Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.405 - Provider Responsibilities

Current through Register 1525, July 5, 2024
In addition to meeting all other provider requirements set
				forth in
				130 CMR
				442.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
, the provider of orthotics must:
(A) accept rates of payment established by
			 the Executive Office of Health and Human Services as set forth in
			 101 CMR
			 334.00:
Prostheses, Prosthetic Devices and
			 Orthotic Devices
for all orthotic services provided to MassHealth
			 members, unless otherwise determined by the MassHealth agency or its designee
			 through a selective contracting or other process;
(B) notify the MassHealth agency or its
			 designee within 14 days prior to any changes in any of the information
			 submitted in the provider application in accordance with 130 CMR 450.215:
Provider Eligibility: Notification of Potential Changes in
			 Eligibility
and 130 CMR 450.223(B) including, but not limited to,
			 change of ownership, change of address, change in scope of service, and
			 additional service locations. The provider may not bill for new service
			 locations until approved by MassHealth. The provider must maintain records of
			 all such communications and transactions and make such records available to the
			 MassHealth agency or its designee for review upon request;
(C) ensure that the orthotic services
			 provided are consistent with industry quality standards or any applicable
			 standards established by the MassHealth agency, given the medical need for
			 which the orthotics are prescribed and the member's functional
			 limitations;
(D) ensure prompt
			 amelioration, repair or replacement of all orthoses or other orthotic services
			 that have been provided to a member and which are subject to recall, in
			 accordance with the specifications in the recall notice. The orthotics provider
			 shall provide the member with a copy of the recall notice and fully address the
			 recall as specified in the recall instructions no later than five business days
			 from the date the orthotic provider receives the recall notice;
(E) evaluate and access the member's need for
			 orthotic services, and for delivery of the product(s) to the member either at
			 the orthotic provider's service facility location or other setting as deemed
			 appropriate by the member and the orthotics provider, including education of
			 the member, or caregivers, as appropriate, in the use of the product;
(F) ensure that all orthotic services are
			 furnished to MassHealth members by employees of the orthotics provider, and
			 that such employees are qualified in their respective disciplines to perform
			 the orthotic services that they provide, consistent with
			 130
			 CMR 442.404(B)(8);
(G) comply with MassHealth administrative and
			 billing regulations at 130 CMR 450.000:
Administrative and Billing
			 Regulations
, including any third-party liability or member
			 cost-sharing requirements;
(H)
			 comply with applicable state and federal third-party liability requirements for
			 MassHealth members with other insurance, including dually eligible members.
			 This includes compliance with state and federal law and other subregulatory
			 requirements necessary to obtain payment from other liable parties;
(I) comply with all applicable Medicare
			 billing and authorization requirements and make diligent efforts to identify
			 and obtain payment from all other liable parties, including Medicare, before
			 billing MassHealth, in accordance with
			 130
			 CMR 450.316:
Third-party Liability:
			 Requirements
. This includes appealing a denied claim when the service
			 is payable in whole or in part by Medicare or other liable parties or
			 payers;
(J) report to the proper
			 authorities any suspected abuse or neglect that staff may observe when
			 providing service to a member, as mandated by M.G.L. c. 19A, § 15, M.G.L.
			 c. 19C, § 10, M.G.L. c. 111, § 72G and M.G.L. c. 119m, § 51A, in
			 addition to any other suspected abuse or neglect as required by other state and
			 Federal law;
(K) adhere to the
			 Medicare supplier standards set forth by CMS;
(L) not alter any invoice or medical
			 documentation;
(M) not solicit
			 members to purchase additional orthotic services;
(N) submit prior-authorization requests, as
			 specified by
			 130
			 CMR 442.412, to the MassHealth agency, or its
			 designee. Prior authorization requests should only be submitted when the
			 orthotic service is medically necessary and when prior-authorization is a
			 prerequisite in accordance with
			 130
			 CMR 442.412, and when other MassHealth
			 guidance requires it;
(O) respond
			 to members' complaints or complaints made on behalf of a member within two
			 business days;
(P) not share a
			 service facility or physical location (including a consignment closet, unless
			 permitted by specific MassHealth guidance) with a provider who is authorized to
			 prescribe orthotics, or with another orthotics provider, except as permitted by
			 42 CFR
			 424.57(C)(29)(ii) (Medicare
			 Supplier Standard 29);
(Q) have a
			 complaint resolution protocol to promptly address members' complaints and keep
			 written complaints, related correspondence, and any notes of actions taken in
			 response to written and oral complaints, and maintain such information in
			 accordance with
			 130
			 CMR 442.423(I). This
			 includes responding to any member complaints within two business
			 days;
(R) ensure that the member
			 and the member's caregivers, as appropriate, can use all orthotics provided
			 safely and effectively in the settings of anticipated use;
(S) comply with applicable CMS and MassHealth
			 quality standards and any applicable quality measurement program requirements;
			 and
(T) provide MassHealth members,
			 currently being serviced by the provider, with written notification at least 60
			 days in advance of any change in the orthotics provider's scope of business or
			 services (for example, if a provider decides to no longer provide certain
			 products, or if the scope of the provider's Medicare accreditation changes).
			 Notification to the member must include:
(1) a
			 statement that the member can contact MassHealth Customer Service or other
			 agency designee to request a list of MassHealth participating Orthotics
			 providers in their area;
(2) offer
			 assistance to the member regarding transfer of services to another provider if
			 appropriate; and
(3) if prior
			 authorization is required for the service:
(a)
			 information about any unbilled units remaining on the PA; and
(b) a copy of the original PA approval from
			 MassHealth for the member to provide to the new orthotics provider.