DAR File No. 43832

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-23

Provider Enrollment

Notice of Proposed Rule

(New Rule)

DAR File No.: 43832
Filed: 06/28/2019 12:04:05 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to implement Medicaid policy for the revalidation of Medicaid providers.

Summary of the rule or change:

This new rule includes definitions and requirements that implement policy for provider revalidation.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• 42 CFR 455.414
• Sec. 6401 Patient Protection & Affordable Care Act
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this rule only implements current practice for provider revalidation. It neither affects member services nor provider reimbursement.

local governments:

There is no impact on local governments because they neither fund nor provide services under the Medicaid program.

small businesses:

There is no impact on small businesses because this rule only implements current practice for provider revalidation. It neither affects member services nor provider reimbursement.

persons other than small businesses, businesses, or local governmental entities:

There is no new impact on Medicaid providers and Medicaid members because this rule only implements current practice for provider revalidation based on federal regulation. It neither affects member services nor provider reimbursement.

Compliance costs for affected persons:

There are no additional costs to a single Medicaid provider or to a Medicaid member because this rule only implements current practice for provider revalidation based on federal regulation. It neither affects member services nor provider reimbursement.

Comments by the department head on the fiscal impact the rule may have on businesses:

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/14/2019

This rule may become effective on:

08/21/2019

Authorized by:

Joseph Miner, Executive Director

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs	FY 2020	FY 2021	FY 2022
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Person	$0	$0	$0
Total Fiscal Costs:	$0	$0	$0
Fiscal Benefits
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Persons	$0	$0	$0
Total Fiscal Benefits:	$0	$0	$0
Net Fiscal Benefits:	$0	$0	$0

 

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described in the narrative. Inestimable impacts for Non - Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non - Small Businesses

Non-small businesses will not be impacted because this rule only implements current policy for revalidation of Medicaid providers. It neither affects member services nor provider reimbursement.

 

 

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-23. Provider Enrollment.

R414-23-1. Introduction and Authority.

This rule is authorized by Sections 26-1-5 and 26-18-3, and implements requirements for provider revalidation as set forth in the Code of Federal Regulations and in the Patient Protection and Affordable Care Act.

 

R414-23-2. Definitions.

(1) " Provider" means an individual or entity that has been approved by the Department to provide services to Medicaid members, and has signed a provider agreement with the Department.

(2) " Revalidation" means the mandatory process of screening enrolled providers of medical services, other items, and suppliers, as required by Section 6401 of the Patient Protection and Affordable Care Act.

(3) " PRISM" means Provider Reimbursement Information System for Medicaid.

(4) "CFR" means Code of Federal Regulations.

 

R414-23-3. Revalidation Requirements.

(1) An e nrolled provider must revalidate with Medicaid through PRISM at intervals not to exceed five years as required by 42 CFR 424.515, depending on the provider's risk level.

(2) The Department shall notify a provider, when it is time to revalidate, with a letter mailed to the pay-to address in the PRISM system.

(3) A provider must complete and submit the revalidation process within 60 days from the date of the letter, or the Department will place a temporary payment hold on the provider account.

(4) The Department shall terminate a provider that fails to revalidate within 90 days from the date on the letter. The provider, however, has the option to request a fair hearing.

(5) A provider terminated for any reason must reenroll and be approved as a new provider.

(6) The Department may only reimburse a provider for services rendered during an enrollment period.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2019

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3