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Department of Health and Social Services

Division of Social Services

Statutory Authority: 31 Delaware Code, Chapter 5, Section 512 (31 Del.C. Ch.5, §512)


Provider Contractual/Programmatic Responsibilities


In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code) and under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Social Services / is proposing to amend the Delaware Medicaid/Medical Assistance Program Provider Manual to add language to Section 1.6 of the General Policy to promote provider accuracy in processing claims.

Any person who wishes to make written suggestions, compilations of data, testimony, briefs or other written materials concerning the proposed new regulations must submit same to Sharon L. Summers, Policy and Program Development Unit, Division of Social Services, P.O. Box 906, New Castle, Delaware 19720 by December 31, 2004.

The action concerning the determination of whether to adopt the proposed regulation will be based upon the results of Department and Division staff analysis and the consideration of the comments and written materials filed by other interested persons.

Summary Of Proposed Changes

Medical services are reimbursed by the Delaware Medicaid/Medical Assistance Program (DMAP) under Title XIX of the Social Security Act, as amended. Direct health care services are provided by a variety of provider groups. This amendment clarifies general provider participation requirements and provider responsibilities for claims submitted to the DMAP.

All DMAP providers are responsible for their own claims preparation and submission. The effects of this amendment are: 1) more efficient service delivery through more detailed billing requirements; and, 2) increase level of provider accountability for services rendered.


1.6 Provider Contractual/Programmatic Responsibilities

1.6.1 A provider who signs a contract with the DMAP is responsible to meet certain conditions in order to remain an eligible provider and receive payment for services rendered. The provider must abide by the DMAP's policies and procedures, for example, including but not limited to:

Directing clients to the most appropriate, medically necessary, and cost-efficient care possible.
Acceptance of final DMAP payment disposition as payment in full for Medicaid covered services; [therefore, providers cannot charge the client for any services reimbursable by the DMAP (refer to Billing DMAP Clients section in this General Policy for exceptions)].
Billing all other insurance resources or legally liable third parties prior to billing DMAP (unless under special arrangement as a managed care provider in which third party liability is accounted for in the capitated rate).
Keeping records necessary to verify the services provided and permitting federal/state representatives access to the records.
Determining that the client has valid Medical Assistance eligibility before rendering service and, if the client is enrolled in managed care, assuring that all necessary authorizations from the managed care organization are obtained prior to the delivery of services.
Informing the client of any service that will not be covered by the DMAP prior to the delivery of the service.
Making restitution for any overpayment promptly.
Notifying the DMAP of any suspensions or exclusions from any program.
Sending copies of professional license or certifications to EDS, the fiscal agent, whenever renewed or altered.
Notifying EDS in writing of any changes related to their
General Policy Provider Policy Manual Medicaid participation including but not limited to, changes in group affiliation.

1.6.2 Providers are responsible for the accuracy, truthfullness, and completeness of all claims submitted to DMAP. The provider is further responsible for all costs associated with the preparation for the submission of claims, whether prepared or submitted by the provider or by an outside agency or service. State employees are prohibited from submitting claims on behalf of non-government providers.

Providers acknowledge that by submitting a claim to DMAP they certify the services were rendered prior to the submission of the claim.

8 DE Reg. 854 (12/01/04)