Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.405 - Provider Responsibilities

Current through Register 1525, July 5, 2024
In addition to meeting all other provider requirements set
				forth in
				130 CMR
				409.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
, the DME provider must:
(A) accept, as payment in full, rates of
			 payment established by EOHHS through regulations at
			 101 CMR
			 322.00:
Durable Medical Equipment, Oxygen and
			 Respiratory Therapy Equipment
, including as determined by the
			 MassHealth agency through a preferred supplier contracting process or by other
			 means;
(B) 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
through
			 130
			 CMR 450.318:
Third-party Liability:
			 Payment Limitations on Medicare Crossover Claim Submissions
, and all
			 subregulatory guidance. This includes appealing a denied claim, before filing a
			 MassHealth claim, when the service is payable in whole or in part by Medicare
			 or other liable parties or payers. If documentation requested by the MassHealth
			 agency, or its designee, is not received within the timeframe specified by the
			 MassHealth agency or its designee, or the documentation is incomplete or does
			 not support coverage by MassHealth, the associated claims will be denied.
			 Failing to seek payment from all other liable parties may result in an
			 overpayment pursuant to
			 130 CMR
			 450.235(A)(4).
(C) comply with Medicare Competitive Bid
			 Provider requirements for items subject to the CMS competitive bid process,
			 which require that only qualified Medicare Competitive Bid Providers may
			 provide DME that is subject to Medicare's competitive bid process to members
			 with both MassHealth and Medicare coverage. MassHealth reimbursement is
			 pursuant to
			 130
			 CMR 450.318:
Third-party Liability:
			 Medicare Payment Limitations on Medicare Crossover Claim
			 Submissions
.
(D) except as
			 provided in 130 CMR 409.405(O) regarding change in scope of service or
			 business, notify the MassHealth agency in writing within 14 days of any changes
			 in any of the information submitted in the provider application in accordance
			 with
			 130 CMR
			 450.223(B)  and
			 130
			 CMR 450.215(A)  including,
			 but not limited to, change of ownership, change of address, change in scope of
			 the provider's Medicare accreditation, and addition of, or reduction in service
			 locations. The DME provider must maintain records of all such communications
			 and transactions and make such records available to the MassHealth agency for
			 review upon request;
(E) ensure
			 that the DME provided is from the least costly, reliable source, and are
			 consistent with MassHealth and industry quality standards, given the medical
			 need for which the DME is prescribed and the member's medical
			 condition;
(F) ensure that
			 EOHHS-specified absorbent products meet the quality performance standards for
			 disposable adult absorbent products used by the National Association for
			 Continence (NAFC) or other such standards as EOHHS may adopt;
(G) ensure that all DME are free from defects
			 and are in proper working order. This includes, but is not limited to, prompt
			 amelioration, repair or replacement of DME that has been provided to a member
			 and is subject to recall, in accordance with the specifications in the recall
			 notice. For recalls of potentially dangerous or defective DME that predictably
			 could cause serious health problems or death, the DME provider must give the
			 member 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 DME
			 provider receives the recall notice;
(H) 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. 111, § 72G, M.G.L. c. 119 § 51A,
			 M.G.L. c. 19A § 15, M.G.L. c. 19C, § 10, and any regulations
			 promulgated under these laws, as well as any other suspected abuse or neglect
			 as required by state and federal law;
(I) give employees a picture identification
			 to be presented to a member when making a delivery;
(J) not alter any invoice or medical
			 documentation;
(K) not solicit
			 members to purchase additional DME;
(L) submit prior authorization requests, as
			 specified by
			 130 CMR
			 409.418, to the MassHealth agency or its
			 designee, only when the DME is medically necessary and when prior authorization
			 is a prerequisite in accordance with
			 130 CMR
			 409.418, or required by MassHealth agency
			 guidance;
(M) not share a service
			 facility or physical location (including a consignment closet, unless permitted
			 by specific MassHealth guidance) with an ordering practitioner, or other
			 provider who is authorized to prescribe DME or with another supplier of DME,
			 except as permitted by
			 42
			 CFR 424.57(c) (Medicare
			 Supplier Standard 29);
(N) have a
			 complaint resolution protocol to promptly address members' complaints by
			 responding to any member complaints within two business days, 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
			 409.430(I). MassHealth may
			 request a copy of the provider's complaint log/records and may specify the time
			 period for the requested records in accordance with 130 CMR 409.426;
(O) provide MassHealth members and the
			 MassHealth agency with written notification at least 60 days in advance of any
			 change in the DME provider's scope of business or services (for example, if a
			 provider decides to no longer provide certain products, if the scope of the
			 provider's Medicare accreditation changes, or if a provider will be
			 disenrolling as a MassHealth provider. Notification to the member must include
(1) a statement that the member can contact
			 MassHealth Customer Service to request a list of DME providers in their area;
			 and
(2) if prior authorization is
			 required for the service
(a) the number of
			 non-billed units remaining on the PA; and
(b) a copy of the original PA approval from
			 MassHealth for the member to provide to the new DME provider;