Section 514.1 - Policy.

Section 514.1 Policy. (a) In order to avoid unnecessary processing of medical assistance (MA) claims, administrative expense to the MA program, provider billing errors resulting in nonpayment of claims and to reduce unacceptable provider practices, the department may require a provider to verify MA recipient eligibility. The department may also require a provider to verify orders for care, services or supplies.

(b) A provider required to do so must verify MA recipient eligibility by making an inquiry to an electronic data system prior to furnishing any item of care, services or supplies for which payment will be claimed under the MA program. A provider required to do so must make an inquiry to an electronic data system to determine whether an order for care, services or supplies has been posted in the electronic data system by the ordering provider and is therefore subject to reimbursement if filled by the inquiring provider.

(c) The department may require a provider to verify recipient eligibility if the department determines that the provider engages in a significant number of MA transactions, or the provider's service profile exceeds the department's utilization control criteria. The department may require a provider to verify orders for care, services or supplies if the provider engages in a significant number of MA transactions, or the provider's service profile exceeds the department's utilization control criteria, or other circumstances warrant imposition of this control to assure validity of orders for care, services or supplies.

(d) A provider required to verify recipient eligibility or orders for care, services or supplies who fails to verify properly may have payment for claims under the MA program withheld or denied or be subject to sanctions, as defined in Part 515 of this Title.

 

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