Section 514.7 - Clearing of orders for care, services or supplies.

514.7 Clearing of orders for care, services or supplies. (a) The department may direct a provider who furnishes ordered MA care, services or supplies to obtain authorization to furnish such care, services or supplies through inquiry to EMEVS ("clearing"). A provider may be directed to clear prescriptions or fiscal orders as the department determines that the clearing 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, or the clearing provider is furnishing care, services or supplies ordered by a provider required to post, or patterns or volumes of MA transactions by ordering or furnishing providers within a specified geographic area or within a specific provider type warrant the imposition of this additional control to assure the validity of prescriptions or fiscal orders.

(b) When a provider who furnishes ordered care, services or supplies ordered by a provider required to post orders for care, services or supplies clears a prescription or fiscal order, EMEVS will respond with a message indicating whether the payment of claims for care, services or supplies will be made.

(c) If a provider who is directed by the department to clear prescriptions or fiscal orders fails to clear a prescription or fiscal order which is required to be posted to EMEVS and which either has not been posted or has been posted and already filled, the department will deny payment for the ordered care, services or supplies. If the department finds a significant number of unjustified failures by the provider to clear orders, the department may treat such provider failures as an unacceptable practice under Part 515 of this Title.

 

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