10A NCAC 22G .0306. PAYMENT ASSURANCE

(a)  The State shall pay each provider of ICF‑MR services, who furnishes the services in accordance with the requirements of the State Plan and the Participation agreement, the amount determined under the plan.

(b)  In no case shall the payment rate for services provided under the plan exceed the facility's customary charges to the general public for such services.

(c)  The payment methods and standards set forth herein 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 State Plan.  This reimbursement plan is effective consistent with and on approval of the State Plan for Medical Assistance.

(d)  In all circumstances involving third party payment, Medicaid is the payor of last resort.

(e)  The State may withhold payments to providers under the following circumstances:

(1)           If the State has an expectation that the provider will not expend the total prospective rate for reasonable and allowable patient care costs, the State may, at its discretion, withhold a portion of each payment so as to avoid a large amount due back to the State.

(2)           Upon provider termination from the Medicaid Program the State may withhold a sum of money from provider payments that it reasonably expects will be due when final reimbursement settlements for all previous periods, including the period in which the termination occurred, are completed.

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

(4)           Upon written request of the provider, and with good cause shown, the Division of Medical Assistance may approve a repayment schedule in lieu of withholding funds.

(5)           The State may withhold up to 20 percent per month of a provider's payment for failure to file a timely cost report or other relevant information related to a facility's operation and requested by the Division of Medial Assistance.  These funds shall be released to the provider after the cost report or the related information requested by the Division of Medical Assistance 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:        Filed as a Temporary Adoption Eff. July 8, 1993 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 1985, c.479, s. 86; 42 C.F.R. 447, Subpart C;

Eff. November 1, 1993.