Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.212 - Provider Eligibility: Eligibility Criteria

Current through Register 1525, July 5, 2024
(A) To be eligible to participate in
			 MassHealth as any provider type, a provider must
(1) meet all statutory requirements
			 applicable to such provider type;
(2) meet all conditions of participation
			 applicable to such provider type under Titles XVIII and XIX of the Social
			 Security Act and regulations promulgated thereunder;
(3) meet all conditions of participation
			 applicable to such provider type. Program regulations applicable to specific
			 provider types appear in 130 CMR 400.000 through 499.000. This requirement does
			 not apply to providers participating pursuant to 130 CMR 450.212(D) and
			 (E);
(4) be fully licensed,
			 certified, or registered as an active practitioner by the agency or board
			 overseeing the specific provider type, and where the regulations define
			 "specialist" credentials or require other credentials, providers must possess
			 those credentials;
(5) be
			 registered with appropriate state and federal agencies to prescribe controlled
			 substances, for any provider type that is legally authorized to write
			 prescriptions for medications and biologicals;
(6) never have been subject and never have
			 had common parties in interest with any provider subject to any disciplinary
			 action, sanction, or other limitation or restriction of any nature imposed with
			 or without the consent of the provider, by any state or federal agency, or
			 board, including MassHealth or any other state's Medicaid program. These
			 include, but are not limited to, revocation, suspension, termination,
			 reprimand, censure, admonishment, fine, probation agreement, agreements not to
			 practice or other practice limitation, practice monitoring, or remedial
			 training or other educational or public service activities;
(7) not have purchased or otherwise obtained
			 its practice or business entity from any provider suspended or terminated from
			 MassHealth participation due to violations of applicable laws, rules, or
			 regulations; or from a provider that is currently subject to a withholding of
			 payments for a credible allegation of fraud under
			 130 CMR
			 450.249 or who terminates or has its
			 participation terminated while subject to such a withholding of
			 payments;
(8) cooperate with the
			 MassHealth agency during any application, revalidation of enrollment, or other
			 review process, which may include, but not be limited to, permitting and
			 facilitating site visits, as determined by the MassHealth agency. In addition,
			 applicants and providers must, within 30 days upon request from CMS or the
			 MassHealth agency, complete any requisite forms authorizing a criminal offender
			 record check and ensure that the applicant or provider, or any person with a 5%
			 or more direct or indirect ownership interest (as defined under
			 130 CMR
			 450.221 ) in the applicant or provider,
			 submits a set of fingerprints in a form and manner determined by the MassHealth
			 agency. Such applicants, providers, or persons may be required to pay costs
			 associated with fingerprinting;
(9)
			 not be subject to a moratorium on enrollment imposed in accordance with
			 42 CFR
			 455.470; and
(10) if the provider is a group practice,
			 ensure that all individual practitioners in the group who provide services to
			 MassHealth members and for whom the group practice bills MassHealth obtain an
			 individual MassHealth provider number by completing a fully participating
			 application, and meet all the requirements of 130 CMR 450.212(A)(1) through
			 (9). Such practitioners may not enroll as nonbilling providers under 130 CMR
			 450.212(E). In addition, for a group practice to participate in MassHealth, it
			 must file a group practice provider application with the MassHealth agency, and
			 meet all of the following requirements.
(a)
			 It must be a recognized legal entity (for example, partnership, corporation, or
			 trust). A sole proprietorship may not be a group practice.
(b) It must satisfy at least one of the
			 following:
1. all of the beneficial interest
			 in the group practice must be held by individual practitioners who are members
			 of the group practice serviced by the group practice; or
2. all members of the group practice must be
			 employees or contractors of the group practice.
(c) It must not be currently or have
			 previously been suspended from MassHealth participation due to violations of
			 applicable laws, rules, or regulations or have common parties in interest with
			 any provider that is currently under suspension or has been
			 suspended.