Current through Register 1531, September 27, 2024
(A)
Applicability.
The provisions set forth in 130 CMR 450.211 establish the MassHealth agency's
review process for provider disputes concerning the Medicaid Electronic Health
Records Incentive Payment Program established pursuant to § 4201 of the
American Recovery and Reinvestment Act of 2009,
P.L.
111-5 and 42 CFR Part 495.
(B)
Medicaid Electronic Health
Records Incentive Payment Program Notice. The MassHealth agency
will notify the provider in writing of the agency's determination of the
provider's Medicaid Electronic Health Records Incentive Payment Program
eligibility and payment amount. The notice will identify the provider's
eligibility, determination of payment amount, and right to review. The
MassHealth agency will notify the provider by letter, report, computer
printout, electronic transmission, or other format. This notification is the
Medicaid Electronic Health Records Incentive Payment Program Notice referred to
in 130 CMR 450.211.
(C)
Requesting MassHealth Agency Review of Medicaid Electronic Health
Records Incentive Payment Program Determinations.
(1) To preserve its right to an adjudicatory
hearing and judicial review, a provider must request MassHealth agency review
of the agency's determination specified in the Medicaid Electronic Health
Records Incentive Payment Program Notice. A provider's request for review may
be based on either an alleged error in the MassHealth agency's determination of
the provider's Medicaid Electronic Health Records Incentive Payment Program
eligibility and payment amount or on information that was not initially
supplied during the application process. The provider's request for review must
be made in writing and be received by the MassHealth agency within 30 calendar
days of the date appearing on the Medicaid Electronic Health Records Incentive
Payment Program Notice. Only those determinations specifically identified in
dispute by the provider in its request for an agency review are subject to
review.
(2) A provider's request
for review may request reconsideration of the following findings:
(a) the provider's eligibility for incentive
payments; and
(b) incentive payment
amounts.
(3) Any request
for agency review submitted pursuant to 130 CMR 450.211(C)(1) must
(a) identify with specificity all
determinations with which the provider disagrees;
(b) specify in sufficient detail the basis
for the provider's disagreement with those determinations;
(c) identify and address all issues in the
Medicaid Electronic Health Records Incentive Payment Program Notice with which
the provider disagrees; and
(d)
include any documentary evidence and information that the provider 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 450.211(C)(1) through
(3). 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 Medicaid Electronic Health Records
Incentive Payment Program determinations 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) Any findings specified in the Medicaid
Electronic Health Records Incentive Payment Program 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. The provider has no right to an adjudicatory hearing pursuant to
130 CMR
450.241 or judicial review of such findings
because of the failure to exhaust its administrative remedies.
(3) If the provider does not submit a request
for agency review, the Medicaid Electronic Health Records Incentive Payment
Program Notice constitutes the MassHealth agency's final determination. If a
provider requests agency review but fails to timely comply with the
requirements of 130 CMR 450.211(C)(1) through (3), the request for agency
review may be denied. In either case, the Medicaid Electronic Health Records
Incentive Payment Program 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.
