Section 471-2-003 - PROVIDER REQUIREMENTS003.01PROVIDER ELIGILIBITY. To be eligible to participate in Title XIX (Medicaid) and Title XXI Children's Health Insurance Program (CHIP), the provider must meet the general standards for all providers in 471 Nebraska Administrative Code (NAC) Chapters 1, 2, and 3, if appropriate, and the standards for participation for each provider type included within: (A) Each provider specific chapter of Title 471 NAC;(B) Title 480 NAC for Home and Community-Based Waiver Services;(C) Title 403 and 404 NAC for Community-Based Services for Individuals with Developmental Disabilities; and(D) Title 482 NAC for Managed Care Services.003.02PROVIDER ENROLLMENT. The Department will not cover services rendered, ordered, or referred by a provider, or pay a provider for services, when that provider is not enrolled with Medicaid in accordance with 471 NAC 2. Each provider business location where services are rendered must be enrolled. 003.02(A)PROVIDER SCREENING. The Department will, at a minimum, screen all providers as provided in 42 Code of Federal Regulations (CFR) Part 455, Subpart E. In accordance with 42 CFR 455.452, the Department may enact additional or more stringent screening methods which will be included within either the NAC or Nebraska state law. The Department will deny or terminate the enrollment of any provider that fails to comply with or meet all applicable screening requirements. 003.02(A)(i)SITE VISITS. A provider must permit the Centers for Medicare and Medicaid Services (CMS) and the Department to conduct unannounced onsite inspections of any and all provider locations. The Department may deny or terminate the enrollment of a provider who fails to permit a site visit. The Department may also deny or terminate a provider if, based on the site visit, the Department determines the provider location does not match the service provider agreement or does not meet the standards for participation.003.02(A)(ii)CATEGORICAL RISK LEVELS. All provider types are categorized into one of three risk levels based on a determination by the Centers for Medicare and Medicaid Services (CMS) and the state Medicaid agency of the risk of fraud, waste, and abuse. The risk level of a provider will be raised to high risk, regardless of their provider type risk level, when payments are suspended based on a credible allegation of fraud, the provider has an existing Medicaid overpayment, or the provider has been excluded by the Office of the Inspector General or any state's Medicaid program within the last 10 years. Provider types are subject to screening requirements based on their applicable risk level. 003.02(A)(ii)(1)LOW RISK. Low risk screening includes. 003.02(A)(ii)(1)(a)LICENSE. Verification that the provider's applicable license(s) is not expired and has no current limitations.003.02(A)(ii)(1)(b)DATABASES. Pre- and post-enrollment database checks to confirm the identity and participation eligibility of the provider, owners, and managing employees.003.02(A)(ii)(2)MODERATE RISK. Moderate risk screening includes all components of low risk screening as well as pre- and post-enrollment site visit.003.02(A)(ii)(3)HIGH RISK. High risk screening includes all components of low and moderate risk screening as well as fingerprint based criminal background checks of the provider or any person who owns five percent or more direct or indirect ownership interest in the providers.003.02(A)(iii)CRIMINAL BACKGROUND CHECKS. As a condition of enrollment, providers must consent to criminal background checks including fingerprinting when required to do so under State law or by risk level determined for that category of provider. Failure to consent to criminal background checks will result in the denial or termination of the service provider agreement.003.02(A)(iv)FINGERPRINT SUBMISSION. Any high risk provider, or any person with a five percent or more ownership interest in a high risk provider, must submit a set of fingerprints, in a form and manner determined by the State Medicaid agency, within 30 days upon request from the Centers for Medicare and Medicaid Services (CMS) or the State Medicaid agency. Failure of the provider or owner, as applicable, to meet this requirement will result in the denial or termination of the service provider agreement.003.02(B)SERVICE PROVIDER AGREEMENTS. Each provider must have an approved service provider agreement with the Department. By signing the service provider agreement, a provider agrees to comply with all provisions stated therein. A service provider agreement is not an employment agreement or contract, and enrollment as a Medicaid provider does not constitute employment by or with the Department and does not guarantee referrals. Service provider agreements cannot be transferred to any other person or entity. 003.02(B)(i)REQUIRED FORMS. Providers must complete, sign, and submit to the Department the following forms as appropriate. (1) MC-19, "Service Provider Agreement";(2) MLTC-62, "Nebraska Ownership/Controlling Interest and Convictions Disclosure";(3) All applicable addendum forms;(4) "United States Citizenship Attestation form"; and(5) MS-84 "State of Nebraska ACH/EFT Enrollment form". Certain providers of home and community-based services must also complete provider agreement forms as indicated in Title 480 NAC. Certain providers of medical transportation services must also complete the service provider agreement form as indicated in Titles 473 and 474 NAC.
The Department may require a provider to periodically complete a new service provider agreement to update information or eligibility, and may terminate the enrollment of a provider that fails to comply with this requirement.
003.02(C)APPROVAL AND ENROLLMENT. The Department will review and screen each submitted service provider agreement and upon approval and enrollment will assign an effective date to the provider and a Medicaid provider number to use when billing Medicaid.003.02(D)ORDERING AND REFERRING PROVIDERS. Ordering and referring physicians or other professionals providing Medicaid services must be enrolled providers and must include their National Provider Identifier (NPI) on any claims for items or services ordered or referred.003.02(E)REACTIVATION. At the discretion of the Department, providers who have previously been terminated or excluded may or may not be reactivated as providers of Title XIX (Medicaid) and Title XXI Children's Health Insurance Program (CHIP) services. At the end of a technical or time-limited termination period, the provider may request in writing that the Department reactivate the service provider agreement. The Medicaid Division may approve or deny reactivation of the service provider agreement. The provider may be reactivated conditionally with a closed-end service provider agreement or other restrictions or requirements as deemed to be necessary by the Department.003.02(F)REVALIDATION. The Department must revalidate the enrollment of all providers at least every five years. Providers who do not complete revalidation will not be eligible past their revalidation due date.003.02(G)APPLICATION FEE. At initial enrollment, re-enrollment, reactivation, and revalidation providers must submit to the Department an application fee before the Department can execute a service provider agreement. Exempt from this application fee requirement are the following. (i) Individual physicians and non-physician practitioners;(ii) Providers enrolled in or that have paid an application fee to Medicare or another State's Medicaid or Children's Health Insurance Program (CHIP); and(iii) Providers or categories of providers that have received an application fee waiver from the Centers for Medicare and Medicaid Services (CMS).003.02(H)TEMPORARY MORATORIA. A moratorium imposed under this section lasts for an initial period of six months and if necessary may be extended in six-month increments by the Department. Notice of any moratoria issued by the Department will be provided through a provider bulletin. The Department, in its discretion and under mandate from the Secretary of the United States Department of Health and Human Services enforces temporary moratoria under either of the following conditions.(i) The Department must impose temporary moratoria on the enrollment of new providers or provider types that pose an increased risk to the Medicaid program as identified by the Secretary of the United States Department of Health and Human Services unless the Department determines that a temporary moratorium would adversely affect access to medical assistance; and(ii) The Department may impose temporary moratoria or place numerical caps or other limits on the enrollment of new providers that it and the Secretary of the United States Department of Health and Human Services have identified as having significant potential for fraud, waste, or abuse unless the Department determines that such action would adversely affect access to medical assistance.003.03STANDARDS FOR PARTICIPATION. Providers must meet the following minimum requirements: (1) Accept the philosophy of service provision which includes acceptance of, respect for, and a positive attitude toward Medicaid clients and the philosophy of client empowerment;(2) Meet any applicable licensure or certification requirements and maintain current licensure or certification;(3) Obtain adequate information on the medical and personal needs of each client, if applicable;(4) Not discriminate against any client, employee, or applicant for employment because of race, age, color, religion, sex, handicap, or national origin, in accordance with 45 CFR Parts 80, 84, 90, and 41 CFR Part 60;(5) Agree to a law enforcement criminal background check and Adult Protective Services and Child Protective Services Central Registry checks;(6) Operate a drug-free workplace;(7) Attend training on Medicaid as deemed necessary by the Department;(8) Provide services within the scope of practice identified in state and federal law, and under all applicable state and federal licensure or certification requirements; and(9) Agree to maintain up-to-date and accurate service provider agreement information by submitting any changes, within 35 days of the change, to the Department.003.03(A)PROVIDER EMPLOYEES. Employees of providers are subject to the same standards.003.04DEPARTMENT EMPLOYEES AS PROVIDERS. No employee of the Department and its subdivisions, and Department contractors, except clinical consultants, may serve as providers under Medicaid or as paid consultants to enrolled providers without the express written approval of the Medicaid Director.003.05PRINCIPLES OF PROVIDING MEDICAL ASSISTANCE. The amount and type of service required is defined for each case through utilization review. The provider will limit services to essential health care. The plan for providing services within program guidelines through Medicaid is based on the following principles: (A) All plans for medical care must provide for essential health services and for integration of treatment with social planning to reduce economic dependency;(B) Medical care and services must be coordinated with health services available through existing public and private sources;(C) Medical care and services must be provided as economically as is consistent with accepted standards of medical care and fair compensation to providers;(D) Medical care and services must be within the licensure of the provider giving the care or service; and(E) The client must be allowed, within these limitations, to exercise free choice in the selection of a qualified provider.003.06PROVIDER MATERIALS. The provider is responsible for understanding and complying with all applicable regulations and ensuring that employees, consultants, and contractors are informed about all applicable regulations, including: (B) Each service specific chapter in Title 403, 404, 471 and 480 NAC that is applicable to services rendered by the provider, and instructions for forms and electronic transactions.003.07PROVIDER BULLETINS. The provider must comply with the information in each provider bulletin when conducting enrollment activities, rendering services and submitting claims for payment.003.08ELECTRONIC INFORMATION EXCHANGE. Any entity that exchanges standard electronic transactions with the Department must have an approved trading partner agreement with the Department.003.09VERIFICATION OF LAWFUL PRESENCE. Individual providers enrolling as a solo practitioner must attest to: (A) United States citizenship; or(B) Status as a qualified alien under the Federal Immigration and Nationality Act, including disclosure of the alien number and official immigration documents as needed to verify status and work authorization.471 Neb. Admin. Code, ch. 2, § 003
Amended effective 12/5/2015.Adopted effective 2/10/2020Amended effective 9/21/2020