Md. Code Regs. 10.09.20.04

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.20.04 - Conditions for Provider Participation - General Requirements

A. To participate as a provider of a service covered under this chapter, a provider:

(1) Shall meet all of the conditions for participation as a Medicaid provider as set forth in COMAR 10.09.36, except as otherwise specified in this chapter;

(2) Shall verify the qualifications of all individuals who render services on the provider's behalf and provide a copy of the current license or credentials on request;

(3) Shall implement the reporting and follow-up of incidents and complaints in accordance with the Department's established policy by:

(a) Reporting incidents and complaints within 24 hours of knowledge of the event;

(b) Submitting a written report within 7 calendar days on a form designated by the Department; and

(c) Notifying the local department of social services immediately if the provider has a reason to believe that the participant has been subjected to abuse, neglect, self-neglect, or exploitation, in accordance with COMAR 07.02.16;

(4) Shall agree to cooperate with required inspections, reviews, and audits by authorized governmental agents;

(5) Shall agree to provide services, and to subsequently bill the Department in accordance with the reimbursement methodology specified in this chapter, for only those services covered under this chapter which have been:

(a) Preauthorized in the participant's plan of service;

(b) Provided in a manner consistent with the participant's plan of service; and

(c) Identified in the provider agreement as within the scope of the provider's Medicaid participation;

(6) Shall agree to maintain and have available written documentation of services, including dates and hours of services provided to participants, for a period of 6 years from the date of service, in a manner approved by the Department;

(7) Shall agree not to suspend, terminate, increase, or reduce services for an individual without authorization from the Department and only after consultation and input from the participant or, when applicable, the participant's representative;

(8) Shall submit a transition plan to the case manager or supports planner and participant or, when applicable, the participant's representative when suspending or terminating services;

(9) Shall verify Medicaid eligibility at the beginning of each month that services will be rendered;

(10) May not be a Medicaid provider or principal of a Medicaid provider that has overpayments that remain due to the Department; and

(11) Shall be free from conflicts of interest.

B. To participate as a provider of a service covered under this chapter, a provider or its principals may not, within the past 24 months, have:

(1) Had a license or certificate suspended or revoked as a health care provider, health care facility, or direct care services worker;

(2) Been suspended or removed from participating as a Medicaid provider under COMAR 10.09.84;

(3) Undergone the imposition of sanctions under COMAR 10.09.36.08;

(4) Been subject to disciplinary action, including actions by the licensing board or any provider or principal of any provider agency;

(5) Been cited by a State agency for deficiencies which affect participants' health and safety; or

(6) Experienced a termination of a Medicaid provider agreement or been barred from work or participation by a public or private agency due to:

(a) Failure to meet contractual obligations; or

(b) Fraudulent billing practices.

C. A provider who renders health-related services to participants shall agree to:

(1) Periodically provide information about a participant in accordance with the procedures and forms designated by the Department; and

(2) Share and discuss the documented information at the request of the participant.

Md. Code Regs. 10.09.20.04

Regulations .04 amended effective April 6, 1986 (13:7 Md. R. 795)
Regulation .04C amended effective October 22, 1984 (11:21 Md. R. 1813)
Regulation .04 amended effective January 31, 2005 (32:2 Md. R. 146)
Regulation .04B amended effective November 14, 2011 (38:23 Md. R. 1421)
Regulation .04D, E, F adopted effective July 1, 1988 (15:13 Md. R. 1554)
Regulation .04D amended as an emergency provision effective July 1, 2006 (33:15 Md. R. 1274); amended permanently effective October 23, 2006 (33:21 Md. R. 1675)
Regulation .04E, F repealed effective August 29, 2005 (32:17 Md. R. 1438); adopted effective 43:5 Md. R. 385, eff.3/14/2016; amended effective 45:26 Md. R. 1242, eff. 12/31/2018