Minnesota Administrative Rules

9505.0195 PROVIDER PARTICIPATION.

Subpart 1.

Department administration of provider participation.

The department shall administer the participation of providers in the medical assistance program. The department shall:

A.

determine the vendor's eligibility to enroll in the medical assistance program according to parts 9505.0170 to 9505.0475;

B.

enroll an eligible vendor located in Minnesota retroactive to the first day of the month of application, or retroactive for up to 90 days to the effective date of Medicare certification of the provider, or retroactive to the date of the recipient's established retroactive eligibility;

C.

enroll an out-of-state vendor as provided in subpart 9; and

D.

monitor and enforce the vendor's compliance with parts 9505.2160 to 9505.2245 and with the terms of the provider agreement.

Subp. 2.

Application to participate.

A vendor that wants to participate in the medical assistance program shall apply to the department on forms provided by the department. The forms must contain an application and a statement of the terms for participation. The vendor shall complete, sign, and return the forms to the department. Upon approval of the application by the department under subpart 3, the signed statement of the terms for participation and the application constitute the provider agreement.

Subp. 3.

Department review of application.

The department shall review a vendor's application to determine whether the vendor is qualified to participate according to the criteria in parts 9505.0170 to 9505.0475.

Subp. 4.

Notice to vendor.

The department shall notify an applicant, in writing, of its determination within 30 days of receipt of the complete application to participate.

A.

If the department approves the application, the notice must state that the application is approved and that the applicant has a provider agreement with the department.

B.

If the department denies the application, the notice to the applicant must state the reasons for the denial and the applicant's right to submit additional information in support of the application.

C.

If the department is unable to reach a decision within 30 days, the notice to the applicant must state the reasons for the delay and request any additional information necessary to make a decision.

Subp. 5.

Duration of provider agreement.

A provider agreement remains in effect until an event in items A to E occurs:

A.

the ending date of the agreement specified in the agreement; or

B.

the provider's failure to comply with the terms of participation; or

C.

the provider's sale or transfer of ownership, assets, or control of an entity that has been enrolled to provide medical assistance services; or

D.

30 days following the date of the department's request to the provider to sign a new provider agreement that is required of all providers of a particular type of health service; or

E.

the provider's request to end the agreement.

Subp. 6.

Consequences of failure to comply.

A provider who fails to comply with the terms of participation in the provider agreement or parts 9505.0170 to 9505.0475 or 9505.2160 to 9505.2245 is subject to monetary recovery, sanctions, or civil or criminal action as provided in parts 9505.2160 to 9505.2245. Unless otherwise provided by law, no provider of health services shall be declared ineligible without prior notice and an opportunity for a hearing under Minnesota Statutes, chapter 14, on the commissioner's proposed action.

Subp. 7.

Vendor who is not a provider.

A vendor of health services who does not have a provider agreement in effect, but who provides health services to recipients and who otherwise receives payments from the medical assistance program, is subject to parts 9505.0170 to 9505.0475 and 9505.2160 to 9505.2245.

Subp. 8.

Sale or transfer of entity providing health services.

A provider who sells an entity which has been enrolled to provide medical assistance services or who transfers ownership or control of an entity that has been enrolled to provide medical assistance services shall notify the department of the sale or transfer no later than 30 days before the effective date of the sale or transfer. The purchaser or transferee shall notify the department of transfer or sale no later than the effective date of the sale or transfer. Nothing in this subpart shall be construed to limit the right of the department to pursue monetary recovery or civil or criminal action against the seller or transferor as provided in parts 9505.2160 to 9505.2245.

Subp. 9.

Out-of-state vendor.

An out-of-state vendor may apply for retroactive enrollment as a provider effective on the date of service to a recipient. To be eligible for payment under the Minnesota medical assistance program, an out-of-state vendor must:

A.

comply with the licensing and certification requirements of the state where the vendor is located;

B.

complete and sign the forms required in subpart 2;

C.

obtain department approval as in subpart 3; and

D.

comply with the requirements of parts 9505.0170 to 9505.0475.

For purposes of this subpart, "out-of-state vendor" refers to a vendor who provides a health service to a Minnesota recipient at a site located in a state other than Minnesota.

Subp. 10.

Condition of participation.

A provider shall comply with title VI of the Civil Rights Act of 1964 and all regulations under the act, and with Minnesota Statutes, chapter 363. A provider shall not place restrictions or criteria on the services it will make available, the type of health conditions it will accept, or the persons it will accept for care or treatment, unless the provider applies those restrictions or criteria to all individuals seeking the provider's services. A provider shall render to recipients services of the same scope and quality as would be provided to the general public. Furthermore, a provider who has such restrictions or criteria shall disclose the restrictions or criteria to the department so the department can determine whether the provider complies with the requirements of this subpart.

Statutory Authority:

MS s 256B.04

History:

12 SR 624

Published Electronically:

December 2, 2013