Current through Register 1531, September 27, 2024
(1)
General. Each Provider must file or make available
information that the Health Safety Net Office deems necessary to verify that a
service for which a Provider submits a claim is an Eligible Service.
(a) The Health Safety Net Office may revise
the data specifications, the data collection scheduled, or other administrative
requirements by administrative bulletin.
(b) Providers must maintain records
sufficient to document compliance with all screening and documentation
requirements of
101 CMR 613.00. Providers
must maintain records documenting claims for Reimbursable Health Services to
Low Income Patients, Bad Debt for Emergency or Urgent Care services, and
Medical Hardship.
(c) The Health
Safety Net Office may deny payment for claims by any Provider that fails to
comply with the reporting requirements of
101 CMR 613.00 or
614.00: Health
Safety Net Payments and Funding until such Provider complies with the
requirements. The Health Safety Net Office will notify such Provider of its
intention to withhold payment.
(2)
Medical, Dental and
Professional Claims Submission Deadlines. The Health Safety Net
pays only for claims that are submitted within the time frames listed in 101
CMR 613.07(2)(a) through (f).
(a) Unless
otherwise specified in 101 CMR 613.07(2)(b) through (f), claims must be
submitted within 90 days of the date of service. If a service is provided
continuously on consecutive dates, the date from which the 90-day deadline is
measured is the latest date of service.
(b) If the Health Safety Net is the primary
payer, and Low Income Patient status is determined after services are provided,
claims must be submitted within 90 days of Low Income Patient determination. A
waiver may be requested if the Patient was determined to be a Low Income
Patient after services are provided, and the claim cannot be submitted within
90 days of service.
(c) For claims
that are not submitted within the 90-day period but that meet one of the
exceptions specified in 101 CMR 613.07(2)(c)1. through 3., a Provider must
request a waiver of the billing deadline pursuant to the billing instructions
provided by the MassHealth Agency. The exceptions are as follows.
1. A medical service was provided to a person
who was not a Low Income Patient on the date of service, but was later
determined to be a Low Income Patient for a period that includes the date of
service.
2. A medical service was
provided to a Patient who failed to inform the Provider in a timely fashion of
the member's eligibility for MassHealth or status as a Low Income
Patient.
3. A medical service was
provided to a Patient with health insurance and the Provider delayed submission
of the claim in order to bill the Patient's insurer. Claims must be submitted
by the later of 90 days of the date of service or 90 days after the date of the
primary insurer's explanation of benefits, but no later than 18 months after
the date of service.
(e)
Claims for Emergency or Urgent Care Bad Debt may be written off by the Provider
no earlier than 120 days after services are provided. Such claims must be
submitted within 90 days after the date on which the claim is written off as
uncollectible.
(f) Claims related
to Medical Hardship must be submitted to the Health Safety Net Office by the
deadline specified in
101 CMR
613.05(6).
(3)
Final Deadline for
Submission of Claims.
(a) If the
Health Safety Net Office has denied a claim that was initially submitted within
the 90-day deadline, the Provider may resubmit the claim with appropriate
corrections or supporting information.
(b) The Health Safety Net does not pay any
claim submitted or resubmitted for services provided more than 12 months before
the date of submission or resubmission, except as provided in 101 CMR
613.07(2).
(4)
Pharmacy Billing Deadlines. Pharmacy claims must be
submitted to POPS by the later of 90 days after services are provided or 90
days after the date of the primary insurer's explanation of benefits.
(5)
Other Acute Hospital Claim
Requirements.
(a) Each Acute
Hospital claim must contain a site-specific identification number as assigned
by the Health Safety Net Office. The Health Safety Net Office assigns
individual identification numbers to each Acute Hospital, Hospital Licensed
Health Center, Satellite Clinic, and school-based health center that provides
Eligible Services.
(b) The Health
Safety Net Office may require Acute Hospitals to submit interim data on
revenues and costs to monitor compliance with federal upper payment limits and
Safety Net Care pool payment limits, including cost limits. Such data may
include, but not be limited to, gross and net patient service revenue for
Medicaid non-managed care, Medicaid managed care, and all payers combined; and
total Patient service expenses for all payers combined.
(6)
Other Community Health
Centers Claim Requirements.
(a)
Each Community Health Center must submit claims to the Health Safety Net Office
according to the requirements of
101 CMR 613.00 and
614.00: Health
Safety Net Payments and Funding and the data specification
requirements of the Office.
(b)
Each Community Health Center must, upon request, provide the Health Safety Net
Office with Patient account records and related reports as set forth in
101 CMR
613.03(1)(b).
(7)
Audits. The Health Safety Net Office or its agent may
audit claims and may adjust claims that are not in compliance with the
provisions of
101 CMR 613.00.
(a) The Health Safety Net Office may adjust
claims for services covered by MassHealth, another program of public
assistance, or other Health Insurance Plan in which the Patient is enrolled, or
may adjust claims for services that do not meet the criteria for Eligible
Services including claims for Reimbursable Health Services to Low Income
Patients, Bad Debt, or Medical Hardship.
(b) The Health Safety Net Office may adjust
claims for which the Provider cannot provide documentation required by
101 CMR 613.00 or
614.00: Health
Safety Net Payments and Funding.
(c) The Health Safety Net Office may adjust
payments using a methodology to appropriately extrapolate the audit results of
a representative sample of accounts.
(d)
1.
Notification. The Health Safety Net Office will notify
the Provider of its proposed audit adjustments. The notification will be in
writing and will contain a complete listing of all proposed adjustments.
2.
Objection
Process.
a. A Provider may file
a written objection to a proposed audit adjustment within 15 business days of
the mailing of the notification letter.
b. The written objection must, at a minimum,
contain
i. each adjustment to which the
Provider is objecting;
ii. the
Fiscal Year for each disputed adjustment;
iii. the specific reason for each objection;
and
iv. all documentation that
supports the Provider's position.
c. Upon review of the Provider's objections,
the Health Safety Net Office will notify the Provider of its determination in
writing. If the Health Safety Net Office disagrees with the Provider's
objections, in whole or in part, the Health Safety Net Office will provide the
Provider with an explanation of its reasoning.
d. The Provider may request a conference on
objections after receiving the Health Safety Net Office's explanation of
reasons. The Health Safety Net Office will schedule such conference on
objections if it determines that further articulation of the Provider's
position would promote resolution of the disputed adjustments.
(8)
Grievances. A Provider must provide any information or
documentation requested by the Health Safety Net Office related to a grievance
request filed in accordance with
101 CMR
613.04(5) within 30 days of
the request from the Office.