N.H. Admin. Code § He-M 504.04

Current through Register No. 45, November 7, 2024

Section He-M 504.04 - Provider and Provider Agency Participation

(a) Each provider agency who seeks to be enrolled to provide and receive reimbursement for home and community based waiver services shall:

(1) Complete an application for enrollment via the MMIS portal at: in order to apply to be and operate as a New Hampshire Medicaid enrolled provider in accordance with 42 CFR 455.410 and He-W 520.06, unless they choose to contract with an OHCDS for pass-through billing, pursuant to He-M 504.06;

(2) Contact the bureau to request a screening in accordance with (b) below:

a. Following initiation of an application in accordance with (1) above; or

b. Not less than 120 days prior to expiration of the current enrollment period when the provider agency intends to submit an application for re-enrollment;

(3) Meet the applicable licensing, certification, or other requirements of the specific service they provide, such as but not limited to, criteria required in New Hampshire RSA 151, RSA 171-A, 42 CFR 441.301, or a contract with the bureau or OHCDS; and

(4) Have an executed Medicaid provider participation agreement with the department in order to obtain Medicaid agency identification numbers from the department for the specific services for which the provider agency is enrolling.

(b) Each provider applicant shall participate in a department screening upon enrollment and re-enrollment to review the following:

(1) Mission and vision statements, as applicable;

(2) Training practices, such as but not limited to, requirements per specific position, purchased training platforms, and continuing education hours requirements;

(3) Service-specific competencies, as related to developmental services defined in chapter He-M 500;

(4) Three references that illustrate the provider applicant's ability to meet their service obligations in accordance with their mission and vision statement;

(5) Financial indicators of fiscal integrity, including but not limited to;

a. Financial statements identifying current portion of long-term debt payments including principal and interest; and

b. A measure of total current assets available to cover the cost of current liabilities;

(6) Liability protections;

(7) Policies and practices regarding restraint and seclusion;

(8) Attestation that criminal background and appropriate registry checks were completed pursuant to He-M 504.03(g)-(h); and

(9) Attestation that office of inspector general checks were completed in accordance with He-M 504.03(n).

(c) The screening in (b) above shall occur within 90 days of application for enrollment and within 120 days for reenrollment.

(d) A provider applicant shall not be enrolled pursuant to (a)(4) above until the department has completed the screening in (b) above and has communicated this to the department's program integrity office.

(e) In addition to the reasons set forth in He-W 520.06, the department shall deny an application for provider agency enrollment or re-enrollment, as applicable, due to any of the following reasons:

(1) Failure to complete the screening required in (b) above;

(2) Any reported abuse, neglect, or exploitation of an individual by an applicant, provider, provider agency, or contractor, if such abuse, neglect, or exploitation is reported on the state registry of abuse, neglect, and exploitation in accordance with RSA 161-F:49 or RSA 169-C:35 and the provider agency failed to take appropriate action;

(3) A provider agency fails to ensure that its providers, staff, and contractors meet the training requirements in chapter He-M 500, He-M 1001, He-M 1201, or Nur 404;

(4) A provider agency, provider, staff, or contractor has an illness or behavior that, as evidenced by documentation obtained or the observations made by the department, would endanger the well-being of the individuals or impair the ability of the provider agency to comply with department rules and the provider agency failed to take appropriate action to address and respond;

(5) A provider agency, or any of its providers, staff, contractors, or any representative thereof, knowingly provides materially false or misleading information to the department;

(6) A provider agency, or any of its providers, staff, contractors, or any representative thereof, fails to permit or interferes with any inspection or investigation by the department;

(7) A provider agency, or any of its providers, staff, contractors, or representatives thereof, fails to provide required documents to the department or entities acting on its behalf;

(8) Federal or state laws, regulations, or guidelines are modified in such a way that either providing the services under the medicaid provider participation agreement is prohibited or the department is prohibited from paying for such services from the planned funding source; or

(9) The provider agency, provider, or contractor no longer holds a required license, certification, or other credential to qualify as a provider of services.

(f) Enrollment or re-enrollment shall be denied upon the written notice by the department to the provider agency stating the specific rule(s) with which the provider agency does not comply.

(g) A provider agency may request an appeal, in accordance with He-C 200, regarding a proposed denial of enrollment or re-enrollment within 30 business days of the decision.

(h) The provider agency's enrollment status shall be suspended until the appeal determination is adjudicated.

(i) The denial shall not become final until the period for requesting an appeal has expired, or, if the provider agency requests an appeal, until such time as the administrative appeals unit issues a decision upholding the department's decision.

(j) If the department's decision is not upheld, the denial would be ineffective, and the provider shall continue to provide services.

(k) Appeals shall be submitted in writing, to the bureau administrator in care of the department's office of client and legal services.

(l) Each enrolled provider shall:

(1) Submit claims for payment in accordance with He-M 504.05; and

(2) Be subject to monitoring by the department or entities acting on its behalf, in accordance with the requirements of He-M 504.09, He-M 500, and He-M 1201.

(m) An enrolled provider or applicant shall update MMIS and notify the department, in writing to the bureau chief, or designee, of any material change in any status or condition of any element on their application within 30 days of the change occurring for changes such as, but not limited to:

(1) Business affiliation;

(2) Ownership and control information;

(3) Federal tax identification number;

(4) Criminal convictions;

(5) Addition to the bureau of elderly and adult services (BEAS) or DCYF state registries; and

(6) The types of services that are offered.

(n) An enrolled provider shall notify any applicable service coordination agency if any change results in a change to the provider agency's ability to deliver services to an individual as outlined in that individual's service agreement within 2 business days.

(o) An enrolled provider or provider applicant shall notify any applicable area agency or service coordination agency if any change impacts their status as a provider agency within 2 business days.

(p) An enrolled provider shall immediately notify, in writing, the department, any applicable area agencies, any applicable service coordination agencies, and any individuals receiving services from the provider agency, in accordance with He-M 504.13 of their decision to terminate their status as an enrolled provider and update the MMIS at least 90 days prior to the termination date.

(q) Enrolled providers terminating in accordance with (n) above shall ensure each individual's full service file and any other pertinent documentation is transferred to their respective service coordination agency within 2 business days of the notification.

(r) Documentation of services provided between the date of notice and the last date of service provision shall be transferred to the respective service coordination entity no more than 2 business days after the end of service provision.

(s) Claims submitted by, or payments made to, enrolled provider agencies who have not timely furnished the notification of changes or have not submitted any of the items that are required due to a change, in accordance with (n)-(q) above, shall be denied payment or be subject to recovery.

N.H. Admin. Code § He-M 504.04

Derived from Number 28, Filed July 13, 2023, Proposed by #13679, EMERGENCY RULE, Effective 6/28/2023, Expires 12/25/2023.

Amended by Number 50, Filed December 14, 2023, Proposed by #13807, Effective 11/17/2023, Expires 11/17/2033.