NC DHHS Out of State Lite 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, provider manuals, implementation updates, and bulletins published by CMS, the Department, its divisions and/or its fiscal agent as referenced in Section 3, below, no alterations or modifications shall be made to the terms of the Agreement.
    
3. Governing Law and Venue

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

1. 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
2. The Family Educational Rights and Privacy Act (FERPA); and
3. N.C.G.S §108A-80, NCGS 108A Art 2, part 6, NCGS 108C, and 42 U.S.C 1396a-1396v.
4. 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 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 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 30 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 the North Carolina Medicaid program.
 

4. Terms

The Provider agrees to:

1. Be licensed, certified, registered, accredited and/or endorsed as required by provider’s home state, 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 held to all the terms of this Agreement.
3. Be equally subject to the withholding, recoupment or recovery of any overpayment, penalty, or invalid payment incurred by any Provider 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.
4. 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.
5. Notify the Department through the North Carolina Department of Health and Human Services Fiscal Agent of any material and/or substantial change in information contained in the enrollment application given to the Department by the Provider.  This notification must be made in writing within thirty (30) calendar days of the event triggering the reporting obligation.  Material and/or substantial change including, but not limited to, a change in ownership, licensure, federal tax identification number, bankruptcy, additions, deletions, or replacements in group membership; and any change in address, telephone number, or email.
6. Submit to the Department and Secretary upon request professional, business, and personal information concerning the Provider, any person with an ownership interest in the Provider, any managing employee, and any authorized agent of the Provider in accordance with the disclosure requirements set forth in 42 CFR Chapter IV, part 455, Subpart B.
7. Submit to a criminal background check before or any time after approval of this agreement. (The Provider, any person with an ownership interest in the Provider, any managing employee, and any authorized agent of the            Provider.)
8. 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. Keep, maintain and make available complete and accurate medical and fiscal records that fully justify and disclose the extent of the services or items furnished. 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.
10. Allow Federal and State officials, employees and their agents to visit the Provider. Such visits including unannounced visits must be allowed at any time during normal hours of operation.  Failure to grant immediate access upon reasonable request may result in suspension of the Provider.
11. Allow either the Department or the Provider to terminate this Agreement with or without cause at any time upon 30 days written notification to the other; and the Department may summarily terminate without giving 30 days written notice under the following circumstances:
    1. 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
    2. 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
    3. 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 relating to fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct; or
    4. The Provider fails to disclose information required under 42 CFR §1002.3; or
    5. Any person with ownership or controlling interest in the Provider, or an agent as that term is defined in accordance with 42 CFR §1001.1001 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
    6. The Provider poses an imminent health or safety risk to a patient; or
    7. 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.
12. Appeal or otherwise contest any termination only in accordance with Controlling Authority.
13. Not assign this Agreement, or any rights or obligations contained in this Agreement to a third party except as allowed by federal law.
14. Fully release and discharge the State of North Carolina, the Department and any of their officers, agents and employees, 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 officers, agents and employees 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.

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.
 

15. Agree 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.
16. That 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.
17. This Agreement is effective on the date the Provider meets all requirements of participation as set forth in state and federal regulations.