(A)
Provider Participation Requirements. Payment for
services described in 130 CMR 409.000 is made to DME providers who, as of the
date of service, are participating in MassHealth; to providers also enrolled as
MassHealth-participating OXY providers, orthotic services providers, or
prosthetic services providers and who meet all program-specific requirements;
and to MassHealth-enrolled pharmacy providers who have been assigned a DME
specialty in accordance with
130
CMR 409.404(C) as of the
date of service. Applicants must meet the requirements in 130 CMR 450.000:
Administrative and Billing Regulations as well as the
requirements in 130 CMR 409.000. Participating DME providers must continue to
meet provider eligibility participation requirements throughout the period of
their provider contract with the MassHealth agency.
(B)
General
Qualifications. To qualify as a MassHealth DME provider, all
applicants and providers must enter into a provider contract or agreement with
MassHealth, and:
(1) have a service facility
that
(a) is open a minimum of 30 hours per
week;
(b) is staffed with an
employee during posted business hours;
(c) is available to members during regular,
posted business hours;
(d) has
available inventory for all products for which the DME provider has been
accredited by an Accrediting Body, and for which the DME provider is enrolled
in MassHealth, with the exception of items provided by
subcontractors;
(e) is accessible
to all members, including members with disabilities;
(f) has clear access and space for
individualized ordering, returns, repair, and storing of business
records;
(g) has a sign visible
from outside the facility identifying the business name and hours that the
service facility is open. If the DME provider's place of business is located
within a building complex, the sign must be visible at the main entrance of the
building where the service facility is located;
(h) has a primary business telephone number
listed in the name of the business with a local toll-free telephone number that
is answered by customer service staff during business hours, and that has TTY
transmission and reception capability. During business hours, this number
cannot be a pager, answering service, or voice message system; and
(i) during off hours, must maintain a voice
message system and/or answering service;
(2) obtain separate approval from the
MassHealth agency and a separate provider number for each service facility
operated by the DME provider;
(3)
engage in the business of providing DME or DME repair services to the
public;
(4) be accredited by an
Accrediting Body to participate or enroll in the Medicare program as a DME
provider for the same business and service facility for which the applicant is
applying to become a MassHealth provider, unless the provider supplies only
items not covered by Medicare;
(5)
meet all applicable federal, state, and local requirements, certifications, and
registrations;
(6) conduct
applicable Office of Inspector General (OIG) verifications on all
staff;
(7) at the time of
application and recredentialing, or any other time as requested by the
MassHealth agency, provide all required documentation specified in 130 CMR
450.000:
Administrative and Billing Regulations, and updated
documentation in accordance with
130
CMR 450.223(B) and
130
CMR 450.215:
Provider Eligibility:
Notification of Potential Changes in Eligibility, including:
(a) a list of contracted manufacturers used
for purchased products;
(b) a copy
of all current liability insurance policies;
(c) a copy of the property lease agreement
pertinent to the service facility, or a copy of the most recent property tax
bill if applicant owns the business site; and
(d) for mobility providers only, a copy of
current RESNA ATP certificate for each certified staff member.
1. DME providers who furnish mobility systems
corresponding to one of the HCPCS codes for which CMS requires a certified ATP
must employ at least one certified ATP at each service facility.
2. The ATP at each service facility must
possess knowledge of the standards of acceptable practice in the provision of
DME, including ordering, assembling, adjusting, and delivering DME, and
providing ongoing support and services to meet a person's rehabilitation
equipment needs;
(e) a
copy of all current signed employee professional licenses, as
applicable;
(f) a copy of current
accreditation letters;
(g) a copy
of the purchase and sale agreement if the applicant or DME provider has
recently been purchased by another entity or has purchased the company for
which they are applying to become a MassHealth DME provider;
(h) a copy of subcontracts, if applicable, as
described in
130
CMR 409.412. For PERS providers, the
subcontract must include the central monitoring station contract, if
applicable;
(i) a copy of the
applicant's emergency preparedness plan as approved by the accrediting
body;
(j) a copy of written
policies and procedures, including the customer service protocol, customer
complaint tracking and resolution protocol, the protocol on transfer and
discharge of members, staff training; and
(k) for PERS providers only, a copy of
documentation demonstrating compliance with UL Standards 1637 in accordance
with 130 CMR
409.429(C);
(l) Controlled Substances Registrations
through the Commonwealth of Massachusetts Department of Public Health, Division
of Food and Drug (if provider provides oxygen);
(m) a Sterilization/Sanitation of Bedding,
Upholstered Furniture, and Filling Materials License through the Department of
Public Health, Division of Food and Drug (if applicable);
(8) for a provider of home infusion services,
be a licensed pharmacy in Massachusetts or in the state where the provider is
located, and be accredited by an Accrediting Body, and be assigned a DME
specialty by the MassHealth agency (see
130
CMR 409.404(C));
(9) conduct pre-employment CORI checks on
employees and subcontractors and keep CORIs on file at the DME provider's place
of business;
(10) not accept
prescriptions for MassHealth DME from any ordering practitioner who has a
financial interest in the DME provider;
(11) cooperate with the MassHealth agency or
its designee during the application and recredentialing process including, but
not limited to, site visits or periodic inspections to ensure compliance with
130 CMR 409.000 and applicable state and federal laws and regulations;
and
(12) comply with applicable CMS
provider requirements, including supplier standards listed at
42 CFR
424.57(c) and any CMS or
MassHealth quality standards.
(C)
Providers Assigned DME
Specialty. An applicant or provider enrolled as a MassHealth
provider of pharmacy services under 130 CMR 406.000: Pharmacy
Services may qualify to provide DME services if the following
conditions are met:
(1) the applicant or
provider meets all other conditions under
130
CMR 409.404 and 405 to provide DME services;
and
(2) MassHealth has assigned a
specialty of DME to the applicant's or provider's existing provider number for
pharmacy services; or
(3) the
MassHealth agency has determined that the applicant proposes to provide repairs
of DME and meets the MassHealth agency requirements for participation as a DME
repair provider.
(D)
In State. To qualify as an in-state DME provider, the
applicant or provider must have a service facility located in Massachusetts
that meets the criteria described in
130
CMR 409.404(B)(1).
(E)
Out of State. An
applicant or provider of DME with a service facility located outside of
Massachusetts may qualify as a MassHealth DME provider only if the following
condition is met:
(1) all applicable
requirements under 130 CMR 409.000 and 130 CMR 450.000: Administrative
and Billing Regulations, and
42 CFR
431.52 are met;
(2) the out-of-state DME provider
participates in the Medicaid program of the state in which the provider
primarily conducts business;
(3)
the DME provider participates in the Medicare program, unless the DME provider
provides only PERS or absorbent products;
(4) the provider has a service facility that
can readily replace and repair products when needed by the member;
and
(5) the MassHealth agency has
determined that the out-of-state applicant proposes to provide durable medical
equipment or supplies that meet a need identified by the MassHealth
agency.
