Standards for Qualified Service Provider(s) 525-05-45

(Revised 5/1/16 ML #3471)

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Provider Enrollment

Purpose

 

The purpose of Provider Enrollment is to ensure that Qualified Service Providers meet the standards and qualifications set by the Department of Human Services and Federal Regulations for providing services to eligible Home and Community Based Service recipients.

 

Legal Authority

 

Code of Federal Regulations (CFR) Title 42, Chapter IV, Subchapter C, Part 455, Subpart E

 

Century Code 50-11-02.4

Century Code 50-11-06.8

Century Code 50-11-06.9

N.D. Admin. Code 75-03-23-07

N.D. Admin. Code 75-03-23-08

N.D. Admin. Code 75-03-23-10

N.D. Admin. Code 75-03-21-08

 

Standards for Qualified Service Providers

 

  1. Must be 18 years of age.
  2. Must meet the standards of CFR Part 455-Program Integrity Medicaid.
  3. Must meet the provider standards and agreements according to the N.D. Admin. Code and CFR.
  4. Per ND Admin. Code 75-03-23-08(1)(n)(2)(o)(p), QSPs must have been actively billing in the past 12 months or have valid reason for inactivity to renew or they may be closed for inactivity.
  5. No outstanding debts can be owed to the Department of Human Service.
  6. Documentation of Competency, registered nurse licensure, licensed practical nurse, certified nurse assistant certification, physician, physician assistant, nurse practitioner, physical therapist license, or occupational therapist must be current and up to date. (FHC does not require a documentation of competency)
  7. Family home care and family personal care providers must have an eligible client identified by the HCBS Case Manager before enrollment will be completed.
  8. Bureau of Criminal Investigation background checks and fingerprint screening must be done for Adult Foster Care (AFC) and Respite providers in an AFC home per Admin. Code 75-03-21-08(1)(h) and Century Code 50-11-02.4, 50-11-06.8, and 50-11-06.9.

 

For additional information about provider standards refer to the current QUALIFIED SERVICE PROVIDER (QSP) HANDBOOKS. For a copy of one or both QSP Handbooks, contact the HCBS Program Administration.

 

Standards for Qualified Service Providers for Environmental Modification

 

Standards for Home Delivered Meal Providers

 

Provider Enrollment Limitations

  1. All verification screenings required by the federal and state laws, rules, or regulations must be complete before enrollment can be finalized.
  2. The enrollment effective date cannot be prior to the required verification screening date.
  3. Effective enrollment date for services of Family Home Care or Family Personal Care may not be prior to client/member’s signature on care plan.
  4. A Monthly Rate Worksheet SFN 1012 must be sent to the QSP provider enrollment Program Administrator before final approval of QSP for Family Home Care or Family Personal Care will be granted.
  5. If enrollment is not complete by the end of the 30 day notice period, the QSP status will be stopped and a new start date will be given if/when a complete application is received and approved.
  6. Any break in licensure or documentation of competency dates will result in a stop and new start date.
  7. A break in renewal status greater than 30 days from the QSP closed date will result in a stop and a new start date and a complete application will be required. (This is due to the monthly renewal verification checks not being completed as required)

Provider Reimbursement Limitations

  1. QSP’s will not be paid with public funds until the enrollment requirements are fulfilled and a current authorization is received from the Case Manager.
  2. QSP’s will not be eligible for payment during the period when their QSP enrollment status lapsed.
  3. QSP’s are not eligible for payment earlier than the effective date on the authorization to provide services issued by the case manager, therefore the enrollment date may not be the date a provider can start billing.

Enrollment Process for New Applicants

  1. All forms must be completed correctly and the required verification checks by the HCBS Program Administrator must be complete before an enrollment start and end date will be given (dates cannot be retroactive).
  2. The following provider verifications must be completed by the HCBS Program Administrator according to the CFR and state regulations:
  3. QSP will be issued an “enrollment end date” no longer than 24 months from the date of enrollment.
  4. Enrollment end date may be up to 23 months from original competency date to allow sufficient time for renewal.

Enrollment Process for Family Home Care and Family Personal Care

  1. All forms must be completed correctly and the required verification checks by the HCBS Program Administrator must be complete before an enrollment start and end date will be given.
  2. The following provider verifications must be completed by the HCBS Program Administrator according to the CFR and state regulations:
  3. Family Home Care does not require documentation of competency.
  4. Family Personal Care requires that a valid proof of competency be sent with the application.
  5. Effective enrollment date of QSP enrollment for the services of Family Home Care or Family Personal Care may not be prior to the date of the client/member’s signature on the care plan.
  6. A monthly rate worksheet must be sent to the QSP provider enrollment Program Administrator before final approval of QSP for Family Home Care or Family Personal Care will be granted.
  7. A start date will be determined by reviewing:
  8. QSP will be issued an “enrollment end date” no longer than 24 months from enrollment.
  9. Enrollment end date may be up to 23 months from original competency date for family personal care or the date of signature on the Medicaid Agreement for family home care, to allow sufficient time for renewal.

Enrollment Process for Renewals

  1. All forms must be completed correctly, and the required verification checks by the HCBS Program Administrator must be complete before renewal of QSP status can be approved.
  2. The following provider verifications must be completed by the HCBS Program Administrator according to the CFR and state regulations:
  1. QSP is given an “enrollment end date” no longer than 24 months from enrollment.
  2. Enrollment end date may be up to 23 months from original competency date to allow sufficient time for renewal.
  3. Six to eight weeks prior to the end date, the QSP will be sent a renewal application.
  4. If renewal is not received by the renewal end date, the QSP and the HCBS Case Manager and/or the DD Program Manager will be sent a written notification of a 30 day stop notice period, allowing the provider 30 extra days to renew.
  5. If renewal is not received and processed during the 30 day stop notice period, the QSP must be taken off the care plan.
  6. QSP wishing to continue to provide care must have a complete application submitted and approved before. (There will be no retroactive dates after the 30 day notice).

Exceptions

  1. Requests for exceptions will be reviewed and considered but will not be granted unless the provider meets all the competency requirements and all required screenings and verifications have been completed.
  2. Prior approval is required by the HCBS Program Administrator.

 

Provider Addresses

 

QSP mail returned twice, with no forwarding address, will result in a closure of QSP status. The HCBS Case Manager or DD Program Manager will be notified of closure date.

 

If the QSP provides a valid address and meets all provider enrollment requirements, the QSP status will be opened.

 

If the QSP mail is returned notifying the department that the QSP has moved to a state that does not border North Dakota, the QSP will be closed and given a stop notice.

 

30 Day Stop Notice

 

A 30 day stop notice is the period of time when a written notification is sent to the QSP and case manager, allowing the QSP time to renew enrollment status, without losing eligibility for reimbursement from the state. During this period a valid Documentation of Competency SFN 750, licensure, or certification and all completed renewal forms must be received by the Department and all required provider verifications must be completed.

 

NOTE: The QSP must meet all requirements and is still competent during the 30 day stop notice period. The notice is sent to assure QSPs understand that they have 30 days to complete the application or they will no longer be eligible for reimbursement.

 

If the application is not complete after the 30 day stop notice period has ended, the case manager must remove the QSP from the care plan.

 

Stop and Start dates

 

If the 30 day stop notice date has passed, and the QSP has not submitted an application, or their submitted application is not complete, QSP status will be closed. If the QSP submits a complete application or finalizes a previously submitted application they will receive a new QSP enrollment start date. The QSP will not be eligible for reimbursement between the stop and new start date.

 

Closure for Inactivity

 

QSPs with no billing activity within the last 12-15 months will receive a 30 day stop notice. The notice will allow the QSP time to notify the Department of the reason for inactivity.

 

If a valid reason for inactivity is not received within the 30 day stop notice, the QSP status will be stopped.

 

15 minute unit rates

Providers must deliver at least 8 minutes of service before they can bill for the first 15 minute unit. Providers should not bill for services performed for less than 8 minutes. This applies to all procedure codes billed using a 15 minute unit rate.

 

The amount of time required to bill for a larger number of units is as follows:

2 units: at least 23 minutes       6 units: at least 83 minutes

3 units: at least 38 minutes       7 units: at least 98 minutes

4 units: at least 53 minutes       8 units: at least 113 minutes

5 units: at least 68 minutes

 

The pattern remains the same for allowable tasks performed in excess of 8 units (2 hours).