reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.206 - Determination of Compliance with Medical Standards

Current through Register 1525, July 5, 2024
Violations of
				130 CMR 450.204
				may be determined by peer review. Except as otherwise required by law, the
				MassHealth agency will decide the level and manner of peer review in each
				instance. Such peer review may be conducted by a qualified MassHealth agency
				employee or consultant or by one or more qualified persons provided by
				health-care foundations, professional societies, or such other professional
				organizations as the MassHealth agency may select. In appropriate cases, the
				MassHealth agency may rely in part or in whole upon reviews conducted by a
				utilization and quality-control review organization or a board of registration.
				In the event that the MassHealth agency decides to pursue any sanction or
				recovery of overpayment as a result of a peer-review recommendation, the
				provisions of
				130 CMR 450.235
				through
				450.260
				apply.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.208 - Utilization Management: Admission Screening for Acute Inpatient Hospitals

Current through Register 1525, July 5, 2024
(A)
Requirements
.
(1) The MassHealth agency conducts admission
			 screening on elective admissions only. The admitting provider must telephone or
			 fax the MassHealth agency at least seven calendar days before a proposed
			 elective admission and provide the information specified in the appendix
			 described in
			 130
			 CMR 450.207(B). When the
			 admitting provider cannot notify the MassHealth agency within seven calendar
			 days, the admitting provider must notify the MassHealth agency prior to the
			 elective admission, and no later than 5:00 P.M. on the first day after the
			 decision to admit. The provider must explain to the MassHealth agency why the
			 seven-calendar-day notice requirement was not met. If the MassHealth agency
			 cannot complete the admission-screening process before the scheduled elective
			 admission, when neither the admitting provider nor the acute inpatient hospital
			 has informed the MassHealth agency at least seven calendar days before the
			 admission was scheduled, the provider may be required to reschedule the
			 admission.
(2) Providers must
			 notify the MassHealth agency of any changes in an approved elective admission
			 as soon as those changes are known, but in any event, before the admission
			 occurs. The MassHealth agency will deny payment if a service or procedure that
			 is provided is not what was proposed and approved, and such procedure, service,
			 or admission is not medically necessary.
(3) For postponed admissions, the admitting
			 provider must contact the MassHealth agency and provide updated information no
			 later than 5:00 P.M. on the second business day following the originally
			 planned admission date.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.209 - Utilization Management: Prepayment Review for Acute Inpatient Hospitals

Current through Register 1525, July 5, 2024
(A)
Introduction
.
(1) The MassHealth agency conducts prepayment
			 reviews to evaluate acute inpatient hospital admissions for
(a) medical necessity including, but not
			 limited to, the appropriateness of the inpatient admission and any
			 services;
(b) the stability of the
			 member at the time of discharge;
(c) the quality of care provided;
			 and
(d) compliance with the
			 MassHealth agency's billing procedures and requirements.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.210 - Pay-for-performance Payments: MassHealth Agency Review

Current through Register 1525, July 5, 2024
(A)
Applicability
.
			 The provisions set forth in 130 CMR 450.210 establish the MassHealth agency's
			 review process for provider disputes concerning MassHealth pay-for-performance
			 payment amounts for acute hospitals, MCOs, SCOs, ICOs, and the behavioral
			 health contractor. For purposes of 130 CMR 450.210, "pay for performance" means
			 a value-based purchasing program implemented by the MassHealth agency to pay
			 providers to perform activities related to improving the quality of care
			 delivered to MassHealth members.
(B)
MassHealth
			 Pay-for-performance Payment Notice
. The MassHealth agency will
			 notify the provider in writing of the agency's determination of the provider's
			 pay-for-performance payment amount for the time period specified in the notice.
			 The notice will identify the aggregate pay-for-performance payment amount
			 calculated for the provider, and may separately identify the amount calculated
			 for components of such payment amount. The MassHealth agency will notify the
			 provider by letter, report, computer printout, electronic transmission, or
			 other format; this notification is the "MassHealth Pay-for-performance Payment
			 Notice" referred to in 130 CMR 450.210.
(C)
Requesting MassHealth Agency
			 Review of Pay-for-performance Amounts
.
(1) To preserve its right to an adjudicatory
			 hearing and judicial review, a provider must request MassHealth agency review
			 of the provider's pay-for-performance payment amounts specified in the
			 MassHealth Pay-for-performance Payment Notice. The request for agency review
			 must be made in writing and be received by the MassHealth agency within 30
			 calendar days of the date appearing on the MassHealth Pay-for-performance
			 Payment Notice. Only those payment amounts specifically identified as in
			 dispute by the provider in its request for agency review are subject to
			 review.
(2) Any request for agency
			 review submitted pursuant to 130 CMR 450.210(C)(1) must
(a) identify with specificity all payment
			 amounts and components of such payment amounts in dispute;
(b) specify in sufficient detail the basis of
			 the provider's disagreement with those amounts as calculated;
(c) identify and address all issues in the
			 MassHealth Pay-for-performance Payment Notice with which the provider
			 disagrees; and
(d) include any
			 documentary evidence and information it wants the MassHealth agency to
			 consider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.211 - Medicaid Electronic Health Records Incentive Payment Program

Current through Register 1525, July 5, 2024
(A)
Applicability
.
			 The provisions set forth in 130 CMR 450.211 establish the MassHealth agency's
			 review process for provider disputes concerning the Medicaid Electronic Health
			 Records Incentive Payment Program established pursuant to § 4201 of the
			 American Recovery and Reinvestment Act of 2009,
			 P.L.
			 111-5 and 42 CFR Part 495.
(B)
Medicaid Electronic Health
			 Records Incentive Payment Program Notice
. The MassHealth agency
			 will notify the provider in writing of the agency's determination of the
			 provider's Medicaid Electronic Health Records Incentive Payment Program
			 eligibility and payment amount. The notice will identify the provider's
			 eligibility, determination of payment amount, and right to review. The
			 MassHealth agency will notify the provider by letter, report, computer
			 printout, electronic transmission, or other format. This notification is the
			 Medicaid Electronic Health Records Incentive Payment Program Notice referred to
			 in 130 CMR 450.211.
(C)
Requesting MassHealth Agency Review of Medicaid Electronic Health
			 Records Incentive Payment Program Determinations
.
(1) To preserve its right to an adjudicatory
			 hearing and judicial review, a provider must request MassHealth agency review
			 of the agency's determination specified in the Medicaid Electronic Health
			 Records Incentive Payment Program Notice. A provider's request for review may
			 be based on either an alleged error in the MassHealth agency's determination of
			 the provider's Medicaid Electronic Health Records Incentive Payment Program
			 eligibility and payment amount or on information that was not initially
			 supplied during the application process. The provider's request for review must
			 be made in writing and be received by the MassHealth agency within 30 calendar
			 days of the date appearing on the Medicaid Electronic Health Records Incentive
			 Payment Program Notice. Only those determinations specifically identified in
			 dispute by the provider in its request for an agency review are subject to
			 review.
(2) A provider's request
			 for review may request reconsideration of the following findings:
(a) the provider's eligibility for incentive
			 payments; and
(b) incentive payment
			 amounts.
(3) Any request
			 for agency review submitted pursuant to 130 CMR 450.211(C)(1) must
(a) identify with specificity all
			 determinations with which the provider disagrees;
(b) specify in sufficient detail the basis
			 for the provider's disagreement with those determinations;
(c) identify and address all issues in the
			 Medicaid Electronic Health Records Incentive Payment Program Notice with which
			 the provider disagrees; and
(d)
			 include any documentary evidence and information that the provider wants the
			 MassHealth agency to consider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.213 - Provider Eligibility: Termination of Participation for Ineligibility

Current through Register 1525, July 5, 2024
When a provider fails or ceases to meet any one or more of the
				eligibility criteria applicable to such provider, the provider's participation
				in MassHealth may be terminated, subject to
				130 CMR
				450.212(B)  and
				450.216.
				If such termination is based upon a finding, ruling, conviction, decision,
				order, notification, or statement of any nature (including an agreement with
				the provider) by any federal, state, or quasi-public board, department (other
				than the MassHealth agency), or other agency or another state's Medicaid
				program that revokes, voids, suspends, or denies the issuance, renewal, or
				extension of a license, certificate, or other statement of qualification that
				constitutes a statutory prerequisite or other eligibility criterion, or that
				takes any action of the nature set forth in
				130 CMR
				450.212(A)(6), the
				correctness or validity of the action taken by the issuing agency will be
				presumed, the termination will be effective as of the earliest date on which
				the provider failed or ceased to meet any of such criteria, and the MassHealth
				agency will not afford a hearing as to the correctness or validity of such
				action. If such termination is based solely upon a determination of
				ineligibility by the MassHealth agency, the provider will be afforded notice
				and an opportunity for hearing in substantially the manner set forth in
				130 CMR
				450.241 through
				450.248,
				and any termination will be effective as of the date of receipt of notice
				thereof.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.214 - Provider Eligibility: Suspension of Participation Pursuant to United States Department of Health and Human Services Order

Current through Register 1525, July 5, 2024
When a provider is the subject of a notice by the United States
				Department of Health and Human Services (HHS) requiring the provider's
				suspension or the denial, termination, or refusal to renew a provider contract
				pursuant to §1902(a)(39) (
				42 U.S.C.
				1396a(a)(39) ) or any other
				section of the Social Security Act, the provider's participation in MassHealth
				will be suspended or its provider contract will be denied, terminated, or not
				renewed in accordance with the HHS notice, subject, however, to the provisions
				of
				130 CMR
				450.216. The MassHealth agency will not
				afford a hearing to the provider as to the correctness or validity of the
				action taken by HHS.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.215 - Provider Eligibility: Notification of Potential Changes in Eligibility

Current through Register 1525, July 5, 2024
(A) The provider must notify the MassHealth
			 agency in writing, within 14 calendar days of receipt, of any written
			 communication or electronic notification from an issuing federal or state
			 agency, board, quasi-public board department (other than the MassHealth agency)
			 or another state's Medicaid program that expresses an intention, conditionally
			 or otherwise, to alter, revoke, void, suspend, or deny the issuance, renewal,
			 or extension of any license, certificate, or other statement of qualification
			 that constitutes a provider eligibility criterion, or take any action of the
			 nature set forth in
			 130 CMR
			 450.212(A)(6).
(B) The provider must notify the MassHealth
			 agency in writing, within 14 calendar days of sending to an issuing agency, of
			 any communication that expresses an intention or desire to register as an
			 inactive practitioner, resign, surrender, terminate, or substantially modify
			 the conditions of any such license, certificate, or other statement of
			 qualification that constitutes a provider eligibility criterion.
(C) Without limiting the generality of 130
			 CMR 450.215(A), the provider must notify the MassHealth agency in accordance
			 with 130 CMR 450.215(A) and (B) whenever the provider
(1) has received notice of denial of Medicare
			 or Medicaid certification from the Massachusetts Department of Public
			 Health;
(2) has received notice of
			 a denial of an application for renewal of a license;
(3) has filed application with the Department
			 of Public Health to convert from nursing facility to rest home
			 status;
(4) has received an order
			 to show cause from a board of registration;
(5) becomes subject to any action of the
			 nature set forth in
			 130 CMR
			 450.212(A)(6); or
(6) has been terminated or suspended from
			 participation in Medicare or another state's Medicaid program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.216 - Provider Eligibility: Limitations on Participation

Current through Register 1525, July 5, 2024
If termination or suspension of a provider's participation in
				MassHealth has occurred or is imminent, the MassHealth agency will take such
				action as may be reasonably necessary or appropriate to prevent or to mitigate
				injury to members or MassHealth or both, resulting from such termination or
				suspension. Such action may be taken immediately upon notice to the provider
				notwithstanding the exercise of such rights as the provider may have to secure
				administrative or judicial review of the action of the issuing agency, or of
				the U.S. Department of Health and Human Services, or of the MassHealth agency,
				or any combination of them. With respect to chronic disease and rehabilitation
				hospitals and other long-term-care facilities, such action may include an order
				barring further admissions of members pending final resolution of the issues
				that prompted such action, or an order that the institution will continue to be
				paid by the MassHealth agency, for a period specified in the order, for
				services to members admitted to the facility prior to an order barring new
				admissions, or prior to such termination. Such action will be reasonably
				calculated to achieve, so far as possible, the following goals:
(A) protecting the health and safety of
			 members, including present and prospective patients of the provider;
			 and
(B) maximizing federal
			 financial participation in the cost of medical assistance.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.217 - Provider Eligibility: Ineligibility of Suspended Providers

Current through Register 1525, July 5, 2024
A provider suspended from participation in MassHealth is not
				eligible to participate during the period of such suspension, cannot receive
				payments for any services rendered to members during the period of such
				suspension, and is not eligible to participate until such time as a new
				application is filed, reviewed, and approved, and the provider contract is
				effective. If the violations resulted in overpayments, the MassHealth agency
				may deny the participation of such provider until such time as arrangements
				satisfactory to the MassHealth agency have been made for the restitution of all
				overpayments. The MassHealth agency has discretion to deny a new application
				after review of the any prior for cause suspensions, if in the judgment of the
				MassHealth agency, such participation would
(A) threaten the health, welfare, or safety
			 of members; or
(B) compromise the
			 integrity of the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.222 - Provider Contract: Application for Contract

Current through Register 1525, July 5, 2024
A person or entity may become a participating provider only by
				submitting an Application for Provider Contract. If approved by the MassHealth
				agency, the application will be part of any subsequent provider contract
				between the applicant and the MassHealth agency. Any omission or misstatement
				in the application will (without limiting any other penalties or sanctions
				resulting therefrom) render such contract voidable by the MassHealth
				agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.224 - Provider Contract: Exclusion and Ineligibility of Convicted Parties

Current through Register 1525, July 5, 2024
The MassHealth agency may terminate, or refuse to enter into or
				to renew a provider contract if:
(A)
			 the provider, any party in interest in such provider, an agent or managing
			 employee of such provider, or in the case of a group practice, any individual
			 practitioner enrolled as a member of the group, has been convicted of a
			 criminal offense relating to that person's involvement in any program
			 established under Title XVIII, XIX, or XXI of the Social Security Act, or of a
			 crime of such a nature that, in the judgment of the MassHealth agency, the
			 participation of such provider will compromise the integrity of MassHealth;
			 or
(B) the provider or an
			 individual practitioner enrolled as a member of a group practice has been a
			 party in interest, a managing employee, or an agent of a provider that has been
			 convicted of a criminal offense relating to that person's involvement in any
			 program established under Title XVIII, XIX, or XXI of the Social Security Act,
			 or of a crime of such a nature that, in the judgment of the MassHealth agency,
			 the participation of such provider will compromise the integrity of
			 MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.226 - Provider Contract: Issuance of Provider ID/Service Location Numbers

Current through Register 1525, July 5, 2024
(A) Upon execution of the provider contract,
			 the MassHealth agency will issue a provider ID/service location number or
			 numbers to be used to identify the provider that is the subject of the
			 contract.
(B) For every case in
			 which a provider is assigned two or more provider ID/service location numbers,
			 the provider must use each provider ID/service location number only in
			 conjunction with the facility or location to which the provider ID/service
			 location number is assigned. The MassHealth agency, however, maintains its
			 right to commence proceedings in accordance with the provisions of
			 130 CMR 450.235
			 through
			 450.248
			 against any or all of its provider ID/service location numbers, regardless of
			 the location or facility where the violation has been alleged to have occurred
			 or the overpayment received.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.227 - Provider Contract: Termination or Disapproval

Current through Register 1525, July 5, 2024
The MassHealth agency may at its discretion disapprove a
				provider contract, and may terminate an existing contract, if the provider
				fails to disclose any information in accordance with the provisions of
				130 CMR
				450.222,
				450.223,
				or 42 CFR §§ 455.100 through 106,
				42 CFR
				455.436, 42 CFR §1002, or as otherwise
				required by state or federal law.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.231 - General Conditions of Payment

Current through Register 1525, July 5, 2024
(A) Except
			 to the extent otherwise permitted by state or federal regulations, no provider
			 is entitled to any payment from MassHealth unless on the date of service the
			 provider was a participating provider and the person receiving the services was
			 a member.
(B) The "date of service"
			 is the date on which a medical service is provided to a member or, if the
			 medical service consists principally of custom-made goods such as eyeglasses,
			 dentures, or durable medical equipment, the date on which the goods are
			 delivered to a member. If a provider delivers to a member medical goods that
			 had to be ordered, fitted, or altered for the member, and that member ceases to
			 be eligible for such MassHealth services on a date before the final delivery of
			 the goods, the MassHealth agency will pay the provider for the goods only under
			 the following circumstances:
(1) the member
			 must have been eligible for MassHealth on the date of the member's last visit
			 with the provider before the provider orders or fabricates the goods;
(2) the date on which the provider orders or
			 fabricates the goods occurs no later than seven days after the last
			 visit;
(3) the provider has
			 submitted documentation with the claim to the MassHealth agency that verifies
			 both the date of the member's last visit that occurred before the provider
			 ordered or fabricated the goods and the date on which the goods were actually
			 ordered or fabricated;
(4) the
			 provider must not have accepted any payment from the member for the goods
			 except copayments as provided in
			 130 CMR
			 450.130; and
(5) the provider must have attempted to
			 deliver the goods to the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.232 - Rates of Payment to In-state Providers

Current through Register 1525, July 5, 2024
Payment to all providers is made in accordance with the payment
				methodology applicable to the provider, subject to federal payment limitations.
				Without limiting the generality of the foregoing, payment to a Massachusetts
				in-state noninstitutional provider for any medical services payable by the
				MassHealth agency is made in accordance with the applicable payment methodology
				established by EOHHS, subject to any applicable federal payment limit
				(
see
42 CFR
				447.304 ).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.233 - Rates of Payment to Out-of-state Providers

Current through Register 1525, July 5, 2024
(A)
			 Except as provided in
			 130 CMR
			 450.233(D)  and
			 435.405(B),
			 payment to an out-of-state institutional provider for any medical service
			 payable by the MassHealth agency is the lowest of
(1) the rate of payment established for the
			 medical service under the other state's Medicaid program;
(2) the MassHealth rate of payment
			 established for such medical service or comparable medical service in
			 Massachusetts; or
(3) the
			 MassHealth rate of payment established for a comparable provider in
			 Massachusetts.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.234 - Rates of Payment to Chronic Disease, Rehabilitation, or Similar Hospitals with Both Out-of-state Inpatient Facilities and In-state Outpatient Facilities

Current through Register 1525, July 5, 2024
Payment to a chronic disease, rehabilitation, or similar
				hospital with both out-of-state inpatient facilities and in-state outpatient
				facilities, for any medical service payable by the MassHealth agency is made as
				follows:
(A)
Inpatient
			 Services
. For inpatient services, payment is in accordance with
			 130 CMR
			 435.405(B).
(B)
Outpatient
			 Services
.
(1) For outpatient
			 services provided out-of-state, payment is in accordance with
			 130 CMR
			 450.233(A) and
			 (B).
(2) For outpatient services provided
			 in-state, payment is the median in-state outpatient hospital cost-to-charge
			 ratio for similar hospitals.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.235 - Overpayments

Current through Register 1525, July 5, 2024
(A) Overpayments include, but are not limited
			 to, payments to a provider
(1) for services
			 that were not actually provided or that were provided to a person who was not a
			 member on the date of service;
(2)
			 for services that were not payable under MassHealth on the date of service,
			 including services that were payable only when provided by a different provider
			 type and services that were not medically necessary (as defined in 130 CMR
			 450.204 );
(3) in excess of the
			 maximum amount properly payable for the service provided, to the extent of such
			 excess;
(4) for services for which
			 payment has been or should be received from health insurers, worker's
			 compensation insurers, other third-party payers, or members;
(5) for services for which a provider has
			 failed to make, maintain, or produce such records, prescriptions, and other
			 documentary evidence as required by applicable federal and state laws and
			 regulations and contracts;
(6) for
			 services provided when, as of the date of service, the provider was not a
			 participating provider, or was in any breach or default of the provider
			 contract;
(7) for services billed
			 that result in a duplicate payment; or
(8) in an amount that a federal or state
			 agency (other than the MassHealth agency) has determined to be an
			 overpayment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.236 - Overpayments: Calculation by Sampling

Current through Register 1525, July 5, 2024
In any action or administrative proceeding to determine or
				recover overpayments, the MassHealth agency may ascertain the amount of
				overpayments by reviewing a representative sample drawn from the total number
				of claims paid to a provider during a given period and extrapolating the
				results of the review over the entire period. The MassHealth agency employs
				statistically valid techniques in establishing the size and distribution of the
				sample to ensure that it is a valid and representative
				sample.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.238 - Sanctions: General

Current through Register 1525, July 5, 2024
(A)
Introduction
. All providers are subject to the rules,
			 regulations, standards, and laws governing MassHealth. 130 CMR 450.238 through
			 450.240
			 set forth the MassHealth agency's procedures for imposing sanctions for
			 violations of those rules, regulations, standards, and laws. Such sanctions may
			 include, but are not limited to, administrative fines, provider services
			 restrictions, and suspension or termination from participation in MassHealth.
			 The MassHealth agency determines the amount of any fine and may take into
			 account the particular circumstances of the violation. The MassHealth agency
			 may assess an administrative fine whether or not overpayments have been
			 identified based on the same set of facts.
(B)
Instances of
			 Violation
. Instances of violation include, but are not limited to
(1) billing a member for services that are
			 payable under MassHealth, except copayments as provided in
			 130 CMR
			 450.130;
(2) submitting claims under an individual
			 provider's MassHealth provider number for services for which the provider is
			 entitled to payment from an employer or under a contract or other
			 agreement;
(3) billing the
			 MassHealth agency for services provided by someone other than the provider,
			 unless expressly permitted by the applicable regulations;
(4) billing the MassHealth agency before
			 delivery of service, unless permitted by the applicable regulations;
(5) failing to comply with recordkeeping and
			 disclosure requirements;
(6)
			 overstating or misrepresenting services, including submitting separate claims
			 for services or procedures provided as components of a more comprehensive
			 service for which a single rate of payment is established;
(7) failing to return credit balance funds to
			 the MassHealth agency within 60 days of their receipt;
(8) failing to obtain or provide a
			 physician's order, prescription, or referral when required by the applicable
			 regulations;
(9) failing to comply
			 with MassHealth enrollment, licensure, or certification requirements;
			 and
(10) misapplication or
			 misappropriation of personal needs allowance funds.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.239 - Sanctions: Calculation of Administrative Fine

Current through Register 1525, July 5, 2024
(A) The MassHealth agency may assess an
			 administrative fine not to exceed the greater of
(1) $100 for each instance of violation of
			 the rules, regulations, standards, or laws governing MassHealth;
(2) $100 for each day of violation of the
			 rules, regulations, standards, or laws governing MassHealth; or
(3) three times the payable amount of each
			 claim, in accordance with 130 CMR 450.239.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.241 - Hearings: Claim for an Adjudicatory Hearing

Current through Register 1525, July 5, 2024
(A)
			 A provider may challenge the findings set forth in the MassHealth agency's
			 final determination, issued pursuant to
(1)
			 regulations, including but not limited to,
			 130
			 CMR 450.208(C)(2),
			 450.209(C)(3),
			 450.209(D),
			 450.210(D)(1),
			 450.211(D)(1),
			 450.213 (as to provider termination based solely upon a determination of
			 ineligibility by the MassHealth agency), 450.237(D), or 450.240(E);
			 or
(2) other formal written
			 issuances of the MassHealth agency which specify that the provider has a right
			 to challenge the findings set forth in the MassHealth agency's final
			 determination using the process set forth in 130 CMR 450.241 through
			 450.248.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.242 - Hearings: Stay of Suspension or Termination or Provider Service Restriction

Current through Register 1525, July 5, 2024
A timely claim will stay any suspension or termination or
				provider service restriction described in the final determination until there
				has been a final agency action pursuant to
				130
				CMR 450.243(D)  or
				450.248;
				provided, however, that if the MassHealth agency finds on the basis of
				information it has before it that a provider's continued participation in
				MassHealth or in the case of provider service restrictions, participation
				without such restrictions, during the pendency of the administrative appeal
				could reasonably be expected to endanger the health, safety, or welfare of
				members or compromise the integrity of MassHealth, the suspension, termination,
				or provider service restrictions will not be stayed. A timely claim will not
				stay any withholding of payments under
				130 CMR
				450.249.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.243 - Hearings: Consideration of a Claim for an Adjudicatory Hearing

Current through Register 1525, July 5, 2024
(A) A timely claim must specifically identify
			 each issue and fact in dispute and state the provider's position, the pertinent
			 facts to be adduced at the hearing, and the reasons supporting that
			 position.
(B) If a matter has been
			 referred to or is under investigation by the Attorney General's Medicaid Fraud
			 Division or other criminal investigation agency, or if a question of quality of
			 care has been referred to a professional licensing board for investigation, the
			 Board of Hearings, upon notice from the MassHealth agency, will postpone the
			 hearing until the conclusion of such investigation and the final disposition of
			 any criminal complaint, indictment, or order to show cause that ensues, or
			 until the MassHealth agency notifies the Board to schedule the hearing. A
			 provider may not request a postponement of the hearing under 130 CMR
			 450.243(B).
(C) The Board of
			 Hearings will grant a hearing only if the claimant demonstrates all of the
			 following.
(1) The claim was filed with the
			 Board of Hearings and the MassHealth agency within the time limits set forth in
			 130 CMR
			 450.241.
(2) There is a genuine and material issue of
			 adjudicative fact for resolution.
(3) The factual issues can be resolved by
			 available and specifically identified reliable evidence as set forth in M.G.L.
			 c. 30A, § 11(2). A hearing will not be granted on the basis of general
			 allegations or denials or general descriptions of positions and
			 contentions.
(4) The allegations of
			 the provider, if established, would be sufficient to resolve a factual dispute
			 in the manner urged by the provider. A hearing will not be granted if the
			 provider's submissions are insufficient to justify the factual determination
			 urged, even if accurate.
(5)
			 Resolution of the factual dispute in the way sought by the provider is relevant
			 to and would support the relief sought.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.244 - Hearings: Authority of the Hearing Officer

Current through Register 1525, July 5, 2024
The hearing officer does not render a decision about the
				legality of federal or state laws including, but not limited, to the MassHealth
				regulations. If the legality of such law or regulation is raised by the
				provider, the hearing officer renders a decision based on the applicable law as
				interpreted by the MassHealth agency. Such decision includes a statement that
				the hearing officer cannot rule on the legality of such law or regulation and
				is subject to judicial review in accordance with M.G.L. c.
				30A.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.245 - Hearings: Burden of Proof

Current through Register 1525, July 5, 2024
The provider has the burden of establishing by a preponderance
				of the evidence that the provider has complied with the MassHealth requirements
				cited in the MassHealth agency's final determination or otherwise has correctly
				received, or is entitled to receive, any amounts in dispute.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.246 - Hearings: Procedure

Current through Register 1525, July 5, 2024
The hearing is conducted in accordance with M.G.L. c. 30A,
				§§ 9, 10 and 11 and
				801 CMR 1.00:
Standard
				Adjudicatory Rules of Practice and Procedure
, as modified or
				supplemented by
				130 CMR
				450.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.247 - Hearings: Hearing Officer's Decision

Current through Register 1525, July 5, 2024
The hearing officer's decision is in the form of a proposed
				decision to the Medicaid director. The proposed decision may affirm, modify, or
				overturn the actions proposed in the MassHealth agency's final determination.
				The proposed decision includes a determination of the amount of overpayments,
				if overpayments have been alleged, and a statement of reasons for the decision,
				including determination of each issue of fact or law necessary to the decision.
				If the provider makes a written request for the proposed decision prior to its
				issuance, the Board of Hearings notifies the provider by mail of the proposed
				decision. The decision of the hearing officer is effective when and to the
				extent it is adopted by the Medicaid director.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.248 - Medicaid Director's Decision

Current through Register 1525, July 5, 2024
If the provider has made a written request for a copy of the
				proposed decision prior to its issuance, the provider has seven calendar days
				from its receipt of the proposed decision to file written objections with the
				Medicaid director. The Medicaid director may adopt or modify the proposed
				decision, or return the matter to the hearing officer for further
				consideration, based on evidence already in the record or, if necessary,
				additional evidence to be included in the reopened record. The hearing officer
				will resubmit the proposed decision to the Medicaid director, as modified
				pursuant to
				130 CMR
				450.247 and 450.248. The provider is notified
				of the Medicaid director's action. When the Medicaid director has adopted or
				modified the proposed decision, the Medicaid director's decision is a final
				agency action reviewable pursuant to M.G.L. c. 30A.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.259 - Overpayments Attributable to Rate Adjustments

Current through Register 1525, July 5, 2024
(A) Whenever an overpayment occurs due to a
			 rate adjustment that is established by the MassHealth agency in accordance with
			 applicable law, the MassHealth agency notifies the provider in writing by
			 issuing a remittance advice identifying the impact of the rate adjustment on
			 all previously paid claims and stating the amount of the overpayment.
(B) A provider must pay to the MassHealth
			 agency the full amount of any overpayment attributable to a rate adjustment.
			 The applicable recoupment account will be systematically established against
			 all future payments until the full amount is repaid, unless the provider enters
			 into a payment arrangement with the MassHealth agency under
			 130 CMR
			 450.260(H).
(C) If a provider disputes the MassHealth
			 agency's computation of an overpayment attributable to a rate adjustment, the
			 provider must submit proposed corrections, including a detailed explanation, in
			 writing to the MassHealth agency within 30 calendar days after the date of
			 issuance of the remittance advice under 130 CMR 450.259(A). The fact that any
			 rate adjustment is under appeal is not considered a factor in determining the
			 amount of liability. The fact that a provider has submitted proposed
			 corrections to the MassHealth agency does not delay or suspend the provider's
			 payment obligations set forth under 130 CMR 450.259(B).
(D) If proposed corrections are timely
			 submitted in accordance with 130 CMR 450.259(C), the MassHealth agency reviews
			 the proposed corrections and notifies the provider of its decision within 30
			 calendar days of receipt of the provider's corrections. If the MassHealth
			 agency determines that corrections are required, the MassHealth agency makes
			 any appropriate payment adjustments reflecting the corrections.
(E) A provider must pay the MassHealth agency
			 the full amount of the overpayment stated in a remittance advice under 130 CMR
			 450.259(A), regardless of any pending appeal, action, or other proceeding
			 contesting the overpayment, including but not limited to, any appeal, action,
			 or other proceeding contesting any rate on which the overpayment is computed.
			 If required by a final disposition of any such appeal, action, or proceeding,
			 the MassHealth agency issues a revised remittance advice and makes any
			 appropriate payment adjustments to effect the final disposition.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.261 - Member and Provider Fraud

Current through Register 1525, July 5, 2024
All members and providers must comply with all federal and
				state laws and regulations prohibiting fraudulent acts and false reporting,
				specifically including but not limited to 42 U. S .C. 1320a-7b. Providers shall
				also promptly notify the MassHealth agency if it suspects a member is not
				eligible to receive MassHealth or someone other than the member is using the
				member's MassHealth card to receive or attempt to receive services or if any
				provider may be engaging in Medicaid fraud. The provider shall cooperate with
				and provide all information requested by the MassHealth agency, the Attorney
				General's Medicaid Fraud Division, the State Auditor's Office, or any other law
				enforcement entity investigating such fraud.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.271 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency may identify certain services as requiring individual consideration
			 (I.C.) in program regulations, associated lists of service codes and service
			 descriptions, billing instructions, provider bulletins, and other written
			 issuances from the MassHealth agency. For services requiring individual
			 consideration, the MassHealth agency establishes the appropriate amount of
			 payment based on the standards and criteria set forth in 130 CMR 450.271(B).
			 Providers claiming payment for any I.C .-designated service must submit with
			 such claim a report that includes a detailed description of the service, and is
			 accompanied by supporting documentation that must minimally include where
			 applicable, but is not limited to, an operative report, pathology report, or in
			 the case of a purchase, a copy of the supplier's invoice. The MassHealth agency
			 does not pay claims for "I.C." services unless it is satisfied that the report
			 and documentation submitted by the provider are adequate to support the
			 claim.
(B) The MassHealth agency
			 determines the appropriate payment for an I.C. service in accordance with the
			 following standards and criteria:
(1) the
			 amount of time required to perform the service;
(2) the degree of skill required to perform
			 the service;
(3) the severity and
			 complexity of the member's disease, disorder, or disability;
(4) any applicable relative-value studies;
			 and
(5) any complications or other
			 circumstances that the MassHealth agency deems relevant.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.275 - Teaching Physicians: Documentation Requirements

Current through Register 1525, July 5, 2024
In order to be paid for physician services provided in a
				teaching setting, physicians must comply with the following documentation
				requirements.
(A)
Definitions
. Whenever one of the following terms is
			 used in 130 CMR 450.275, it has the meaning given in the definition, unless the
			 context clearly requires a different meaning.
Resident
- an individual who
				participates in an approved Graduate Medical Education (GME) program, including
				interns and fellows. A medical student is never considered a resident.
Teaching Physician
- a physician (not
				a resident) who involves residents in the care of his or her patients. Where
				applicable and appropriate, the use of the phrase "teaching physician" will be
				construed to include teaching podiatrists and teaching dentists.
Teaching Setting
- a setting in which
				there is an approved GME residency program in medicine, osteopathy, dentistry,
				or podiatry.
(B)
General Requirements
.
(1) Under MassHealth, the MassHealth agency
			 pays for physician services (which are otherwise payable) furnished in teaching
			 settings only if documentation in the patient's medical record clearly
			 substantiates that the key portions of the services are personally provided by
			 a teaching physician, or the key portions of the services, which include
			 decision making processes, are provided jointly by a teaching physician and
			 resident, or by a resident in the presence of a teaching physician. (The
			 teaching physician must determine which portions of the service or procedure
			 are to be considered key and require his or her presence.) Any contribution of
			 a medical student to the performance of a service or procedure must be
			 performed in the physical presence of a teaching physician, or jointly with a
			 resident.
(2) The teaching
			 physician may not bill for the supervision of residents.
(3) The teaching physician may not bill for
			 services provided solely by residents.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.301 - Claims

Current through Register 1525, July 5, 2024
(A) Except as provided in other program
			 regulations, a claim for a medical service may be submitted only by the
			 provider that provided the service. In the absence of a specific exception or
			 qualification, 130 CMR 450.301(A) and (B) apply.
(1) An individual practitioner may not claim
			 payment under his or her own name and provider ID/service location number for
			 services actually provided by another individual, whether or not the individual
			 who provided the service is also a participating provider, or is an associate,
			 partner, or employee of the individual practitioner.
(2) An individual practitioner may not claim
			 payment under his or her own name and provider ID/service location number for
			 medical services provided by the individual practitioner and for which the
			 practitioner is paid by another entity (for example, hospital, clinic,
			 long-term-care facility, pharmacy, home health agency, health maintenance
			 organization, community health center, psychiatric day treatment program, day
			 habilitation center, and adult day care center). In such cases, payment may be
			 claimed only by the institution or facility.