N.H. Admin. Code § He-W 521.03

Current through Register No. 50, December 12, 2024

Section He-W 521.03 - Provider Responsibilities

(a) Prior to the delivery of items, supplies, or services, the provider shall verify the recipient's medicaid coverage and other insurance information on the date of service.

(b) When an item, supply, or service requires prior authorization, the provider shall obtain approval from the department, the third party insurance, if applicable, or the recipient's MCO prior to the delivery of said items, supplies, or services.

(c) A provider may only bill a medicaid recipient for items, supplies, or services if:

(1) The individual is not eligible for medicaid on the date of services;

(2) The recipient chooses to receive an item, supply, or service, from a provider who does not accept medicaid recipients. This also includes providers that accept third party insurance, but not medicaid, unless the recipient is on the health insurance premium payment (HIPP) program;

(3) The item, supply, or service is not covered under medicaid or exceeds the allowed limits and when providing an item, supply, or service not covered by medicaid, the provider has advised the recipient in writing and the recipient has declined alternative treatments that are covered by medicaid; or

(4) The provider informs the recipient in writing and the recipient agrees in writing prior to services being performed, including payment of charges for co-pays and deductibles of third party insurers. The written acknowledgement shall include, but is not limited to, the following information:

a. The provider's name;

b. The provider's medicaid ID number;

c. The recipient's name;

d. The recipient's medicaid ID number;

e. The date on which the item, supply, or service is requested;

f. A description of the item, supply, or service being requested; and

g. Certification by signature of the recipient that the recipient understands that:

1. The medicaid program shall not cover the item, supply, or service being requested; and

2. The recipient shall be responsible for payment if the recipient still chooses to receive the item, supply, or service.

(d) If the recipient is a minor or is incapacitated and unable to sign the written acknowledgement described in (c) above, the parent, guardian, or legal representative may sign on behalf of the recipient.

(e) When the provider accepts a patient into the practice as a medicaid patient, the provider shall accept medicaid payment as payment in full, less any medicaid cost-sharing requirement.

(f) The provider shall not bill medicaid recipients for any of the following:

(1) The difference between the provider's usual and customary charge and the medicaid payment for services rendered, except any medicaid cost sharing;

(2) Missed, also known as no shows, or cancelled appointments;

(3) Costs associated with supplying copies of the recipient's medical records to another health care provider;

(4) Any goods or services provided to the recipient that are offered to other individuals free of charge;

(5) Additional fees, such as membership, boutique, or concierge fees; or

(6) Any third party remaining co-insurance, co-payment, or deductible not paid by medicaid.

(g) If a recipient has paid for a service and then becomes retroactively eligible for medicaid, the provider may refund the recipient the amount paid and then bill medicaid for the covered services that were rendered.

(h) If the provider refuses to repay the recipient for a medical item, service, or prescribed medication, and the recipient wishes to be reimbursed, then the recipient may request reimbursement from the department.

(i) If the recipient wishes to pursue reimbursement from the department as described in (h) above, the recipient shall contact their district office and provide a statement signed by the provider stating that the provider refuses to refund the recipient and directly bill medicaid. In addition to the statement, the recipient shall also provide to the district office the following information:

(1) For each medical item:

a. The receipt verifying the recipient's name who received the medical item;

b. The date on which the medical item was purchased;

c. The name of the medical item;

d. The amount charged for the medical item;

e. The amount paid for the medical item; and

f. The name of the individual who paid the bill;

(2) For each service provided:

a. The receipt verifying the recipient's name who received the service;

b. The date on which the service was received;

c. The type of service received

d. The amount charged for the service;

e. The amount paid for the service; and

f. The name of the individual who paid the bill; or

(3) For each prescribed medication:

a. The name of the licensed professional prescribing the medication;

b. The receipt verifying the recipient's name on the prescribed medication;

c. The date on which the medication was prescribed;

d. The specifics of the prescribed medication including:

1. The name of the medication;

2. The category of the medication;

3. The quantity of each medication;

4. The prescription number of each medication;

5. The refill number of each medication; and

6. The national drug code of the medication;

e. The amount charged for the prescribed medication;

f. The amount paid for the prescribed medication; and

g. The name of individual who paid for the prescribed medication.

(j) In order for the recipient to be reimbursed for services, as described in (h) above, the date of service shall have been after the recipient's retroactive eligibility start date.

(k) If the recipient is reimbursed after complying with (i) and (j) above, the recipient shall only be reimbursed up to the medicaid allowable amount.

(l) The provider shall maintain accurate and complete medical, financial, and administrative records as required by the specific program state rules in chapters He-A 400, He-C 6000, He-E 800, He-M 300 - 500, He-M 1000, He-P 600, He-P 800, He-P 4000, and He-W 500, including relevant medical and third party records for payment from medicaid to justify the provision of and support for any items, supplies, or services supplied to medicaid recipients. Providers shall maintain complete records for at least 6 years from the date of service, or until the resolution of any personal action(s) commenced during the 6-year period, or whichever is longer.

(m) At a minimum, all medical records required in (l) above shall:

(1) Be typed or legibly written, recorded on paper, or in electronic format;

(2) Be dated;

(3) Clearly identify the recipient with full legal name and medicaid ID;

(4) Document the medical necessity of the service(s) billed;

(5) Document that the service(s) provided are consistent with the diagnosis of the recipient's condition;

(6) Document that the service(s) are consistent with professionally recognized standards of care;

(7) Document the name of the performing or rendering provider and supervising provider, if required, and their credentials;

(8) Document all complaints and symptoms, medical history, examination findings, diagnostic test results, assessment results, clinical impressions or diagnosis, plans for care, dates of services, and the identity of the observing medical practitioner;

(9) Document all specific procedures or treatments performed;

(10) Document any medications administered or medical supplies utilized or provided;

(11) Record each item of service provided on the claim and include all supporting documentation;

(12) Include all physician orders; and

(13) Include a signature of a licensed qualified medical professional.

(n) The provider shall provide the records described in (l) above to the department, MCO, federal auditors, medicaid fraud control unit (MFCU), or the department's designated representatives, upon request, as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and 45 CFR 164.512(d). If records are not available, or do not support items, supplies, or service supplied, or the provider refuses to cooperate with the request, then payment for items, supplies, or service supplied shall be denied or shall be recovered, if already paid and recovery shall be done by the department or MCO by recoupment of future payments or direct billing.

(o) The provider shall report to the department within 35 days any changes related to the provider's practice that may impact medicaid payments, including, but not limited to:

(1) A change of name or address;

(2) A lapse of licensure;

(3) A change in ownership; or

(4) A change in affiliations per 42 CFR 455.104(c)(1).

(p) If the changes described in (o) above are not reported, provider enrollment and payment shall be suspended if the provider is not in contact with the department, the provider is not responding to department inquiries, the provider does not submit the proper information, or the change precludes the department from paying claims, such as a lapse of license, until the issue is rectified.

(q) Providers shall maintain active licensure or certification per appropriate licensure board for services provided and any facility licensure or certification as required by state law.

(r) Providers shall follow all requirements outlined in the provider participation agreement upon enrollment and revalidation.

N.H. Admin. Code § He-W 521.03

Derived from Number 10, Filed March 7, 2024, Proposed by #13884, Effective 2/22/2024, Expires 2/22/2034 (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521).