Sec. 10.09.30.03. Conditions for Participation

A. General requirements for participation in the Medical Assistance Program are that providers shall:

(1) Ensure that employees performing STEPS meet the licensure requirements as provided in Regulation .02 of this chapter;

(2) Apply for participation in the Program using the application form designated by the Department;

(3) Be approved for participation by the Department;

(4) Have a provider agreement in effect;

(5) Verify the licenses and credentials of all professionals who are employed by, or who contract with, the provider of services;

(6) Verify the eligibility of recipients;

(7) Accept payment by the Program as payment in full for services rendered and make no additional charge to any person for STEPS specified under Regulation .04 of this chapter;

(8) Provide services without discrimination on the basis of race, color, age, sex, national origin, marital status, physical or mental handicap;

(9) Place no restrictions on a recipient's right to select among available health care providers;

(10) Maintain adequate records for a minimum of 5 years, and make them available, upon request, to the Department or its designee;

(11) Not knowingly employ or contract with a person, partnership, or corporation which has been disqualified from the Program to provide or supply service to Medical Assistance recipients, unless prior written approval has been received from the Department; and

(12) Agree that claims rejected for payment due to late billing may not be billed to the participant.

B. Specific requirements for participation in the Program are that STEPS providers shall:

(1) Meet the requirements of §A of this regulation;

(2) Have a written plan for the implementation of STEPS;

(3) Be available to participants at least 8 hours a day, 5 days a week and have established hours of daily operation, including after hours procedures for handling emergency cases;

(4) Have existing policies and procedures concerning the completion of STEPS functions that the provider in the provider agreement has agreed to perform;

(5) If approved as a provider of STEPS multidisciplinary assessments, develop procedures to expedite comprehensive evaluations when necessary, including the assurance that comprehensive evaluations for inpatients will be completed within 3 working days of an appropriate referral unless the client is not medically stable;

(6) If approved as a provider of STEPS multidisciplinary assessments, convene the multidisciplinary team for the participant which:

(a) Assesses the appropriateness of institutional or community based long term care services for the participant,

(b) Determines the medical, psychological, social, and functional status of each participant, and

(c) Develops an individual plan of care reflecting both needed services and available services that are, or can be anticipated to be, rendered;

(7) Develop, as appropriate, interagency, intra-agency and other agreements in order to facilitate access to long term care services and coordinate with local public agencies and other providers of long term care;

(8) If approved as a provider of STEPS multidisciplinary assessments, inform participants of the results of the multidisciplinary assessment and of available long term care services; and

(9) If approved as a provider of STEPS case management, provide case management covered services to recipients meeting the qualifications of STEPS case management participants.