TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES
Emergency Rule
LSA Document #18-284(E)
DIGEST
Temporarily adds provisions to amend and clarify the requirements for provider enrollment and credentialing in
405 IAC 5-4-1. Statutory authority:
IC 12-15-11-9. Effective 30 days after filing with the Publisher.
(b) In order to receive reimbursement from the office, a provider shall be enrolled to participate as a provider. A provider is enrolled to participate in Medicaid when all of the following conditions have been met:
(1) The provider is duly licensed, registered, or certified by the appropriate professional regulatory agency pursuant to state or federal law, or otherwise authorized by the office.
(2) The provider has submitted an application to participate in Medicaid and fully and accurately completed such forms as may be required.
(3) The provider has signed and returned a Medicaid provider agreement.
(4) The provider has received a provider number.
(5) For an institutional or individual provider located out-of-state, such entity shall, in addition to meeting subsections (b)(2) through (b)(4) [subdivisions (2) through (4)] be either:
(A) certified;
(B) licensed;
(C) registered; or
(D) authorized;
as required by the state in which the entity is located.
(6) The provider maintains state licensure and abides by the office's provider agreement.
(7) The provider successfully completes credentialing under SECTION 2 of this document.
(c) In addition to subsection (b), a provider seeking to enroll in transportation services shall:
(1) make transportation services available to the general public; and
(2) demonstrate that its primary business function is the provision of transportation services.
This requirement does not apply to transportation providers who provide only ambulance, family member transportation services, or school corporations.
(d) With respect to ambulance service, vehicles and staff that provide emergency services must be certified by the emergency medical services commission established under IC 16-31-2-2 to be eligible for Medicaid reimbursement for transports involving either advanced life support or basic life support services that are emergent in nature. Failure to maintain the emergency medical services commission certification on all vehicles involved in transporting Medicaid members will result in termination of the Medicaid provider agreement.
(e) All transportation provider types shall continuously comply with all state statutes, rules, and local ordinances governing public transportation. The following requirements also apply as follows:
(1) A common transportation carrier shall submit proof of, and maintain throughout its period of participation, the following:
(A) Certification by the Indiana motor carrier authority.
(B) Insurance coverage as required by the Indiana motor carrier authority.
(C) Appropriate and valid drivers' licenses for all drivers.
(2) A taxicab transportation entity shall submit proof of and maintain throughout its period of participation the following:
(A) Written acknowledgment by local or county officials of whether there are existing ordinances governing taxi services and written verification from local or county officials that taxicab services operating in the local vicinity are in compliance with those ordinances.
(B) Livery insurance as indicated by existing local ordinances, or in the absence of such ordinances, a minimum of twenty-five thousand dollars/fifty thousand dollars ($25,000/$50,000) public livery insurance covering all vehicles used in the business.
(C) Appropriate and valid drivers' licenses for all drivers.
(3) A not-for-profit transportation entity shall submit proof of, and maintain throughout its period of participation, the following:
(A) An acknowledgment from state or federal officials of their status as a not-for-profit entity.
(B) A minimum of five hundred thousand dollars ($500,000) of combined single limit commercial automobile liability insurance.
(C) Appropriate and valid drivers' licenses for all drivers.
(f) IEP transportation services provided in accordance with 405 IAC 5-30-11 must conform to the requirements set out in IC 20-27 and are exempt from the transportation provider agreement requirements set out in this SECTION.
(g) The office may enroll the family member of a member only when the member must make frequent trips to medical services and that travel creates undue financial hardship for the family. In order to enroll as a transportation provider, a family member shall:
(1) Comply with and maintain compliance with all enrollment requirements under any federal or state law or rule.
(2) Possess a valid driver's license as required by state law.
(3) Possess coverage of the minimum amount of automobile insurance as required by state law.
(4) Utilize as the vehicle for transporting family members, only a vehicle which has been duly licensed and registered.
(5) Include, at a minimum, the following information in an enrollment request:
(A) The member's name and Medicaid number.
(B) The name, address, and relationship of the family member provider.
(C) A description of the circumstances surrounding the request.
(D) A statement of the financial impact on the family as a result of providing transportation services to the recipient.
(E) The desired effective date for the enrollment of the family member as a transportation provider.
(h) A close associate or able-bodied member may enroll to provide transportation services when no family member is available to provide this service. When a family member is enrolled as a transportation provider, that individual may provide services only to the designated recipient, and those services are subject to prior authorization. The local division of family resources office, on behalf of the family member, shall submit the enrollment request to the office or its designee for its approval.
SECTION 2. (a) In addition to SECTION 1 of this document, in order for a provider to enroll in the Medicaid or CHIP program and receive reimbursement, the provider shall complete all credentialing requirements for their type and specialty as defined by the National Committee for Quality Assurance (NCQA), or its successor accrediting body.
(b) Providers' credentials shall be verified by the contracted Credentials Verification Organization (CVO) or the delegated credentialing entities, if deemed appropriate. The office reserves the option to determine if delegated credentialing meets the needs of the program and can opt out of or cancel delegated agreements in the event that delegated credentialing is inconsistent with the requirements of the CVO.
(c) A credentialing committee (hereinafter referred to as committee) shall be established as part of the combined enrollment and credentialing process consistent with NCQA standards:
(1) Each managed care organization, as defined by IC 12-7-2-126.9, shall be required to participate in the committee.
(2) The committee shall consist of the following:
(A) The secretary or the secretary's designee, who shall be the chair of the committee.
(B) Each MCO's medical director or their designee.
(3) The committee shall review credentialing files at least monthly and shall operate as follows:
(A) All members of the committee must hold appropriate education and training to be considered peer reviewers, consistent with NCQA guidelines.
(B) Each member of the committee shall review the screened application and credentials of all providers wishing to enroll, reenroll, or revalidate their enrollment and make a recommendation to the secretary or the secretary's designee.
(C) The secretary or the secretary's designee shall make the final determination to approve or deny enrollment.
(d) Providers wishing to participate in an MCO network must first be successfully credentialed by the office as a Medicaid or CHIP provider, as appropriate, by type and specialty and enrolled pursuant to SECTION 1 of this document.
(e) An MCO must accept the results of the committee for the combined enrollment and credentialing process, as well as a combined revalidation and recredentialing process.
(f) An MCO may collect additional information from the provider in order to complete their contracting process but cannot require enrolled and credentialed providers to go through additional credentialing in order to be added to the MCO network.
(g) An MCO shall not be required to contract with a specific provider who has completed the enrollment and credentialing process.
(h) In order to maintain enrollment, a provider must re-attest periodically that the enrollment and credential information is accurate and up to date and revalidate and recredential the enrollment in a timely manner.
SECTION 3. All provider enrollment and credentialing regulations in this document shall apply to both Medicaid providers and CHIP providers.
Filed with Publisher: July 10, 2018, 8:07 a.m.
Posted: 07/11/2018 by Legislative Services Agency
DIN: 20180711-IR-405180284ERA
Composed: Apr 29,2024 1:13:14PM EDT
A
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