Sec. 10.09.38.03. Conditions for Participation

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

(1) Meet the licensure requirements in Regulation .02 of this chapter, and verify the licenses and credentials of all professionals employed by the provider;

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

(3) Be approved for participation by the Department;

(4) Have a provider agreement with the Department in effect;

(5) Be identified as a Program provider by issuance of an individual provider number;

(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 the covered services specified in Regulation .04 of this chapter;

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

(9) Maintain adequate records concerning service provision for a minimum of 6 years and make them available, upon request, to the Department or its designee;

(10) Not knowingly employ or contract with any 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;

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

(12) Not place a restriction on the recipient's right to choose the provider;

(13) Agree that if the Program denies payment or requests repayment on the basis that an otherwise covered service was not medically necessary or has not been preauthorized, the provider may not seek payment for that service from the participant; and

(14) Be selected by the participant from among qualified providers.

B. Specific requirements for providers of risk assessment-plan of care services are that providers shall:

(1) Be physicians or nurse midwives;

(2) Provide the covered services as specified in Regulation .04A of this chapter in conjunction with the pregnant participant's initial clinical prenatal visit or, otherwise, as early as possible in the pregnancy;

(3) Maintain the participant's consolidated medical record; and

(4) Agree to on-site visits by Department staff to monitor adherence to Regulation .04A of this chapter.

C. Specific requirements for providers of enriched maternity services are that providers shall:

(1) Be physicians or nurse midwives or be under the supervision of a physician or nurse midwife;

(2) Provide the covered services as specified in Regulation .04B of this chapter in conjunction with each prenatal clinical visit of the pregnant participant and each postpartum clinical visit of the postpartum participant up to 60 days after the delivery; and

(3) Agree to on-site visits by Department staff to monitor adherence to Regulation .04B of this chapter.

D. Specific requirements for participation in the provision of high-risk nutrition counseling services are that providers shall:

(1) Be a dietician or nutritionist as specified in Regulation .02C of this chapter;

(2) Contact the recipient within 10 working days of the receipt of a referral from a local health department or private prenatal care provider, unless client-related extenuating circumstances are documented; and

(3) Agree to on-site visits by Department staff to monitor adherence to Regulation .04C of this chapter.