Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.240 - Sanctions: Determination

Current through Register 1525, July 5, 2024
(A)
Sanction Notice
. When the MassHealth agency believes
			 that sanctions should be imposed, the MassHealth agency will notify the
			 provider in writing of the alleged violations and the proposed sanctions. The
			 notice will be sufficiently detailed to reasonably inform the provider of the
			 acts that the MassHealth agency alleges constitute such violations.
(B)
Suspension, Termination, or
			 Provider Service Restrictions upon Sanction Notice
. 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
			 restrictions, participation without such restrictions, during the pendency of
			 the administrative process could reasonably be expected to endanger the health,
			 safety, or welfare of its members or compromise the integrity of MassHealth, it
			 may suspend or terminate the provider's MassHealth participation or impose
			 service restrictions on the provider at the same time the sanction notice
			 described in
			 130 CMR 450.240(A)
			  is sent to the provider. Said suspension,
			 termination, or provider service restriction will remain in effect until either
			 the MassHealth agency, pursuant to
			 130 CMR
			 450.240(D), issues a final
			 determination removing or revising said suspension, termination, or provider
			 service restriction, or the Medicaid Director, pursuant to
			 130 CMR
			 450.248, issues a final agency decision
			 removing or revising said suspension, termination, or provider service
			 restriction.
(C)
Timely
			 Reply
. To preserve its right to an adjudicatory hearing and
			 judicial review, the provider must reply in writing to the MassHealth agency
			 and such reply must be received by the MassHealth agency within 30 calendar
			 days of the date on the sanction notice. The reply must specifically identify
			 and address all allegations in the sanction notice with which the provider
			 disagrees and explain any objections to the proposed sanctions. The provider
			 must also include any additional documentary evidence it wants the MassHealth
			 agency to consider.
(D)
Sanction Determination
. The MassHealth agency will
			 consider and review only information submitted with a timely reply. If, after
			 reviewing the provider's reply, the MassHealth agency determines that sanctions
			 should be imposed because the provider has committed one or more violations of
			 any rule, regulation, standard, or law governing MassHealth, the MassHealth
			 agency will notify the provider in writing of its final determination, which
			 will state any sanctions that the MassHealth agency will impose against the
			 provider.
(E)
Adjudicatory Hearing
. If the provider submits a timely
			 reply, the provider may claim an adjudicatory hearing to appeal the MassHealth
			 agency's final determination, in accordance with
			 130 CMR
			 450.241 and
			 450.243.
			 The MassHealth agency may amend or supplement the sanction notice at any time
			 before the commencement of an adjudicatory hearing as long as any additional
			 findings have been identified in a notice or amended notice. Once an
			 adjudicatory hearing has commenced, the hearing officer may permit amendment of
			 the sanction determination upon proper motion by the MassHealth agency and will
			 permit amendment, where necessary, to conform the sanction determination to the
			 evidence.
(F)
Consequences of Failure to Submit a Timely Reply
. The
			 provider has no right to an adjudicatory hearing or judical review if it fails
			 to submit a timely reply. The MassHealth agency will take appropriate action to
			 implement the proposed sanctions.