471 Neb. Admin. Code, ch. 15, § 003

Current through June 17, 2024

Section 471-15-003 - PROVIDER REQUIREMENTS

003.01GENERAL PROVIDER REQUIREMENTS. To participate in the Nebraska Medicaid program, providers of personal assistance services will comply with all applicable provider participation requirements codified in 471 Nebraska Administrative Code (NAC) 1, 2, and 3.

003.02SERVICE SPECIFIC PROVIDER REQUIREMENTS.

003.02(A)PARTICIPATION STANDARDS. All providers are Medicaid providers as defined under 471 NAC 2 and will meet the following standards:

(i) Follow all applicable Department policies and procedures including those found in NAC 465, 471, 473, 474 and 480. Bill only for services which are authorized and actually provided;

(ii) Accept payment as payment in full for the agreed upon service(s) unless the client has been assigned a portion of the cost by the Department. Provider will not charge clients any difference between the agreed upon rate and private pay rate;

(iii) Spouses or parents of minor children are not eligible to be providers;

(iv) Not engage in any activity that influences service approval or utilization if they are an employee of the Department or, the relative of a Department staff person.

(v) Retain all records related to provider enrollment and service provision, including financial records. Records will be maintained for retention periods in compliance with federal and state law, but no record will be destroyed prior to expiration of a six year retention period;

(vi) Allow federal, state, or local offices responsible for program administration or audit to review service records, in accordance with 45 CFR 74.20- 74.24; and 42 CFR 431.107. Inspections, reviews, and audits may be conducted on site;

(vii) A provider of personal assistance services is not an employee of the Department or of the State;

(viii) Any false claims including claims submitted electronically, statements, documents, or concealment of material fact may be prosecuted under applicable state or federal laws;

(ix) Respect every client's right to confidentiality and safeguard confidential information;

(x) Understand and accept responsibility for the client's safety and property;

(xi) Not transfer this agreement to any other entity or person;

(xii) Not use any federal funds received to influence agency or congressional staff;

(xiii) Not engage in or have an ongoing history of criminal activity that may be harmful or may endanger individuals for whom they provide services. This may include a substantiated listing as a perpetrator on the child and adult central registries of abuse and neglect;

(xiv) Agency providers agree to allow Department staff to review agency policies regarding hiring and reporting to ensure that appropriate procedures regarding abuse, neglect, and law violations are in place;

(xv) Have the knowledge, experience, and skills necessary to perform the tasks of patient care and Electronic Visit Verification (EVV);

(xvi) Be capable of recognizing signs of distress in client and know how to access available emergency resources if a crisis situation occurs;

(xvii) Report changes to appropriate Department staff;

(xviii) Report all incidents in which there is reasonable cause to believe a client has been subjected to abuse, neglect, or exploitation. All such incidents will be reported to law enforcement and the Department;

(xix) Be age 19 or older if an individual provider; or assure that agency staff who assume the following roles are age 19 or older: director, administrator, agency representative for signing legal documents, or provider of in-home client services;

(xx) Not be a recipient of personal assistance services or similar services; and

(xxi) Providers entering the client's home to provide services will not be accompanied in the client's home by any individuals, including the provider's minor children, whose presence is unnecessary to the provision of services to the client, or who are not authorized to provide services to the client. This does not apply when the provider shares a home with the client.

003.02(B)SPECIALIZED PROVIDER QUALIFICATIONS. A personal assistance services provider is considered to be specialized when they provide proof of one or more of the following:

(i) Has passed the Nebraska certified nurse aide equivalency test and can provide evidence of this to the Department;

(ii) Is a licensed registered nurse or licensed practical nurse and presents a copy of the certificate or license to the Department; or

(iii) Has a total of 4,160 hours of experience as a personal assistance service provider and can provide evidence to the Department.

003.02(C)DENIAL, TERMINATION, AND SANCTION OF PERSONAL ASSISTANCE SERVICES PROVIDERS. Refer to 471 NAC 2.

003.02(D)REPORTS OF ABUSE OR NEGLECT. The following provisions apply when reports of abuse or neglect by a provider have been received.

003.02(D)(i)ADULT PROTECTIVE SERVICES AND CHILD PROTECTIVE SERVICES. Medicaid providers are subject to Adult Protective Services and Child Protective Services Central Registry checks to determine if any substantiated reports of abuse or neglect by the provider exist. For services being provided in the same location the provider lists as their home, members of the household may also be checked in the Central Registries to determine if any substantiated reports of abuse or neglect exist.

003.02(D)(ii)REPORTS OF ABUSE OR NEGLECT. If a report of abuse or neglect concerning a provider, or a household member when service is provided in the same location the provider lists as their home address, as a perpetrator is substantiated, Department staff will immediately terminate the service provider agreement. If a report of abuse or neglect is shown as investigation in progress or substantiated, the Department will not enroll the provider.

003.02(E)DENIAL OR TERMINATION OF ENROLLMENT. Refer to 471 NAC 2.

003.02(E)(i)DENIAL OR TERMINATION OF ENROLLMENT. Refer to 471 NAC 2.

003.02(E)(ii)VOLUNTARY WITHDRAWAL. Written notice to the provider applicant is not required if the provider voluntarily withdraws from the enrollment process.

003.02(F)SERVICE PROVIDER AGREEMENT. Refer to 471 NAC 2.

003.02(G)PROVIDER APPEALS. Refer to 471 NAC 2.

003.02(H)PROVIDER RESPONSIBILITIES. An approved provider must:

(i) Adhere to all general provider standards in the service provider agreement and listed in this chapter;

(ii) Perform the personal assistance services described on the service plan;

(iii) Ensure that personal assistance services are provided in a manner that is consistent with the client's choice, needs and desire to live independently;

(iv) Participate in the review of the client's service plan as described in this chapter, if and when the client requests them to participate;

(v) Recognize changes in the client's condition as it relates to the service plan, and report them to the Department;

(vi) Providers are responsible for completion of their electronic claims and any additional required documents prior to submitting them for processing. Providers are also responsible for knowing and understanding the tasks they are authorized to perform for each client they serve;

(vii) Accurately document services related to the service plan that are provided to and on behalf of the client, in the provider Electronic Visit Verification (EVV) system and submit electronic claims for payment;

(viii) Confirm that services were received in the manner authorized according to Department procedures;

(ix) Disclose necessary medical information to all clients for whom services are being provided, to allow for the safety of both client and provider;

(x) Retain the following materials for six years:

(1) Documentation that supports provision of services to each client served;

(2) Any other documentation determined necessary by the Department to support selection and provision of services under a service plan;

(3) Financial information related to the personal assistance services that are necessary to allow for an independent audit under Medicaid;

(4) Documentation that supports requests for payment; and

(5) Provider agreements with the Department;

(xi) Give adequate notice to the client when unable to provide scheduled services and terminating service provision; and

(xii) Not harm or exploit the client or client's household members, including acts of physical or verbal abuse, theft, or misuse of household belongings, personal funds, prescriptions, or other medical supplies.

003.02(I)PROVIDER NOTICE. When a client's personal assistance services are being changed in any way or terminated, the Department will provide written notice to the provider of the change in service provision or termination of payment for personal assistance services.

471 Neb. Admin. Code, ch. 15, § 003

Amended effective 6/6/2022