Provider Enrollment. August 2016

Transcription

1 Provider Enrollment August 2016

2 Overview Enrollment Requirements Provider Responsibilities Enrollment Process Affiliations Signatures and Supporting Documentation 2

3 Enrollment Requirements 3

4 Enrollment Providers must be enrolled to be reimbursed for services provided to eligible members Enrollment may be retroactive up to one year from the date Conduent receives the signed Provider Enrollment Agreement and supporting documents from the enrollment application Licensure or certification may not be predated The provider enrollment record directly impacts claims processing 4

5 Licensure and Certification Certification and licensure requirements are specific to individual provider types and, if applicable, must be fulfilled before enrolling as an Alaska Medicaid provider Information about specific certification and licensure requirements: Professional licensure regulations 12 AAC 2 12 AAC 76* Medicaid Coverage and Payment regulations 7 AAC * Provider Billing Manuals Provider Enrollment FAQs at Questions about provider enrollment? Contact the Conduent Provider Enrollment Unit at (option 2) or (option 1, 3) * Regulations are accessible at select Index (ToC) 5

6 NPI National Provider Identifier (NPI) is a unique 10-digit identification number for covered providers Providers must apply for an NPI Apply online at Have an EFI organization file on their behalf Fill out and submit a paper form Individuals need a Type 1 Individual NPI Organizations or groups need a Type 2 Group NPI 6

7 CLIA CLIA Clinical Laboratory Improvement Amendments Any laboratory services provider must have a CLIA Certificate or a Certificate of Waiver The type and complexity of tests a provider plans to perform dictates which level of certification is needed A CLIA certification must be attached to the enrollment file to be paid for laboratory services CMS maintains a list of tests, including those with waiver indicator, at 7

8 Provider Responsibilities 8

9 Provider Agreement All Alaska Medical Assistance providers must read, sign, and submit a provider agreement as part of their enrollment There are different versions of the provider agreement for different provider types, but all have similar content Provider agreements are available at in the Enrollment Forms section 9

10 Example Provider Agreement 10

11 Example Provider Agreement Provider Agreements CHA/P and DHA Provider Enrollment Agreement Group/Facility Provider Tax Certification and Provider Enrollment Agreement Individual Provider Tax Certification and Provider Enrollment Agreement PCA Provider Enrollment Agreement 11

12 Provider Agreement All provider agreements include items detailing: Requirements to create and maintain records required by state and federal regulations which are necessary to demonstrate the nature and extent of medical necessity, support, care and services provided for which payment is requested Agreement to fully disclose any and all records reflecting the extent of services or items furnished to Alaska Medical Assistance members, including information regarding payments and claims for those services Agreement that upon request, records and information will be made available to the authorized, requesting federal or state agencies or their designees Acknowledgement that the provider has read and understood the penalties for medical assistance fraud 12

13 Recordkeeping Requirements Recordkeeping requirements are documented in 7 AAC Providers must maintain accurate financial, clinical, and other records necessary to support the services for which the provider bills Alaska Medical Assistance Providers must ensure that their staff, billing agent, or other entity responsible for maintaining the provider s records meets regulation requirements Provider records must identify: Member information Financial information Clinical information Providers must maintain records for a minimum of seven years from the date of service Providers who maintain all or part of their record electronically must ensure that required data is accessible 13

14 Record Maintenance Providers must maintain members records for which they have billed Alaska Medical Assistance for at least seven years from the date service is provided Record maintenance requirements apply even if the provider s business is sold or transferred or is no longer operating Providers who close their business must provide the State of Alaska with instructions on how the state can access Alaska Medical Assistance member records in the future All record maintenance requirements apply equally to electronically maintained records 14

15 Grounds for Sanctions The department may impose sanctions for one or more of the following reasons: Submitting fraudulent claims, provider enrollment applications, or cost reports or surveys Submitting false information in order to obtain higher payment or service authorizations Failing to disclose service or payment records Failing provide acceptable standard of quality services to Alaska Medical Assistance members Engaging in practices that are deceptive or abusive of the Alaska Medical Assistance program Breaching terms of the provider agreement Overusing the Alaska Medical Assistance program by inducing a member to receive services or supplies they did not need or request Engaging in kickbacks The list of grounds for sanction included here are those that relate directly to recordkeeping and requests for records. It is not all-inclusive. For a complete listing of grounds for sanctioning providers, see 7 AAC

16 Grounds for Sanctions The department may impose sanctions for one or more of the following reasons: Being excluded, suspended or terminated from Medicare or another governmental medical program Charging members for Alaska Medical Assistance services above the payment made by the department Refusing to execute a new provider agreement when requested to do so Failing to correct deficiencies after receiving written notice Failing to repay or make arrangements for repaying an identified overpayment or otherwise erroneous payment Dispensing smaller quantities of a prescribed drug in order to receive multiple dispensing fees Billing for a prescription drug other than the dispensed drug Billing for a prescription refill that was not authorized by the prescriber Billing more than would be charged to any other customer 16

17 Sanctions The department may impose the following sanctions against a provider: Termination from participation in the Alaska Medical Assistance program Suspension of participation in the Alaska Medical Assistance program Restriction or withholding of payments to a provider Referral to a utilization and quality control peer-review organization Transfer to a closed-end provider agreement not to exceed 12 months, or the shortening of an already-existing closed-end provider agreement Mandatory attendance at provider education sessions, including one-on-one sessions Requirement of prior authorization of services Department review of all claims submitted by the provider before payment Referral to applicable licensing board Public notice of suspension or termination of the provider Reporting the provider to the Healthcare Integrity and Protection Data Bank Restrictions on payment 17

18 Alaska Administrative Code Alaska Administrative Code rules for the Medicaid program are found in 7 AAC AAC 160 Go to Select Index (ToC) > 7 Health and Social Services > Part 8. Medicaid coverage and Payment 7 AAC Provider Enrollment Requirements, Responsibilities, and Requirements for Provider Records 7 AAC Provider Sanctions Providers are responsible for knowing and complying with ALL Medicaid regulations applicable to their provider type 18

19 Enrollment Process 19

20 20 Online Enrollment Process

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55 Affiliations 55

56 Affiliations An Affiliation is an association between one provider entity and another Providers can have more than one affiliation Affiliations affect Alaska Medicaid prior authorizations and billing 56

57 Affiliation Types Group practice to individual provider allows group to bill for the individual provider Employer to employee links sole proprietors to rendering provider employees Supervisor to collaborator used when collaborative agreements are required to practice Hospital to hospital-based provider links hospitals to providers who are their employees Provider to locum tenens used to link enrolled providers to the locum tenens providers who provide services in their absence 57

58 Signatures and Supporting Documentation 58

59 Signatures and Supporting Documents All documentation must be submitted before an application can be approved Documents can be printed from Provider Enrollment Forms page Signatures must be original blue ink is suggested Mail documents to the address given on the application summary page 59

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61 Additional Resources Alaska Medicaid Health Enterprise website at Information necessary for successful billing Includes provider-specific Medicaid billing manuals and fee schedules You may also call: Provider Enrollment at , option 2 or (toll-free), option 1, 3 61

62 2016 Conduent Business Services, LLC. All rights reserved. Conduent and Conduent Design are trademarks of Conduent Business Services, LLC in the United States and/or other countries.