items, or any other fee for service rate for a period of at least five (5) years following the date of final settlement or established rate with the Department. These records must include, but not be limited to: matters of provider ownership; organization; operation; fiscal and other record-keeping systems; federal and state income tax information; asset acquisition; lease, sale or other action; cost of ownership information on leased property even if the property is leased from an unrelated party; franchise or management arrangement; patient service charge schedule; matters pertaining to cost of operation; amounts of income received by service and purpose; and flow of funds and working capital.AA. Attend provider education sessions when required by the Department.BB. Submit all claims for review prior to payment, when required by the Department.CC. Comply with the requirements of the Federal False Claims Act as referenced in Appendix 2 of this Chapter.DD. Comply with this Chapter and all other applicable Chapters and Sections of the MBM. The Department may sanction providers that fail to comply with these requirements.
1.03-9ConfidentialityProviders may disclose information regarding individuals participating in MaineCare only for purposes directly connected with the administration of MaineCare. Providers must maintain the confidentiality of information regarding MaineCare members in accordance with 42 C.F.R. 431, et seq. and other applicable sections of state and federal law and regulations, including compliance with the privacy and security requirements of HIPAA.
The Department will ensure that criteria exist specifying the conditions for release and use of information about MaineCare members. Access to information concerning members is restricted to persons or Department representatives who are subject to standards of confidentiality set by the Department.
The Department may not publish or disseminate, in any way, names of members. Permission must be obtained from a family or individual, whenever possible, before responding to a request for information from an outside source, unless the information is to be used to verify income, eligibility and the amount of a MaineCare payment.
Parents or guardians of minors may be required to provide annual reauthorization regarding the release of confidential information.
1.03-10Requirements for Persons Acting on Behalf of a ProviderAll persons acting on behalf of a provider, such as employees, agents, volunteers or family members, are bound by and must adhere to MaineCare rules and regulations. Violations committed by any of the above named parties may result in sanction actions as defined in Section 1.20 of this Manual.
1.03-11MaineCare Managed CareMaineCare managed care providers are primary care providers when all parties have completed and signed a MaineCare provider Agreement and have received approval from MaineCare to provide comprehensive health care to members receiving managed care benefits. Such providers must comply with Chapter VI, Section 1, Primary Care Case Management and other appropriate sections of the MBM.
Unauthorized use of a primary care provider's NPI identification number by any provider will be deemed to be fraud and may result in the sanctions described in Section 1.20 of this Chapter.
1.03-12Requirements for Agencies Hiring Certified Nursing Assistants (CNAs) and Direct Care Workers (DCWs)MaineCare providers that hire CNAs or DCWs must check the Maine Certified Nursing Assistants and Direct Care Worker Registry to ensure CNAs and DCWs are eligible for employment in Maine and must comply with all requirements stipulated in the Department's Certified Nursing Assistants and Direct Care Worker Registry Rule, 10-144 Code of Maine Rules, Chapter 128.
1.03-13License Verification for Registered NursesProviders shall verify that all registered nurses they hire or employ are currently and validly licensed as a registered professional nurse by the Maine State Board of Nursing or hold a current, unencumbered compact license from another compact state that they claim as their legal residence.
C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.03