Current through Register 1531, September 27, 2024
(A)
Applicability.
The provisions set forth in 130 CMR 450.210 establish the MassHealth agency's
review process for provider disputes concerning MassHealth pay-for-performance
payment amounts for acute hospitals, MCOs, SCOs, ICOs, and the behavioral
health contractor. For purposes of 130 CMR 450.210, "pay for performance" means
a value-based purchasing program implemented by the MassHealth agency to pay
providers to perform activities related to improving the quality of care
delivered to MassHealth members.
(B)
MassHealth
Pay-for-performance Payment Notice. The MassHealth agency will
notify the provider in writing of the agency's determination of the provider's
pay-for-performance payment amount for the time period specified in the notice.
The notice will identify the aggregate pay-for-performance payment amount
calculated for the provider, and may separately identify the amount calculated
for components of such payment amount. The MassHealth agency will notify the
provider by letter, report, computer printout, electronic transmission, or
other format; this notification is the "MassHealth Pay-for-performance Payment
Notice" referred to in 130 CMR 450.210.
(C)
Requesting MassHealth Agency
Review of Pay-for-performance Amounts.
(1) To preserve its right to an adjudicatory
hearing and judicial review, a provider must request MassHealth agency review
of the provider's pay-for-performance payment amounts specified in the
MassHealth Pay-for-performance Payment Notice. The request for agency review
must be made in writing and be received by the MassHealth agency within 30
calendar days of the date appearing on the MassHealth Pay-for-performance
Payment Notice. Only those payment amounts specifically identified as in
dispute by the provider in its request for agency review are subject to
review.
(2) Any request for agency
review submitted pursuant to 130 CMR 450.210(C)(1) must
(a) identify with specificity all payment
amounts and components of such payment amounts in dispute;
(b) specify in sufficient detail the basis of
the provider's disagreement with those amounts as calculated;
(c) identify and address all issues in the
MassHealth Pay-for-performance Payment Notice with which the provider
disagrees; and
(d) include any
documentary evidence and information it wants the MassHealth agency to
consider.
(D)
MassHealth Agency's Final Determination.
(1) The MassHealth agency will review a
provider's request for agency review only if it is submitted in compliance with
the requirements of 130 CMR 450.210(C)(1) and (2). The MassHealth agency is not
obligated to consider any information or documents that the provider failed to
timely submit under time deadlines previously imposed by the MassHealth agency.
The MassHealth agency will issue a final written determination of contested
payment amounts based on its review, which will state the reasons for the
determination, and inform the provider of the provider's right to file a claim
for an adjudicatory hearing in accordance with
130 CMR
450.241.
(2) Payment amounts and components of payment
amounts specified in the MassHealth Pay-for-performance Payment Notice that are
not specifically identified as in dispute in a provider's request for agency
review will, without further notice, constitute the MassHealth agency's final
determination of those amounts. The provider has no right to an adjudicatory
hearing pursuant to
130 CMR
450.241 or judicial review of such amounts
because of the failure to exhaust its administrative remedies.
(3) If the provider does not submit a request
for agency review, the MassHealth Pay-forperformance Payment Notice constitutes
the MassHealth agency's final determination of the provider's
pay-for-performance payment amounts. If a provider requests agency review but
fails to timely comply with the requirements of
130 CMR
450.210 (C)(1) and (2), the request for
agency review may be denied. In either case, the MassHealth Pay-for-performance
Payment Notice constitutes the MassHealth agency's final determination, and the
provider has no right to an adjudicatory hearing pursuant to
130 CMR
450.241 or judicial review because of the
failure to exhaust its administrative remedies.
