(A) To be eligible to participate in
MassHealth as any provider type, a provider must
(1) meet all statutory requirements
applicable to such provider type;
(2) meet all conditions of participation
applicable to such provider type under Titles XVIII and XIX of the Social
Security Act and regulations promulgated thereunder;
(3) meet all conditions of participation
applicable to such provider type. Program regulations applicable to specific
provider types appear in 130 CMR 400.000 through 499.000. This requirement does
not apply to providers participating pursuant to 130 CMR 450.212(D) and
(E);
(4) be fully licensed,
certified, or registered as an active practitioner by the agency or board
overseeing the specific provider type, and where the regulations define
"specialist" credentials or require other credentials, providers must possess
those credentials;
(5) be
registered with appropriate state and federal agencies to prescribe controlled
substances, for any provider type that is legally authorized to write
prescriptions for medications and biologicals;
(6) never have been subject and never have
had common parties in interest with any provider subject to any disciplinary
action, sanction, or other limitation or restriction of any nature imposed with
or without the consent of the provider, by any state or federal agency, or
board, including MassHealth or any other state's Medicaid program. These
include, but are not limited to, revocation, suspension, termination,
reprimand, censure, admonishment, fine, probation agreement, agreements not to
practice or other practice limitation, practice monitoring, or remedial
training or other educational or public service activities;
(7) not have purchased or otherwise obtained
its practice or business entity from any provider suspended or terminated from
MassHealth participation due to violations of applicable laws, rules, or
regulations; or from a provider that is currently subject to a withholding of
payments for a credible allegation of fraud under
130 CMR
450.249 or who terminates or has its
participation terminated while subject to such a withholding of
payments;
(8) cooperate with the
MassHealth agency during any application, revalidation of enrollment, or other
review process, which may include, but not be limited to, permitting and
facilitating site visits, as determined by the MassHealth agency. In addition,
applicants and providers must, within 30 days upon request from CMS or the
MassHealth agency, complete any requisite forms authorizing a criminal offender
record check and ensure that the applicant or provider, or any person with a 5%
or more direct or indirect ownership interest (as defined under
130 CMR
450.221) in the applicant or provider,
submits a set of fingerprints in a form and manner determined by the MassHealth
agency. Such applicants, providers, or persons may be required to pay costs
associated with fingerprinting;
(9)
not be subject to a moratorium on enrollment imposed in accordance with
42 CFR
455.470; and
(10) if the provider is a group practice,
ensure that all individual practitioners in the group who provide services to
MassHealth members and for whom the group practice bills MassHealth obtain an
individual MassHealth provider number by completing a fully participating
application, and meet all the requirements of 130 CMR 450.212(A)(1) through
(9). Such practitioners may not enroll as nonbilling providers under 130 CMR
450.212(E). In addition, for a group practice to participate in MassHealth, it
must file a group practice provider application with the MassHealth agency, and
meet all of the following requirements.
(a)
It must be a recognized legal entity (for example, partnership, corporation, or
trust). A sole proprietorship may not be a group practice.
(b) It must satisfy at least one of the
following:
1. all of the beneficial interest
in the group practice must be held by individual practitioners who are members
of the group practice serviced by the group practice; or
2. all members of the group practice must be
employees or contractors of the group practice.
(c) It must not be currently or have
previously been suspended from MassHealth participation due to violations of
applicable laws, rules, or regulations or have common parties in interest with
any provider that is currently under suspension or has been
suspended.
(B) A provider who does not meet the
requirements of 130 CMR 450.212(A)(6) through (9) or (10)(c) may, at the
MassHealth agency's discretion, participate in MassHealth only if, in the
judgment of the MassHealth agency, such participation would neither
(1) threaten the health, welfare, or safety
of members; nor
(2) compromise the
integrity of MassHealth.
(C) A provider who does not meet the
requirements of 130 CMR 450.212(A) is not entitled to a hearing on the issue of
eligibility.
(D) A Qualified
Medicare Beneficiaries (QMB)-only provider is a provider who provides medical
services only to MassHealth Senior Buy-In members described in
130 CMR
519.010: MassHealth Senior
Buy-In and
130 CMR
505.007: MassHealth Senior Buy-In and
Buy-In and certain MassHealth Standard members who are eligible for
QMB benefits described in
130 CMR 519.002(A)(4)(c)
and
130 CMR
505.002(O): Medicare
Premium Payment. QMB-only providers are subject to all regulations
pertaining to providers participating in MassHealth except as provided below or
as otherwise specified in 130 CMR 450.000. QMB-only providers may bill only for
medical services for QMB members and Standard members eligible for QMB
benefits, whether or not the associated medical services are specified in 130
CMR 400.000 through 499.000.
(E) A
non-billing provider is an individual provider who enrolls with MassHealth
because his or her information (e.g., National Provider
Identifier (NPI)) is required on a claim submitted by a billing provider to
MassHealth pursuant to state or federal statute, regulation, billing
instruction or other subregulatory guidance or is included on a claim because
of a billing provider's own billing procedures, or is otherwise required or
permitted by state or federal law to enroll with MassHealth for a limited
purpose. A nonbilling provider must include his or her individual NPI on all
orders, referrals, and prescriptions for services to MassHealth members, and
must provide his or her individual NPI to a billing provider upon request in
other circumstances in which the billing provider must include the nonbilling
provider's NPI on MassHealth claims. See also
130 CMR
450.231(F).
(1) Nonbilling providers may enroll through a
streamlined application process determined by the MassHealth agency.
(2) Nonbilling providers may not submit
claims to or receive payments from the MassHealth agency.
(3) Nonbilling providers are not subject to
certain provisions of the provider regulations relating to payments and claims
processing. However, nonbilling providers are subject to all other applicable
regulations pertaining to MassHealth billing providers including, but not
limited to, those relating to ordering, prescribing, referring, screening,
prior authorization, medical necessity, utilization management and
recordkeeping and disclosure with respect to services ordered, referred,
prescribed or provided to MassHealth members.
(4) An individual who provides services to
MassHealth members as part of a group practice, which bills on behalf of the
individual, must enroll as a fully participating provider and may not enroll as
a nonbilling provider under 130 CMR 450.212(E).
(F) All individual practitioners comprising
the group and the group practice entity are jointly and severally liable for
any overpayments owed and are subject to sanctions imposed as a result of any
violation of any statute or regulation committed by the individual practitioner
that provided the service.
