NC DHHS OPR Provider 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 North Carolina state and federal law 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; and
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 of program(s) in which the provider participates: federal and state laws, rules, and regulations; medical coverage policies of the Department; and all 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 action 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. Terms:

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. The provider agrees to 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.
2. Be enrolled exclusively as a “non-billing provider”. The non-billing provider will NOT submit claims for reimbursement.
3. Be held to all the terms of this Agreement.
4. Be equally subject to the recoupment or recovery of any overpayment, penalty, or invalid payment incurred by any Providers that share the same IRS Employee Identification Number. Any Provider that does not share the same Employee 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 of an overpayment, penalty, or invalid payment.
5. Not deliver services to Medicaid beneficiaries 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. 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.
7. 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.
8. 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. Evidenceof successor assumption of selling Provider's Medicaid liability arising under the change of ownership. 
9. 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, dateof 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.
10. 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.
11. 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.
12.  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.
13. 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.
14. Monitor and ensure that the contractors or subcontractors of the enrolled provider are subject to the disclosure and reporting requirements required under this Agreement. 
15. Comply with the advance directives requirements for hospitals, nursing facilities, providers of home health care and personal care services, hospices, and HMOs, requirements specified in 42 CFR Chapter IV, part 489, subpart I and 42 CFR §417.436(d); and for physicians pursuant to N.C.G.S. Chapter 90 Article 23.
16. Keep, maintain and make available for a minimum of 7 years from the date of services, or longer if specifically required by Controlling Authority complete and accurate medical and fiscal records that fully justify and disclose the extent of the services or items furnished. Provider further agrees to promptly furnish upon request copies of any and all documentation described in 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. 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. 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.
17. 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.

5. Termination

a. Subject to applicable provisions of Controlling Authority, 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;

b. 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.

c. The Provider’s right to appeal or otherwise contest any termination shall be determined in accordance with Controlling Authority.

6. 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.

7. 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.

8. 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.

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

10.  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.

11. That no waiver of any term, right or condition of this Agreement shall be valid unless it is set forth in a document 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.

12. 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, 4.p., 4.q., 6., and 7.

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