NC DHHS Provider Administrative Participation Agreement

1. Parties to the Agreement

This Provider Administrative Participation Agreement is entered into by and between the North Carolina Department of Health and Human Services hereinafter referred to as the “Department”, and the enrolling provider, hereinafter referred to as the “Provider.”

2. Agreement Document

The Agreement Documents shall consist of this Agreement, any addendum, and the Provider’s application, incorporated herein by reference. Except for changes to Department  medical coverage policies, or other guidelines, policies, provider manuals, implementation updates, and bulletins published by CMS, the Department, its divisions  and/or its fiscal agent and/or other contracted vendors as directed by the Department  as referenced in Section 3, below, no alterations or modifications shall be made to the terms of the Agreement unless through a written amendment executed by both parties.

 3. Governing Law and Venue

This Agreement is required by state and federal regulation and shall be governed by state and federal regulation including the following as applicable (hereinafter referred to as the “Controlling Authority”):

1. The North Carolina Medicaid State Plan, as amended; and
2. North Carolina Medicaid CMS-approved State Plan Waivers; and
3. N.C.G.S. §108A and §108C; and
4. 42 USC 1396a, et seq.; and
5. Code of Federal Regulations, Title 42, Chapter IV, Subchapter C;
6. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements, including but not limited to the Standard for Privacy of Individually Identifiable Health Information and Health Insurance Reform: Security Standards; and
7. The Family Educational Rights and Privacy Act (FERPA); and
8. N.C.G.S §108A-80; and
9. The following that are consistent with and expressly or implicitly authorized by the authority in program(s) in which the provider participates: federal and state laws, rules and regulations; medical coverage policies of the Department; and guidelines, policies, provider manuals, implementation updates, and bulletins published by CMS, the Department, its divisions and/or its fiscal agent and/or other contracted vendors as directed by the Department in effect at the time the service is rendered.

 By execution of this Agreement, the Provider does not release, waive or modify in any way any procedural or substantive rights it may have pursuant to Controlling Authority related to its participation in Department programs.  In case of conflict between any provision of this Agreement and any current or future provision of Controlling Authority, the Controlling Authority shall govern and the terms of this Agreement shall be deemed to be modified so as to comply with Controlling Authority.  In the event of a lawsuit or administrative petition involving this Agreement, venue is proper in Wake County, North Carolina. 

 The Provider agrees to operate and provide services in accordance with the Controlling Authority.  Unless otherwise required by this Agreement or Controlling Authority, the Department may publish notice of changes in policies, guidelines, or other procedures on its website within thirty (30) calendar days advance notice to provide for implementation thereof.

Nothing in this Agreement creates in the provider a property right or liberty right in continued participation in a North Carolina Divisional program.

 4.         License

The Provider agrees to:

1. Be licensed, certified, registered, accredited and/or endorsed as required by Controlling Authority or Department policy, as appropriate for the service provided by the Provider, at all times those services are provided. 
2. Notify the Department within thirty (30) calendar days of learning of any adverse action initiated against any required license, certification, registration, accreditation and/or endorsement of the Provider or any of its officers, agents, or employees. 

 5.         Billing and Payment

The Provider agrees:

1. To submit claims for services rendered to eligible Department recipients (hereinafter “recipients”) in accordance with rules and billing instructions in effect at the time the service is rendered. Provider agrees to include its National Provider Identifier (NPI) if eligible for an NPI on all claims submitted to the Department for reimbursement under the NC Medicaid program and to be responsible for research and correction of all billing discrepancies in claims submitted by the Provider or its authorized agent.
2. To accept as sole and complete remuneration the amount paid in accordance with the finally determined reimbursement rate for services covered by the Department, except for payments from legally liable third parties, and authorized co-payments, coinsurance and/or deductibles authorized by the Controlling Authority or the Department.  In accordance with 10A NCAC 22J .0106, a  Provider may bill a NC Medicaid recipient for goods, services, or supplies provided to a recipient only if such are not covered by the Department and the recipient was notified in advance of receiving such services that such services are not covered and that the recipient is financially responsible. By agreeing to this provision, the Provider does not waive any potential rights to challenge or appeal its reimbursement rate or payment calculation in accordance with Controlling Authority. 
3. That in no event shall the Department be liable or responsible, either directly or indirectly, to any subcontractor of the Provider or any other party that may provide services.
4. To be held to all the terms of this Agreement even though a third party agent may be involved in billing claims to the Department.  It is a breach of this Agreement to discount client accounts to a third party agent or to pay a third party agent a percentage of the amount collected.
5. To inquire about other coverage and bill other insurers and third parties, including the Medicare program, if applicable, before billing the Department, when the recipient is eligible for payment for health care or related services from another insurer or person.
6. To not bill the recipient or any other person for items and services covered by the Department except as permitted by 10A NCAC 22J .0106 and to refund payments made by the recipient or by a third party on behalf of the recipient for Department covered services for any claims for which the recipient has been approved for payment by the Department, including retroactive authorization for payment.  No refund is due by the Provider to the recipient or any other person until payment to the Provider is final and has been made in full by the Department to the Provider.
7. To accept assignment of Medicare payment in order to receive payment from the Department for amounts not covered by Medicare for dually eligible recipients.
8. To refund or allow the Department to recoup or recover any monies received in error or in excess of the amount to which the Provider is entitled from the Department (an overpayment) as soon as the Provider becomes aware of said error and/or overpayment or within thirty (30) calendar days of discovery or of a request for repayment by the Department, regardless of whether the error was caused by the Provider or the Department and/or its agents.
9. That payment for covered services by the Department is limited to those services that are medically necessary, as determined by the Department or its legally authorized agents, contractors, or vendors, their successors and assigns.
10. That items or services provided under arrangements or contracts between the Provider and outside entities and professionals shall meet the same professional standards and principles as herein agreed to by the Provider.
11. That payment and satisfaction of claims will be from federal and state funds.
12. That all claims are subject to the North Carolina False Claims Act, Chapter 1, Article 51 of the North Carolina General Statutes (N.C.G.S §§1-605 through 617), the federal False Claims Act, and when applicable the Medical Assistance Provider False Claims Act (Part 7, Article 2, Chapter 108A of the General Statutes).
13.  That the Department and its legally authorized agents, contractors, or vendors, their successors and assigns at the direction of the Department may suspend or withhold payments to a Provider as authorized by Controlling Authority.  The Department and its legally authorized agents, contractors, or vendors, their successors and assigns at the direction of the Department may recoup or recover overpayments, penalties or invalid payments due to error of the Provider and/or the Department and its legally authorized agents, contractors, or vendors, their successors and assigns.  The Department shall provide timely notice to the Provider that states the Department’s reasons for withholding payments, the conditions that must be met to resolve the irregularity and the Provider’s right to appeal.  This withhold shall be subject to adjustment in accordance with Controlling Authority as a result of any contrary final determination in any challenge or appeal brought by the Provider.  A Provider that is subject to a withhold, recoupment, recovery, suspension, or penalty initiated by the Department shall not directly or indirectly bill through a different provider number for the purpose of evading the action.
14. Any Providers that share the same IRS Employer Identification Number are equally subject to the withholding, recoupment or recovery referred to and in accordance with subsection “m” above until any overpayment, penalty, or invalid payment incurred by such Provider(s) is resolved, either by payment in full or final agency decision. Any Provider that does not share the same Employer Identification Number but that is more than fifty percent (50%) owned, in whole or in part, by an individual or entity that has more than fifty percent (50%) ownership interest in a separate provider entity that owes an outstanding overpayment, penalty, or invalid payment to the Department shall also be subject to the withholding, recoupment or recovery referred to and in accordance with subsection “m” above until such overpayment, penalty, or invalid payment is resolved, either by payment in full or final agency decision. 
15. That billings and reports related to services rendered shall be submitted in the format and frequency specified by the Department and/ or its legally authorized agents, contractors, or vendors, their successors and assigns.  Failure to file mandatory reports or required disclosures within the time-frames established by Departmental rule or policy may result in suspension of payments and/or other enforcement actions.
16. To submit claims to the Department-designated legally authorized fiscal agent, contractors, or vendors, their successors and assigns as appropriate within the timely filing period as specifically required by Controlling Authority.
17. That electronic and non-electronic claims may be submitted without signature and same is binding upon Provider, its employees, or its agents who provide services to recipients or who file claims under the Provider name, National Provider Identifier (NPI), and Department Provider Atypical Number.
18.  That all claims shall be true, accurate, and complete and that services billed shall be personally furnished by Provider, its employees, or persons with whom the Provider has contracted to render services, under its direction. 
19.  Provider shall not bill for services provided at or from a site locations not associated with the approved NPI or Atypical ID and TIN, except for hospital services as set forth in 42 CFR §413.65.
20. That Provider will notify the Department of any change in ownership as defined under N.C.G.S. 108C-10(a) no later than 30 days before effective date of the change in ownership and shall submit a completed Provider Change of Ownership Disclosure Form to indicate whether the new owner/entity has agreed to assignment of this Provider Agreement including assumption of liability or has agreed in writing to assume all liability, including but not limited to cost report settlements, health care assessment settlements, or recoupment actions, that have arisen or that may arise in connection with claims billed by Provider. Provider agrees that if the new owner/ entity has not agreed in writing to assignment of this Provider Agreement or assumption of liability arising in connection with claims billed by Provider, the Provider will remain directly liable for repayment of any liabilities incurred based on services furnished prior to the change of ownership.
21. To not bill the Department for services rendered during any period in which the institutional or professional license, certification, registration, accreditation and/or endorsement required of the Provider has become invalid due to suspension or termination by the issuing agency

6.         Disclosure

1. The Provider agrees to submit to the Department at the time of application, execution of this Agreement, revalidation or renewal of enrollment; and upon request, the following information concerning the Provider, in accordance with the disclosure requirements set forth in 42 USC 1396a(a)(78).  Such submittal shall include:
   • i. Full and accurate disclosure of the name, specialty, social security number, date of birth, and tax identification number; and
   • ii. Proof of a valid license, operating certificate, and/or certification if required by Controlling Authority or policy, or rule of a local jurisdiction in which the Provider is located and that is consistent with Controlling Authority; and
   • iii. Provider’s National Provider Identifier, if Provider is eligible for an NPI.
2. The Provider agrees to provide written notification to the Department through the Department’s agents, vendors, or contractors, their successors or assigns in the manner determined by the Department of any material and/or substantial change in information contained in the enrollment application given to the Department by the Provider within thirty (30) calendar days of an event triggering the reporting obligation.  Material and/or substantial change includes, but is not limited to, a change in:
   • i. licensure;
   • ii. federal tax identification number;
   • iii. National Provider Identifier (NPI), including the addition of a new NPI or change to the NPI under which the Provider previously enrolled with the Department;
   • iv. bankruptcy; 
   • v. additions, deletions, or replacements in group membership; and
   • vi. any change in address, telephone number, or email.

3.  Provider shall notify the Department of any change of ownership as defined by N.C.G.S. §108C-10(a) no later than thirty (30) days before the effective date of any such change in ownership by completion of the Change of Ownership Disclosure Form and submission of any requested supporting evidence regarding the change of ownership. Provider shall also provide to the Department:
   • i. Evidence of the assignment of the Provider Participation Agreement; or
   • ii. Evidence of successor assumption of selling Provider’s Medicaid liability arising under the change of ownership.
4. Provider agrees to submit to the Department at the time of application, execution of this Agreement, revalidation or renewal of enrollment; within thirty-five (35) days following any change of ownership; and upon request, the following information OR the full and complete information required under 42 CFR §455.104 regarding any party with an ownership or controlling interest in Provider, managing employee, and/or any subcontractor in which Provider holds at least a five percent (5%) ownership interest, to include.
   • i. Full name, address, social security number, date of birth, and tax identification number; and
   • ii. Whether any such person is related to another person with ownership or controlling interest in Provider or is the spouse, parent, child, or sibling of the party with ownership or controlling interest in Provider or a subcontractor in which Provider holds at least a five percent (5%) ownership interest.
5. The Provider agrees to furnish within thirty-five (35) calendar days of the Department’s request, full and complete information about the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.
6. Provider shall furnish to the department at the time of executing this Agreement the legal name, tax identification number, and NPI of any entity affiliated with Provider or its owning or managing employees or organizations within the prior five years who has had a disclosable event as defined by 42 CFR § 455.101, including an uncollected debt owed to Medicare or Medicaid; payment suspension under a federal health care program; exclusion from participation in Medicare or a Medicaid program; or whose enrollment in Medicare or Medicaid has been denied, revoked, or terminated.  Provider shall specify the disclosable event and duration, type, degree, and termination date of the affiliation.
7.  Provider agrees to furnish, within 20 business days from receipt of information that any person with ownership or controlling interest in the Provider, agent, or managing employee of the provider has been convicted of a criminal offense related to the person’s involvement in any Medicare, Medicaid, or title XX services program since the program’s inception. The Provider, any person with an ownership interest in the Provider, any managing employee, and any authorized agent of the Provider shall be subject to a criminal background check before or anytime after approval of this Agreement.
8. The Provider agrees to screen all its employees, contractors, and contractor’s employees monthly using the List of Excluded Individuals/Entities (LEIE) database and System for Awards Management (SAM) Exclusion List to determine whether any of its employees, contractors, and contractor’s employees is excluded from participation in Medicare, Medicaid, or other federal health care programs.  The LEIE database is maintained by the United States Department of Health and Human Services, Office of the Inspector General (HHS-OIG) and can be accessed at http://oig.hhs.gov/exclusions The Provider shall promptly notify the Department upon discovery of any excluded employee, contractor, or contractor’s employees.  Provider understands and acknowledges that employment of or contractual arrangements with persons or entities listed in the LEIE will subject the Provider to recoupment of funds paid to the Provider during the period in which the employment or contract was in effect.
9. Provider shall monitor and ensure that the contractors or subcontractors of the enrolled provider are subject to the disclosure and reporting requirements required under this Agreement. 
10. The Provider agrees to comply with the advance directives requirements for hospitals, nursing facilities, providers of home health care and personal care services, hospices, and HMOs specified in 42 CFR Chapter IV, part 489, subpart I and 42 CFR §417.436(d).

 7.         Inspection; Maintenance of Records; Filing Reports

1. For a minimum of 7 years from the date of services, or longer if required specifically by Controlling Authority, the Provider shall:
   • i. Promptly furnish upon request copies of any and all documentation set forth below in subpart ii of this paragraph, whether in the possession of contractors, agents, or subcontractors, for review by the Department and/ or its legally authorized agents, contractors, or vendors, their successors and assigns.  The Provider understands that failure to submit or failure to retain adequate documentation for services billed to the Department may result in recovery of payments for medical or behavioral health care services not adequately documented, and may result in the termination or suspension of the Provider from participation in the Medicaid program. The Provider further understands that it is the Department’s position that failure to promptly furnish records upon request creates a presumption that the records do not exist.
   • ii. Keep, maintain and make available complete and accurate medical and fiscal records in accordance with Department record-keeping requirements that fully justify and disclose the extent of the services or items furnished and claims submitted to the Department.  For providers who are required to submit annual cost reports, fiscal records shall include invoices, checks, ledgers, contracts, personnel records, worksheets, schedules, and such other records as may be required by Controlling Authority or Department policy.
2. Post payment audits or investigation may be conducted to determine compliance with the rules and regulations of the Department and/ or its legally authorized agents, contractors, or vendors, their successors and assigns.  If the Provider is notified that an audit or investigation has been initiated, the Provider shall retain all original records and supportive materials until the audit or investigation is completed and all issues are resolved if the period of retention extends beyond the minimum required 7-year period.
3. Provider agrees to cooperate with all announced and unannounced site visits, audits, investigations, or program integrity activities conducted by Federal and State officials, Department personnel and/ or its legally authorized agents, contractors, or vendors, their successors and assigns for the purpose of certification and compliance surveys, inspections, medical and professional reviews, monitoring, and audits of costs and data relating to services to recipients.  Such visits including unannounced visits must be allowed at any time during normal hours of operation.  Failure to grant prompt and reasonable access upon reasonable request may result in suspension of the Provider and/or of reimbursements or termination from participation in the North Carolina Medicaid programs.

8.         Termination

            Subject to applicable provisions of Controlling Authority:

1. Either the Department or the Provider may terminate this Agreement with or without cause at any time upon 30 days written notification to the other;
2. The Department may summarily terminate this Agreement without giving 30 days written notice under the following circumstances:
   • i. The Provider does not meet conditions for participation, including necessary licensure, certification, or endorsement requirements or other terms and conditions stated in this Agreement; or
   • ii. Any person with ownership or controlling interest in the Provider, or agent, or managing employee of the Provider, has been convicted of a criminal offense set forth in 42 CFR §1001.101 or 42 CFR §1001.201; or
   • iii. The Provider, any person with ownership or controlling interest in the Provider, operator, agent, or managing employee of the Provider, has been convicted of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct, or crime of moral turpitude, or any criminal offense specified in N.C.G.S. §108C-4; or
   • iv. The Provider fails to disclose information required under 42 CFR §1002.3; or
   • v. Any person with ownership or controlling interest in the Provider, or an agent as that term is defined in accordance with 42 CFR §455.101 or managing employee of the Provider, has been excluded by the United States Department of Health and Human Services from participation in the Medicare, Medicaid, or other federal health care programs; or
   • vi. The Provider poses an imminent health or safety risk to a patient; or
   • vii. The Provider has been found by the Department to be in breach or violation of any law, rule, or policy for which summary termination is authorized by Controlling Authority or by a rule authorized by and consistent with the Controlling Authority and adopted pursuant to Chapter 150B of the General Statutes.
3. The Provider’s right to appeal or otherwise contest any termination shall be determined in accordance with Controlling Authority.

9. Assignment

The Provider may not assign this Agreement, or any rights or obligations contained in this Agreement to a third party except as allowed by federal law.

10. Release of Liability

The Provider agrees to fully release and discharge the State of North Carolina, the Department and any of their personnel and/ or legally authorized agents, contractors, or vendors, their successors and assigns, from any and all liability, claims and causes of action that may be brought by third parties against the Provider arising out of this Agreement.  This is a complete and irrevocable release and waiver of liability.  The State of North Carolina, the Department, and any of their personnel and/ or legally authorized agents, contractors, or vendors, their successors and assigns are not liable for claims and causes of action that may be brought by third parties arising out of any act or omission of the Provider or any subcontractor.

11. Severability

The provisions of this Agreement are severable.  If any provision of the Agreement is held invalid by any court that invalidity shall not affect the other provisions of this Agreement and the invalid provision shall be modified to conform to existing law.

12. Independent Contractor

The Provider or its directors, officers, partners, employees and agents, contractors, vendors, successors and assigns are not employees or agents of the Department.

13. Discrimination

The Provider agrees that the Department may make payments for medical or behavioral health care services rendered to Department recipients only to a person or entity who has a provider agreement in effect with the Department; who is performing services or supplying goods in accordance with all requirements under Title VI of the Civil Rights Act of 1964; Section 504 of the 1973 Rehabilitation Act; the 1975 Age Discrimination Act; the 1990 Americans With Disabilities Act; and all applicable federal and state statutes and regulations relating to the protection of human subjects of research. The authority of the Department to limit payment to the Provider under this Section or otherwise shall be restricted exclusively to payments for services rendered on specific dates as to which the above-referenced requirements were not met 

14. Waiver

No waiver of any term, right or condition of this Agreement shall be valid unless it is set forth in a writing duly executed by both parties.  No delay or failure by either party to exercise or enforce at any time any right or provision of this Agreement will be considered a waiver thereof or of such party’s right thereafter to exercise or enforce each and every right and provision of the Agreement.  No single waiver will constitute a continuing or subsequent waiver.

15. Survival 

All provisions of this Agreement which by their nature give rise to continuing obligations of the parties shall survive the expiration or termination of this Agreement, including without limitation the terms of paragraphs 3, 5, 7, 9, and 10.

16. Effective Date

This Agreement is effective on the date the Provider meets all requirements of participation as set forth in state and federal regulation.