R414. Health and Human Services, Integrated Healthcare.R414-23. Provider Enrollment.
R414-23-1. Purpose and Authority.
(1) Sections 26B-1-213 and 26B-3-108 authorize this rule.
(2) This rule implements requirements for provider revalidation as set forth in the Code of Federal Regulations and in the Patient Protection and Affordable Care Act.
R414-23-2. Definitions.
(1) "Provider" means an individual or entity approved by the Department to provide services to Medicaid members, and has signed a provider agreement with the Department.
(2) "Revalidation" means the mandatory process of screening enrolled providers of medical services, other items, and suppliers, as required by Section 6401 of the Patient Protection and Affordable Care Act.
(3) "PRISM" means Provider Reimbursement Information System for Medicaid.
(4) "CFR" means Code of Federal Regulations.
R414-23-3. Revalidation Requirements.
(1) An enrolled provider must revalidate with Medicaid through PRISM at intervals not to exceed five years as required by 42 CFR 424.515, depending on the provider's risk level.
(2) The Department shall notify a provider, when it is time to revalidate, with a letter mailed to the pay-to address in the PRISM system.
(3) A provider must complete and submit the revalidation process within 60 days from the date of the letter, or the Department will place a temporary payment hold on the provider account.
(4) The Department shall terminate a provider that fails to revalidate within 90 days from the date on the letter. The provider, however, has the option to request a fair hearing.
(5) A provider terminated for any reason must reenroll and be approved as a new provider.
(6) The Department may only reimburse a provider for services rendered during an enrollment period.
R414-23-4. Auto Closure of Provider Contracts.
The Department may automatically close a provider contract for any of the following reasons:
(1) failure to revalidate within the required five-year cycle as directed by 42 CFR 424.515;
(2) expiration of professional license, or expiration of any license associated with the program for clinical laboratory improvement amendments;
(3) upon state or federal reporting of a deceased provider; or
(4) failure to bill Medicaid for one or more years without notification.
KEY: Medicaid
Date of Last Change: November 10, 2023
Notice of Continuation: September 16, 2024
Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108
