37.85.1107 ELIGIBLE PROVIDER AND ELIGIBLE HOSPITAL ELIGIBILITY VERIFICATION BY DPHHS
(1) The following information will be verified by the department upon receipt of notification from the CMS that a Montana EP enrolled:
(a) the EP has no sanctions preventing participation;
(b) the EP is alive;
(c) the EP is not hospital-based;
(d) the EP is an eligible provider type (e.g., physician, dentist, nurse practitioner, certified nurse midwife, physician assistant practicing in a FQHC or RHC led by a physician assistant, critical access hospital, or acute care hospital);
(e) the EP is appropriately licensed by the state of Montana; and
(f) the EP is listed on the NLR correctly.
(2) Montana Medicaid will verify eligibility through the Montana Medicaid Management Information System (MMIS). If the provider is listed in the MMIS in an active status, the Montana Medicaid Fiscal Agent has already completed the verification for licensure, sanctions, and death.
(3) An EP must be actively enrolled in Medicaid in order to apply for the MMPIP program. If the provider is not listed as active in the MMIS, the provider must enroll, or clarify enrollment status with the Montana Medicaid Fiscal Agent prior to continuing registration in the MMPIP program.
(4) For an EP to qualify as "not hospital-based" at least 10% of his or her services must be performed somewhere other than a hospital. To verify that the EP is not hospital-based, Montana Medicaid will use Medicaid claims information from the MMIS and apply the formula in (a).
(a) (Paid Claims with Place Of Service (POS) codes 21 and 23) divided by (Total Paid Claims for all Services). A resulting value less than 90% qualifies.
(b) Prior to remittance of any incentive payment by the department, the EP must attest his or her hospital-based services are less than 90%.
History: 53-6-113, MCA; IMP, 53-6-111, MCA; NEW, 2011 MAR p. 1374, Eff. 7/29/11.