Current through Register 1531, September 27, 2024
(1)
General Requirements. Acute Hospitals may submit
claims for Emergency Bad Debt as defined in 101 CMR 613.06(2). Acute Hospitals
and Community Health Centers may submit claims for Bad Debt for Urgent Care
Services as defined in 101 CMR 613.06(3) and (4). Providers may not submit a
claim for a deductible or coinsurance portion of a claim for which an insured
Patient or Low Income Patient is responsible. Providers may only submit claims
for the services described in
101 CMR 613.03(2)
through (4).
(a)
Required Collection
Action. Providers may submit claims for Bad Debt only after
required collection action, including the following.
1.
Collecting Patient
Information.
a.
Inpatient Services. An Acute Hospital must identify
the department responsible for obtaining the information from the Patient, and
make reasonable efforts to obtain the financial information necessary to
determine responsibility for payment of the Acute Hospital bill from the
Patient or Guarantor. If the Patient or Guarantor is unable to provide the
information needed, and the Patient consents, an Acute Hospital must make
reasonable efforts to contact the relatives, friends, and Guarantor and the
Patient for additional information while the Patient is in the Acute Hospital.
If an Acute Hospital has not obtained sufficient Patient financial information
to assess the ability of the Patient or the Guarantor to pay for services prior
to the date of discharge, the Acute Hospital must make reasonable efforts to
obtain the necessary information at the time of the Patient's
discharge.
b.
Emergency
Room, Outpatient Services, and Community Health Center Services. A
Provider must make reasonable efforts, as soon as reasonably possible, to
obtain the financial information necessary to determine responsibility for
payment of the bill from the Patient or Guarantor.
2.
Verification of
Patient-supplied Information.
a.
Inpatient. An Acute Hospital must make reasonable
efforts to verify the Patient-supplied information prior to the Patient
discharge. The verification may occur at any time during the provision of
services, at the time of the Patient discharge, or during the collection
process.
b.
Acute
Hospital Outpatient and Community Health Centers. A Provider must
make reasonable efforts to verify Patient-supplied information at the time the
Patient receives the services. The verification of Patient-supplied information
may occur at the time the Patient receives the services or during the
collection process.
3.
Reasonable Collection Efforts.
a. A Provider must make the same effort to
collect accounts for uninsured individuals as it does to collect accounts from
any other Patient classifications.
b. The minimum requirements before writing
off an account to the Health Safety Net include
i. an initial bill to the party responsible
for the Patient's personal financial obligations;
ii. subsequent billings, telephone calls,
collection letters, personal contact notices, computer notifications, and any
other notification method that constitutes a genuine effort to contact the
party responsible for the obligation;
iii. documentation of alternative efforts to
locate the party responsible for the obligation or the correct address on
billings returned by the postal office service as "incorrect address" or
"undeliverable";
iv. sending a
final notice by certified mail for balances over $1,000 where notices have not
been returned as "incorrect address" or "undeliverable"; and
v. documentation of continuous Collection
Action undertaken on a regular, frequent basis. When evaluating whether a
Provider has engaged in continuous Collection Action, the Health Safety Net
Office may use a gap in Collection Action of greater than 120 days as a
guideline for noncompliance, but may use its discretion when determining
whether a Provider has made a reasonable effort to meet the standard.
c. If, after reasonable attempts
to collect a bill, the debt for Emergency Services for an uninsured individual
remains unpaid after a period of 120 days of continuous Collection Action, the
bill may be deemed uncollectible and billed to the Health Safety Net
Office.
d. The Patient's file must
include all documentation of the Provider's collection effort including copies
of the bill(s), follow-up letters, reports of telephone and personal contact,
and any other effort made.
(b)
Reporting
Requirements.
1.
Claims Submission. Providers must submit claims in
accordance with the requirements of
101 CMR
613.07. Acute Hospitals must submit a claim
for each inpatient Bad Debt. Community Health Centers must submit a claim for
each Bad Debt.
2.
Additional Information. Providers must submit the
following additional information for Community Health Center and Acute Hospital
inpatient Bad Debt services in a form specified by the Health Safety Net
Office. For outpatient services, Acute Hospitals and Hospital-licensed Health
Centers must submit this information within 30 days of a request by the Health
Safety Net Office.
Patient Identifiers:
Name
Address
Phone#
DOB
SSN#
TCN
Med Record*
MassHealth# (RID and/or RHN)
Date of Service
Total Charge for Services
Net Charge submitted to Health Safety Net
Evidence of Reasonable Collection
Efforts:
Date of Initial Bill
Date of Second Bill
Date of Third Bill
Date of Fourth Bill
Date of Returned Mail
Date of Certified Letter for accounts over $1,000
Date of Initial Phone Contact
Date of Follow up Phone Contact
Dates of Other Efforts (other phone calls, letters to Patient,
attorney or referral to collection agency)
Date Account was submitted to Health Safety Net
Office
3. The Health Safety
Net Office may deny payment for any claim for which required documentation is
not submitted. If the Health Safety Net Office notifies a Provider that a claim
will be denied due to insufficient documentation, the Provider must submit the
required documentation within 30 days of the date of the notice that the claim
will be denied.
(2)
Acute Hospital Emergency Bad
Debt Claims. An Acute Hospital may submit a claim for Emergency
Bad Debt if
(a) the services were provided to
1. an uninsured individual who is not a Low
Income Patient, unless the individual is a Dental-only Low Income Patient, and
the Provider has verified through EVS that the individual has not submitted an
Application; or
2. an uninsured
individual whom the Acute Hospital assists in completing an Application and is
determined to be a Low Income Patient or determined into a category exempt from
collection action in accordance with
101 CMR
613.08(3). Bad Debt claims
for these individuals are exempt from the requirements of 101 CMR
613.06(2)(c);
(b) the
services provided were Emergency or Urgent Care Services;
(c) the Acute Hospital can document that it
has undertaken the required Collection Action as defined in 101 CMR
613.06(l)(a) for the account; and
(d) the bill remains unpaid after a period of
120 days of continuous Collection Action.
(3)
Hospital Licensed Health
Center Bad Debt. An Acute Hospital or a Hospital Licensed Health
Center may submit a claim for Bad Debt for Urgent Care Services if
(a) the services were provided at a Hospital
Licensed Health Center;
(b) the
services were provided to
1. an uninsured
individual who is not a Low Income Patient, unless the individual is a
Dental-only Low Income Patient. The Provider may not submit a claim for a
deductible or the coinsurance portion of a claim for which an insured Patient
is responsible. The Provider may not submit a claim unless it has checked EVS
to determine if the Patient has filed an Application; or
2. an uninsured individual whom the Provider
assists in completing an Application is determined into a category exempt from
Collection Action in accordance with 101 CMR 613.08(3). Bad Debt claims for
these individuals are exempt from the requirements of 101 CMR
613.06(3)(e);
(c) the
Provider provided Urgent Care Services as defined in 101 CMR 613.02 to the
Patient. A Provider may submit a claim for all Eligible Services provided
during the Urgent Care Services visit, including Ancillary Services provided on
site;
(d) the responsible
physician determined that the Patient required Urgent Care Services. A Provider
may submit a claim for Urgent Care Services, but not for other services
provided to Patients determined not to require Urgent Care Services;
(e) the Provider undertook the required
Collection Action as defined in 101 CMR 613.06(1)(a) and submitted the
information required in 101 CMR 613.06(1)(b) for the account; and
(f) the bill remains unpaid after a period
of 120 days of continuous Collection Action.
(4)
Community Health Center Bad
Debt. A Community Health Center may submit a claim for Bad Debt
for Urgent Care Services if
(a) the services
were provided to
1. an uninsured individual
who is not a Low Income Patient, unless the individual is a Dental-only Low
Income Patient. The Provider may not submit a claim for a deductible or the
coinsurance portion of a claim for which an insured Patient is responsible. The
Provider may not submit a claim unless it has checked EVS to determine if the
Patient has filed an application for MassHealth; or
2. an uninsured individual whom the Provider
assists in completing an Application is determined into a category exempt from
Collection Action in accordance with
101 CMR
613.08(3). Bad Debt claims
for these individuals are exempt from the requirements of 101 CMR
613.06(4)(d);
(b) the
Provider provided Urgent Care Services as defined in
101 CMR 613.02 to the
Patient. A Provider may submit a claim for all Eligible Services provided
during the Urgent Care Services visit, including Ancillary Services provided on
site;
(c) the responsible physician
determined that the Patient required Urgent Care Services. A Provider may
submit a claim for Urgent Care Services, but not for other services provided to
Patients determined not to require Urgent Care Services;
(d) the Provider undertook the required
Collection Action as defined in
101 CMR 613.06(1)(a)
and submitted the information required in
101 CMR 613.06(1)(b)
for the account; and
(e) the bill remains unpaid after a period of
120 days of continuous Collection Action.
(5)
Department of Revenue
Intercept. The Health Safety Net Office initiates a match with the
Massachusetts Department of Revenue for individuals for whom a Provider has
submitted a claim for Bad Debt. The Health Safety Net Office may request that
the Department of Revenue intercept payments to the individual up to an amount
equal to the amount paid to the Provider for the Services.