The department must pay properly supported claims on time, must not demand repayment when its own eligibility error caused the overpayment, and may impose provider-agreement conditions and enrollment requirements.
§437.13. Powers and duties of the department A. The department shall: (1) Make payment timely at the established rate for goods, services, or supplies furnished to a recipient by the health care provider upon receipt of a properly completed and properly supported claim. (2) Require certification on the claim form that the goods, services, or supplies have been completely furnished to a recipient eligible to receive the goods, services, or supplies and that, with the exception of those goods, services, or supplies specified by the department, the amount billed does not exceed the health care provider's usual and customary charge for the same goods, services, or supplies. (3) Not demand repayment from the health care provider in any instance in which the medical assistance programs overpayment is attributable to error of the department in the determination of eligibility of a recipient. B. The department may: (1) Adopt, and include in the provider agreement, such other requirements and stipulations on either party as the department finds necessary to properly and efficiently administer the medical assistance programs. (2)(a) Revoke any provider agreement as the result of a change of ownership in the named health care provider. (b) Require a health care provider to give the department sixty days written notice before making any change in ownership of the person named in the provider agreement as the health care provider. (3) Require, as a condition of participating in the medical assistance programs and before entering into the provider agreement, the following: (a) An on-site inspection of the health care provider's service location by department representatives or other personnel designated by the secretary to assist in this function. (b) A letter of credit, a surety bond, or a combination thereof, from the health care provider not to exceed fifty thousand dollars. The letter of credit, surety bond, or combination thereof may be required only if either of the following conditions is met: (i) A letter of credit, surety bond, or any combination thereof is required for each health care provider in that category of health care provider. (ii) The health care provider is the subject of a sanction or of a criminal, civil, or departmental proceeding. (c) The submission of information concerning the professional, business, and personal background of the health care provider, any person having an ownership interest in the health care provider, and any agent of the health care provider. Such information shall include: (i) Proof of holding a valid license or operating certificate, as applicable, if required by federal or state law or by rule or by a local jurisdiction in which the health care provider is located. (ii) Any prior violation, fine, suspension, termination, or other administrative action taken under federal or state law or rule or the laws or rules of any other state relative to medical assistance programs, Medicare, or a regulatory body. (iii) Any prior violation of the rules or regulations of any other public or private insurer. (iv) Full and accurate disclosure of any financial or ownership interest that the health care provider, or a person with an ownership interest in that health care provider, may hold in any other health care provider or health care related entity or any other entity that is licensed by the state to provide health or residential care and treatment to persons. (v) If a group health care provider, identification of all members of the group and attestation that all members of the group are enrolled in or have applied to enroll in the medical assistance programs. C. Upon receipt of a completed, signed, and dated application, and after any necessary investigation by the department, which may include the Department of Public Safety and Corrections, office of state police background checks, the department shall either: (1) Enroll the applicant as a Medicaid provider. (2) Deny the application if, based on the grounds listed in R.S. 46:437.14, the secretary determines that it is in the best interest of the medical assistance programs to do so, specifying the reasons for denial. D. In accordance with the provisions of 42 CFR 433.318(d)(2)(ii), the department is hereby granted the authority to certify that a provider enrolled in the Medical Assistance Program is out of business and that any overpayments made to the provider cannot be collected under state law. Acts 1997, No. 1142, §2; Acts 2008, No. 139, §1.