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Provider Participation Requirements – Rule 101

Revised: 09-26-2012

Rule 101 requires providers who want to be paid for other state-sponsored health care programs to participate in MHCP and accept, on a continuous basis, new patients (per CPT definition) who are MHCP recipients. Other state sponsored health care programs include:

  • • State employees' health insurance plans
  • • Workers' compensation insurance
  • • Public employees' insurance program
  • • Insurance plans provided through the Minnesota Comprehensive Health Association
  • • Health insurance plans offered to local statutory or home rule charter city, county, and school district employees
  • Managed care organizations (MCOs), as a condition of retaining a certificate of authority, must participate in MHCP and submit proposals to serve MHCP recipients in a geographic region of the state if the statutory requirements are met.

    MHCP Caseload Limits

    A provider may limit acceptance of new patients who are recipients if the provider:

    1.

    Determines annual active patient caseload by calculating the total number of patient encounters that result in a billing during the provider's most recent fiscal year; or if enrolled as a provider for less than a year, the total number of patient encounters that result in a billing during the period between enrollment and the end of the provider’s fiscal year

    2.

    Determines patient encounters from all service sites enrolled under the provider's NPI/UMPI but counts only one patient encounter per patient per day regardless of the number of services sites involved in the patient’s health care. A provider may count recipients receiving health services on a fee-for-service basis and under a prepaid contract.

    3.

    Is a non-dental provider and the MHCP recipient caseload is at least 20% of the provider's annual active caseload;

    Or

    Is a dental provider and the MHCP recipient caseload is at least 10% of the provider’s annual active caseload, or the dental provider accepts new MHCP recipients who are children with special health care needs For purposes of this provision, children with special health care needs are children up to 18 years of age who:

  • • Require health and related services beyond that required by children generally
  • • Have or are at risk for a chronic physical, developmental, behavioral, or emotional condition, including:
  • • Autism
  • • Bleeding and coagulation disorders
  • • Cancer
  • • Developmental disabilities
  • • Down syndrome and other genetic disorders
  • • Epilepsy, cerebral palsy, and other neurological diseases
  • • Endocrinopathy
  • • Fetal alcohol syndrome
  • • Immunodeficiency disorders
  • • Visual impairment or deafness
  • • Other conditions as designated by the commissioner after consultation with representatives of pediatric dental providers and consumers
  • 4.

    Notifies MHCP Provider Enrollment, before limiting acceptance of new recipients, in writing and includes active patient caseload data used to calculate the percentage of patients who are recipients.

    If MHCP accepts the notice, the acceptance will be effective 10 days after MHCP notifies the provider in writing, and will remain in effect for the remainder of the provider's fiscal year. Providers who wish to continue limiting MHCP caseload must file a new notice each year. A provider who has a contract with an MHCP-contracted MCO must notify each plan of its intention to limit acceptance of new MHCP patients.

    On a quarterly basis, MHCP shares lists of providers who comply with participation requirements to the State Departments of Commerce, Management & Budget, and Labor and Industry. A provider who fails to comply with the requirements of Rule 101 will be excluded from state-sponsored health care programs. MHCP will notify a provider if we have reason to believe they are not complying with these participation requirements. The provider will have 30 days to provide MHCP with evidence of participation compliance. After the response period expires, those who have not submitted evidence of compliance will be excluded from participation in the other state health care programs.

    Legal References

    MS 62D.04, subd. 5 Issuance of Certificate Authority, Participation; government programs

    MS 256B.0644 Reimbursement under Other State Health Care Programs

    Minnesota Rules 9505.5200–9505.5240 Rule 101, purpose, definitions, conditions, reports/exclusion

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