Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.223 - Provider Contract: Execution of Contract

Current through Register 1525, July 5, 2024
(A) If the provider applicant has filed a
			 complete and properly executed application and meets all applicable provider
			 eligibility criteria and nothing in the application or any other information in
			 the possession of the MassHealth agency reveals any bar or hindrance to the
			 participation of the provider applicant, the MassHealth agency will prepare and
			 furnish a provider contract. When fully executed by the provider and the
			 MassHealth agency, the contract will take effect as of the date determined by
			 the MassHealth agency.
(B) Each
			 MassHealth provider must notify the MassHealth agency in writing within 14 days
			 of any change in any of the information submitted in the application. Failure
			 to do so constitutes a breach of the provider contract. In no event may a group
			 practice file a claim for services provided by an individual practitioner until
			 the individual practitioner is enrolled and approved by the MassHealth agency
			 as a member of the group. At its discretion, the MassHealth agency may require
			 a provider to recertify, at reasonable intervals, the continued accuracy and
			 completeness of the information contained in the provider's application.
			 Failure to complete such recertification upon request by the MassHealth agency
			 may result in termination of the provider contract.
(C) The following provisions are a part of
			 every provider contract whether or not they are included verbatim or
			 specifically incorporated by reference. By executing any such contract, the
			 provider agrees
(1) to comply with all laws,
			 rules, and regulations governing MassHealth
(see
M.G.L. c.
			 118E, §36);
(2) that the
			 submission of any claim by or on behalf of the provider constitutes a
			 certification (whether or not such certification is reproduced on the claim
			 form) that
(a) the medical services for which
			 payment is claimed were provided in accordance with
			 130 CMR 450.301;
(b) the medical services for which payment is
			 claimed were actually provided to the person identified as the member at the
			 time and in the manner stated;
(c)
			 the payment claimed does not exceed the maximum amount payable in accordance
			 with the applicable fees and rates or amounts established under a provider
			 contract or regulations applicable to MassHealth payment;
(d) the payment claimed will be accepted as
			 full payment for the medical services for which payment is claimed, except to
			 the extent that the regulations specifically require or permit contribution or
			 supplementation by the member;
(e)
			 the information submitted in, with, or in support of the claim is true,
			 accurate, and complete; and
(f) the
			 medical services were provided in compliance with Title VI of the Civil Rights
			 Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age
			 Discrimination Act of 1975;
(3) to keep for such period as may be
			 required by
			 130 CMR
			 450.205 such records as are necessary to
			 disclose fully the extent and medical necessity of services provided to or
			 prescribed for members and on request to provide the MassHealth agency or the
			 Attorney General's Medicaid Fraud Division with such information and any other
			 information regarding payments claimed by the provider for providing services
(see
42 U.S.C.
			 1396a(a)(27) and the
			 regulations thereunder);
(4) that
			 the contract may be terminated by the MassHealth agency if the provider fails
			 or ceases to satisfy all applicable criteria for eligibility as a participating
			 provider;
(5) to submit, within 35
			 days after the date of a request by the Secretary or the MassHealth agency,
			 full and complete information about:
(a) the
			 ownership of any subcontractor with whom the provider has had business
			 transactions totaling more than $25,000 during the 12-month period ending on
			 the date of the request;
(b) any
			 significant business transactions between the provider and any wholly owned
			 supplier, or between the provider and any subcontractor, during the five-year
			 period ending on the date of the request; and
(c) any information necessary to update fully
			 and accurately any information that the provider has previously delivered to
			 the MassHealth agency or to the Massachusetts Department of Public
			 Health;
(6) that the
			 MassHealth agency may recoup any sums payable by reason of a retroactive rate
			 increase for any period during which the provider owned or operated part or all
			 of a facility against any sums due the MassHealth agency by reason of a
			 retroactive rate decrease for any periods;
(7) to comply with all federal requirements
			 for employee education about false claims laws under
			 42 U.S.C.
			 1396a(a)(68) if the provider
			 is an entity that received or made at least $5 million in Medicaid payments
			 during the prior federal fiscal year;
(8) to furnish to the MassHealth agency its
			 national provider identifier (NPI), if eligible for an NPI, and include its NPI
			 on all claims submitted under MassHealth; and
(9) to permit the Centers for Medicare &
			 Medicaid Services (CMS) and the MassHealth agency, and their agents and
			 designated contractors to conduct unannounced on-site inspections of any and
			 all provider locations.