Section 514.4 - Medicaid eligibility terminal (MET).

514.4 Medicaid eligibility terminal (MET). (a) The MET is an electronic device which permits a provider to verify MA recipient eligibility immediately through EMEVS. Any provider who establishes a need to the department's satisfaction may request the department to provide a MET.

(b) The department may require a provider to verify MA recipient eligibility by using a MET if the department determines that the provider's claims or orders for MA care, services or supplies meet or exceed one or more of the criteria set forth below:

(1) the dollar value of claims submitted or care, services or supplies ordered by the provider for the prior 12 month period exceeds $75,000; or

(2) the dollar value of claims submitted or care, services or supplies ordered by the provider for a weekly period, when projected to a yearly period, will exceed $75,000; or

(3) the number of claims submitted by the provider or amount paid to the provider for a quarterly period places the provider in the upper quartile of a rank order listing of billers in the applicable provider type; or

(4) the claims submitted by the provider indicate frequent, repetitive encounters with recipients or repetitive dispensing patterns; or

(5) the claims submitted by the provider for a weekly period indicate an increase of 10 percent or more in total amount billed, average cost per claim or average cost per recipient encounter from the previous quarter; or

(6) the claims submitted by the provider for a quarterly period exceed by two standard deviations or more the average number of claims per recipient encounter submitted or average dollar value of claims per recipient encounter submitted by billers in the applicable provider type.

(c) If a provider is required to use a MET by the department, the provider must continue the use of the MET until such time as the department informs the provider in writing that MET use by the provider is no longer mandatory. Not less than one year after a provider has been required to use a MET, the provider may request that the department rescind its order for mandatory MET use by such provider on the ground that the provider's billings during the yearly period preceding such request do not fall within any of the criteria set forth in subdivision

(b) of this section.

(d) METS will be provided by the department without charge to providers who establish a need and to providers who are required to use them. METS supplied by the department remain the property of the department.

(e) If the department requires a provider to use a MET, the provider must use the MET verification procedure unless the MET or EMEVS is not functioning. Any MET or EMEVS problems should be reported immediately through the emergency telephone numbers set forth in the EMEVS provider manual.

(f) When the provider who has been required to use a MET is unable to use the MET because the MET or EMEVS is not functioning, the provider must verify eligibility by accessing EMEVS by telephone.

(g) If a provider who is required to use a MET does not use the MET verification procedure or the alternative telephone verification procedure, payments for any claims submitted where eligibility was not verified will be denied. If the department finds a significant number of unjustified failures by the provider to use the MET, the department may treat such provider failures as an unacceptable practice under Part 515 of this Title.

 

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