(A) If the provider applicant has filed a
complete and properly executed application and meets all applicable provider
eligibility criteria and nothing in the application or any other information in
the possession of the MassHealth agency reveals any bar or hindrance to the
participation of the provider applicant, the MassHealth agency will prepare and
furnish a provider contract. When fully executed by the provider and the
MassHealth agency, the contract will take effect as of the date determined by
the MassHealth agency.
(B) Each
MassHealth provider must notify the MassHealth agency in writing within 14 days
of any change in any of the information submitted in the application. Failure
to do so constitutes a breach of the provider contract. In no event may a group
practice file a claim for services provided by an individual practitioner until
the individual practitioner is enrolled and approved by the MassHealth agency
as a member of the group. At its discretion, the MassHealth agency may require
a provider to recertify, at reasonable intervals, the continued accuracy and
completeness of the information contained in the provider's application.
Failure to complete such recertification upon request by the MassHealth agency
may result in termination of the provider contract.
(C) The following provisions are a part of
every provider contract whether or not they are included verbatim or
specifically incorporated by reference. By executing any such contract, the
provider agrees
(1) to comply with all laws,
rules, and regulations governing MassHealth (see M.G.L. c.
118E, §36);
(2) that the
submission of any claim by or on behalf of the provider constitutes a
certification (whether or not such certification is reproduced on the claim
form) that
(a) the medical services for which
payment is claimed were provided in accordance with
130 CMR 450.301;
(b) the medical services for which payment is
claimed were actually provided to the person identified as the member at the
time and in the manner stated;
(c)
the payment claimed does not exceed the maximum amount payable in accordance
with the applicable fees and rates or amounts established under a provider
contract or regulations applicable to MassHealth payment;
(d) the payment claimed will be accepted as
full payment for the medical services for which payment is claimed, except to
the extent that the regulations specifically require or permit contribution or
supplementation by the member;
(e)
the information submitted in, with, or in support of the claim is true,
accurate, and complete; and
(f) the
medical services were provided in compliance with Title VI of the Civil Rights
Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age
Discrimination Act of 1975;
(3) to keep for such period as may be
required by
130 CMR
450.205 such records as are necessary to
disclose fully the extent and medical necessity of services provided to or
prescribed for members and on request to provide the MassHealth agency or the
Attorney General's Medicaid Fraud Division with such information and any other
information regarding payments claimed by the provider for providing services
(see
42 U.S.C.
1396a(a)(27) and the
regulations thereunder);
(4) that
the contract may be terminated by the MassHealth agency if the provider fails
or ceases to satisfy all applicable criteria for eligibility as a participating
provider;
(5) to submit, within 35
days after the date of a request by the Secretary or the MassHealth agency,
full and complete information about:
(a) the
ownership of any subcontractor with whom the provider has had business
transactions totaling more than $25,000 during the 12-month period ending on
the date of the request;
(b) any
significant business transactions between the provider and any wholly owned
supplier, or between the provider and any subcontractor, during the five-year
period ending on the date of the request; and
(c) any information necessary to update fully
and accurately any information that the provider has previously delivered to
the MassHealth agency or to the Massachusetts Department of Public
Health;
(6) that the
MassHealth agency may recoup any sums payable by reason of a retroactive rate
increase for any period during which the provider owned or operated part or all
of a facility against any sums due the MassHealth agency by reason of a
retroactive rate decrease for any periods;
(7) to comply with all federal requirements
for employee education about false claims laws under
42 U.S.C.
1396a(a)(68) if the provider
is an entity that received or made at least $5 million in Medicaid payments
during the prior federal fiscal year;
(8) to furnish to the MassHealth agency its
national provider identifier (NPI), if eligible for an NPI, and include its NPI
on all claims submitted under MassHealth; and
(9) to permit the Centers for Medicare &
Medicaid Services (CMS) and the MassHealth agency, and their agents and
designated contractors to conduct unannounced on-site inspections of any and
all provider locations.
(D) The provider must terminate a provider
contract only by written notice to the MassHealth agency and such termination
will be effective no earlier than 30 days after the date on which the
MassHealth agency actually receives such notice, unless the MassHealth agency
explicitly specifies or agrees to an earlier effective date. Any provision
allowing for termination upon written notice does not constitute the MassHealth
agency's specification of or agreement to an earlier effective date.
