Section 514.6 - Posting of orders for care, services or supplies.

514.6 Posting of orders for care, services or supplies. (a) In certain instances, as defined by Parts 505 and 506 of this Title, a prescription or fiscal order is required before a provider may furnish MA care, services or supplies (e.g., provision of laboratory services, drugs or sickroom supplies requires the fiscal order of a qualified practitioner). With regard to care, services or supplies for which a prescription or fiscal order is required, the department may direct an ordering provider to enter an authorization into EMEVS ("posting") for the ordered care. Services or supplies which are to be furnished by another provider if the department determines that the ordering provider's claims or orders for MA care, services or supplies satisfy one or more of the criteria set forth in section 514.4(b) of this Part.

(b) Posting of the order in EMEVS by the ordering provider establishes a record that the care, services or supplies have been ordered by a qualified provider. The posting process enables the department to verify that the care, services or supplies have been properly ordered before paying a provider who submits a claim for furnishing them. Posting also permits the provider who is requested to furnish ordered care, services or supplies to verify through inquiry to EMEVS that the care, services or supplies have been properly ordered before filling the order. The provider manual addressing the particular care, services or supplies ordered sets forth in detail those service types or procedures requiring written orders.

(c) If an ordering provider who is required to post fails to post properly in a significant number of its weekly MA transactions, the department may withhold payment of claims submitted by the ordering provider which are equivalent in dollar value to established MA reimbursement amounts for care, services or supplies rendered or furnished by the ordering provider to an MA recipient on the same date of service within the weekly transaction period as care, services or supplies ordered for such recipient with respect to which the ordering provider failed to post properly, pending an audit or review of claims submitted and the ordering provider's service and claiming practices. If the department finds a significant number of unjustified failures by the provider to post orders, the department may treat such provider failures as an unacceptable practice under Part 515 of this Title.

 

Doc Status: 
Complete