10A NCAC 22G .0107. PAYMENT ASSURANCE

(a)  The state shall pay each provider of nursing care services, who furnishes the services in accordance with the requirements of the rules in 10A NCAC 22G and the participation agreement, the amount determined under the plan.  In addition, Nursing Facilities must be enrolled in the Title XVIII Program.  However, State‑operated nursing facilities are not required to be enrolled in the Medicare program.

(b)  The payment methods and standards set forth in this Rule are designed to enlist the participation of any provider who operates a facility both economically and efficiently.  Participation in the program shall be limited to providers of service who accept, as payment in full, the amounts paid in accordance with the rules in 10A NCAC 22G.  This reimbursement plan is effective upon approval of the State Plan for Medical Assistance.

(c)  In all circumstances involving third party payment, Medicaid is the payor of last resort.  No payment shall be made for a Medicaid recipient who is also eligible for Medicare, Part A, for the first 20 days of care rendered to skilled nursing patients.  Medicaid payments for co‑insurance for such patients shall be made for the subsequent 21st through the 100th day of care.  The Division of Medical Assistance shall pay an amount for each day of Medicare Part A inpatient co‑insurance, the total of which shall equal the facility's Medicaid per diem rate less any Medicare Part A payment, but no more than the Medicare coinsurance amount. In the case of ancillary services, providers shall:

(1)           maintain detailed records or charges for all patients;

(2)           bill the appropriate Medicare Part B carrier for all services provided to Medicaid patients that may be covered under that program;

(3)           allocate an appropriate amount of ancillary costs, based on these charge records adjusted to reflect Medicare denials of coverage, to Medicare Part B in the annual cost report.  For failure to comply with this requirement, the state may charge a penalty of up to five percent of a provider's indirect patient care rate for each day of care that is provided during the fiscal year in which the failure occurs.  This penalty shall not be considered an allowable cost for cost reporting purposes.

(4)           properly bill Medicare or other third‑party payors or have disallowance of any related cost claimed as Medicaid cost.

(d)  The state may withhold payments to providers under the following circumstances:

(1)           Upon determination of any sum due the Medicaid Program or upon instruction from a legally authorized agent of the State or Federal Government the state may withhold sums to meet the obligations identified.

(2)           The state may arrange repayment schedules within the limits set forth in federal regulations in lieu of withholding funds.

(3)           The state may charge interest on overpayments from the date that the overpayment occurred.

(4)           The state may withhold up to 20 percent per month of a provider's payment for failure to file a timely cost report and associated accounting records.  These funds shall be released to the provider after a cost report is acceptably filed.  The provider shall experience delayed payment while the check is routed to the state and split for the amount withheld.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c. 479, s. 86; Section 95 of Chapter 689, 1991 Session Laws; 42 C.F.R. 447, Subpart C;

Temporary Rule Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985;

Eff. January 28, 1985;

Amended Eff. December 1, 1988;

Temporary Amendment Eff. August 1, 1991 For a Period of 180 Days to Expire on January 31, 1992;

Amended Eff. February 1, 1992; October 1, 1991;

Temporary Amendment Eff. August 3, 2004;

Amended Eff. January 1, 2005.