10- 144 C.M.R. ch. 332, § 18-8

Current through 2024-51, December 18, 2024

Section 144-332-18-8 - PERFORMANCE STANDARDS FOR QUALIFIED HOSPITALS

1.Performance Standards

OFI will use the following standards to determine the accuracy and legitimacy of presumptive eligibility determinations made by each qualified hospital:

A. Was the MaineCare Presumptive Eligibility Card (HPE-Card) received by OFI within 5 working days from the determination date?

B. Was a full MaineCare application received by OFI before the expiration of the presumptive eligibility period?

C. If a full application was received, was the individual found to be eligible for full MaineCare coverage?

2.Corrective Action

A. The first time a qualified hospital fails to meet any of the standards established in Section 8-1 of this Part for any presumptive eligibility determination that the hospital made, OFI will notify the hospital in writing within 5 days from when the standard was not met. The written notice will include:

(1) A description of the standard that was not met and an explanation of why it was not met; and

(2) Confirmation that a second finding will require that all applicable hospital staff participate in mandatory training on hospital presumptive eligibility rules and regulations to be conducted by OFI.

B. The second time a qualified hospital fails to meet any of the standards established in Section 8-1 of this Part for any presumptive eligibility determination that the hospital made, OFI will notify the hospital in writing within 5 days from when the standard was not met. The written notice will include:

(1) A description of the standard that was not met and an explanation of why it was not met;

(2) Confirmation that all applicable hospital staff will be required to participate in a mandatory training on hospital presumptive eligibility rules and regulations to be conducted by OFI (the date, time and location of the training will be determined by OFI); and

(3) Confirmation that if in the future the hospital fails to meet any of the standards established in Section 8-1 of this Part, the hospital will no longer be qualified to make presumptive eligibility determinations.

C. The third time a qualified hospital fails to meet any of the standards established in Section 8-1 of this Part for any presumptive eligibility determination that the hospital made, OFI will notify the hospital in writing within 5 days from when the standard was not met. The written notice will include:

(1) A description of the standard that was not met and an explanation of why it was not met;

(2) Confirmation that because this was the third occurrence of failure to meet the required standards, effective immediately the hospital will no longer be qualified to make presumptive eligibility determinations of any kind.

10- 144 C.M.R. ch. 332, § 18-8