Sec. 10.14.02.16. Department, Local Health Department, Hospital, and Health Care Provider Responsibilities

A. The Department is responsible for the following:

(1) Developing the necessary administrative forms needed for the Program including, but not limited to, a:

(a) Standard application form to determine eligibility of patients;

(b) Release of patient information form; and

(c) Participating health care provider agreement form;

(2) Distributing the administrative forms to the following:

(a) Freestanding ambulatory surgical center;

(b) Home health services provider;

(c) Certified nurse midwife;

(d) Hospital;

(e) Occupational therapist;

(f) Local health department;

(g) Medical laboratory;

(h) Medical supply company;

(i) Nurse anesthetist;

(j) Nurse practitioner;

(k) Pharmacy;

(l) Physical therapist;

(m) Physician assistant;

(n) Physician provider; and

(o) Other appropriate health care providers;

(3) Providing upon request a list of participating health care providers to local health department coordinators and health care providers for referral of eligible patients;

(4) Updating the list of participating health care providers not less than once a year;

(5) Reviewing and reimbursing a bill submitted by a participating physician for the reimbursed medical procedure and service using the payment guidelines specified in Regulations .04E(5) and .15 of this chapter;

(6) Reviewing and reimbursing a bill submitted by a participating physician assistant using the payment guidelines specified in Regulations .04-1 and .15 of this chapter;

(7) Reviewing and reimbursing a bill submitted by a participating certified nurse midwife using the payment guidelines specified in Regulations .04-2 and .15 of this chapter;

(8) Reviewing and reimbursing a bill submitted by a participating nurse practitioner using the payment guidelines specified in Regulations .05 and .15 of this chapter;

(9) Reviewing and reimbursing a bill submitted by a participating nurse anesthetist using the payment guidelines specified in Regulations .06 and .15 of this chapter;

(10) Reviewing and reimbursing a bill submitted by a participating physical therapist using the payment guidelines specified in Regulation .07 of this chapter;

(11) Developing a list of reimbursed medications and pharmacy services;

(12) Updating the medication and pharmacy service list at least annually;

(13) Developing and providing information to the pharmacy;

(14) Reviewing and paying a bill submitted by a participating pharmacy for reimbursed medication, pharmacy service, durable medical equipment, and disposable medical supplies according to Regulation .08E of this chapter;

(15) Reviewing and paying a disposable medical supply and durable medical equipment bill and the required deductible, if applicable, according to Regulation .10 of this chapter;

(16) Receiving the application for an eligible patient from the local health department, hospital, or health care provider;

(17) Developing and issuing to an eligible patient a letter identifying the patient as a participant in the Program;

(18) Reviewing and reimbursing a bill submitted by a participating home health services provider using the payment guidelines specified in Regulation .11 of this chapter;

(19) Reviewing and reimbursing a bill submitted by a participating medical laboratory using the payment guidelines specified in Regulation .12 of this chapter;

(20) Reviewing and reimbursing a bill submitted by a participating freestanding ambulatory surgical center using the payment guidelines specified in Regulation .13 of this chapter;

(21) Reviewing and reimbursing a bill submitted by an occupational therapist using the payment guidelines specified in Regulation .14 of this chapter;

(22) Reviewing and reimbursing in accordance with Regulation .22 of this chapter a bill submitted by:

(a) MHIP or an insurer under contract with MHIP; or

(b) A participating health care provider; and

(23) Ensuring compliance with the applicable regulations within this chapter by performing a periodic review of the records of a:

(a) Hospital; and

(b) Participating health care provider.

B. The local health department, hospital, and a health care provider who refers a patient to the Program, are responsible for the following:

(1) Identifying potentially eligible patients;

(2) Assisting the applicant in completing the application form;

(3) Collecting the completed application form;

(4) Collecting verifying documentation from the applicant, including, but not limited to, proof of residency;

(5) Determining eligibility of the applicant using the general, medical, health insurance, and financial criteria specified in Regulation .03 of this chapter;

(6) Assisting an eligible patient in selecting a participating health care provider and assisting in scheduling an appointment with the participating health care provider for the reimbursed medical procedure or service;

(7) Having an eligible patient sign a release of information form;

(8) Providing an eligible patient with a copy of a temporary referral letter, identifying the patient as a participant in the Program, to be given to the participating health care provider until the card is issued to the eligible patient by the Department;

(9) Sending the original application with verifying information to the Department; and

(10) Evaluating patient progress through follow-up contact with the patient and the participating health care provider.

C. If an additional diagnostic or treatment procedure is necessary, the local health department, hospital, or health care provider who determines patient eligibility and refers an eligible patient to the Program shall repeat the procedure as set forth in §B(6) of this regulation.

D. The local health department, hospital, or other health care provider who determines patient eligibility and refers an eligible patient to the Program shall document in the patient’s medical record the result of the reimbursed diagnostic and treatment procedure performed.