Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.249 - Withholding of Payments

Current through Register 1525, July 5, 2024
(A)
Introduction
. The term "withholding of payments" or
			 "withholding payments" as used in 130 CMR 450.249 means the withholding of all
			 or a portion of payments payable to a provider. While withholding payments, the
			 MassHealth agency continues to process the provider's claims. To avoid
			 rejection of otherwise proper claims because of late submission, a provider
			 whose payments are being withheld must continue to submit timely
			 claims.
(B)
Withholding
			 Payments from Providers for Overpayments or Other Violations
. Upon
			 written notice to the provider, the MassHealth agency may withhold payments to
			 a provider, or any provider under common ownership (defined the same as
			 "provider under common ownership" in
			 130 CMR 450.101 ), if
			 the MassHealth agency believes that the provider has received any overpayments
			 or committed any violations. The notice states the effective date of the
			 withholding, the amount being withheld, and the reason for the withholding. A
			 provider subject to a withhold may submit written evidence for consideration by
			 the MassHealth agency as to why payments in whole or in part should not be
			 withheld. The withholding of payments expires 90 calendar days after the date
			 withholding begins unless the MassHealth agency has sent the provider an
			 overpayment or sanction notice pursuant to
			 130 CMR
			 450.237 or
			 450.240.
			 The withholding of payments continues until the entitlement to the withheld
			 funds and the amount of overpayment or administrative fines has been finally
			 adjudicated and all due amounts have been recovered.
(C)
Withholding Payments for
			 Credible Allegation of Fraud
. Upon written notice to the provider,
			 or without notice as provided for under
			 42 CFR
			 455.23(b), the MassHealth
			 agency may withhold payments to a provider, or to any provider under common
			 ownership (defined the same as "provider under common ownership" in
			 130 CMR 450.101 ),
			 where there is a credible allegation of fraud under
			 42 CFR
			 455.23. The notice complies with
			 42 CFR
			 455.23(b) and informs the
			 provider of the right to submit written evidence for consideration by the
			 MassHealth agency as to why payments in whole or in part should not be
			 withheld. The withholding of payments continues until such time as any
			 investigation and associated enforcement proceedings are completed, and all due
			 amounts have been recovered. If the Attorney General's Medicaid Fraud Division
			 or other law enforcement agency declines to accept any fraud referral, any
			 payments withheld under 130 CMR 450.249(C) are released and no further payments
			 are withheld, unless within ten business days of the MassHealth agency
			 receiving such notice from the Attorney General's Medicaid Fraud Division or
			 other law enforcement agency, the MassHealth agency sends written notice to the
			 provider in accordance with 130 CMR 450.249(B) that the MassHealth agency
			 believes that the provider has received any overpayments or committed any
			 violations.
(D)
Withholding Payments to Providers Withdrawing from
			 MassHealth
.
(1) The MassHealth
			 agency may withhold payments to a provider, or to any providers under common
			 ownership, at any time following receipt by the MassHealth agency of
			 notification of the provider's intention to close or to withdraw from
			 MassHealth. The MassHealth agency may withhold such payments whenever the
			 MassHealth agency reasonably believes that there may be an outstanding issue,
			 claim, or adjustment in connection with or incident to any payment to the
			 provider. Such payment may be withheld regardless of whether the outstanding
			 issue, claim, or adjustment is related to that payment. Circumstances in which
			 there may be an outstanding issue, claim, or adjustment include, without
			 limitation:
(a) an outstanding provider cost
			 report;
(b) an anticipated or
			 pending audit or utilization review;
(c) a rate decrease or other payment
			 adjustment; or
(d) an outstanding
			 or incomplete payment reconciliation.