Transcription of Commonwealth of Massachusetts
1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page i All Provider Manuals Transmittal Letter ALL-XXX220 Date TBD06/16/17 1. Introduction : 1-1 : Purpose of 130 CMR through .. 1-5 : Promulgation of Regulations .. 1-5 (130 CMR Reserved) : Coverage Types .. 1-6 : Emergency Aid to the Elderly, Disabled and Children Program .. 1-15 : Eligible Members and the MassHealth Card .. 1-16 : Selective Contracting .. 1-17 : Out-of-state Services .. 1-17 : Hospital-determined Presumptive Eligibility .. 1-17 (130 CMR Reserved) : Advance Directives.
2 1-19 (130 CMR through Reserved) : Managed Care Participation .. 1-21 : Primary Care Clinician (PCC) Plan .. 1-24 : Primary Care Accountable Care Organizations (ACOs) .. 1-24 (130 CMR through Reserved) : Managed Care Compliance with Mental Health Parity .. 1-29 : Behavioral Health Services .. 1-29 (130 CMR through Reserved) : Copayments Required by the MassHealth Agency .. 1-30 (130 CMR through Reserved) : Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction .. 1-33 : EPSDT Services: Definitions .. 1-33 : EPSDT Services: Medical Protocol and Periodicity Schedule and Dental Protocol and Periodicity Schedule.
3 1-34 : EPSDT Services: Description of Medical Protocol and Periodicity Schedule Visits (EPSDT Visits) .. 1-35 : EPSDT Services: Diagnosis and Treatment .. 1-36 : EPSDT Services: Claims for Visits .. 1-37 : EPSDT Services: Claims for Laboratory Services, Audiometric Hearing Tests, Vision Tests, and Behavioral Health Screening (Physician, Independent Nurse Practitioner, Independent Nurse Midwife, and Community Health Center Providers Only) .. 1-38 (130 CMR Reserved) : EPSDT Services: Payment for Transportation .. 1-39 : EPSDT Services: Recordkeeping Requirements.
4 1-39 : Preventive Pediatric Health-care Screening and Diagnosis (PPHSD) Services for Certain MassHealth Members .. 1-39 (130 CMR through Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page ii All Provider Manuals Transmittal Letter ALL-220 Date 06/16/17 2. Administrative Regulations : Conflict between Regulations and Contracts .. 2-1 : Choice of Provider .. 2-1 : Nondiscrimination .. 2-1 : Payment in Full .. 2-2 : Medical Necessity .. 2-2 : Recordkeeping and Disclosure .. 2-3 : Determination of Compliance with Medical Standards.
5 2-5 : Utilization Management Program for Acute Inpatient 2-5 : Utilization Management: Admission Screening for Acute Inpatient Hospitals .. 2-6 : Utilization Management: Prepayment Review for Acute Inpatient Hospitals .. 2-7 : Pay-for-performance Payments: MassHealth Agency 2-9 : Medicaid Electronic Health Records Incentive Payment Program: Reconsideration and Appeals Process .. 2-11 : Provider Eligibility: Eligibility Criteria .. 2-12 : Provider Eligibility: Termination of Participation for Ineligibility .. 2-14 : Provider Eligibility: Suspension of Participation Pursuant to United States Department of Health and Human Services Order.
6 2-14 : Provider Eligibility: Notification of Potential Changes in Eligibility .. 2-15 : Provider Eligibility: Limitations on Participation .. 2-15 : Provider Eligibility: Ineligibility of Suspended Providers .. 2-16 (130 CMR through Reserved) : Provider Contract: Definitions .. 2-17 : Provider Contract: Application for Contract .. 2-19 : Provider Contract: Execution of Contract .. 2-19 : Provider Contract: Exclusion and Ineligibility of Convicted Parties .. 2-21 (130 CMR Reserved) : Provider Contract: Issuance of Provider ID/Service Location Numbers.
7 2-22 : Provider Contract: Termination or Disapproval .. 2-22 (130 CMR through Reserved) : General Conditions of Payment .. 2-23 (130 CMR Reserved) : Rates of Payment to Out-of-state Providers .. 2-24 : Rates of Payment to Chronic Disease, Rehabilitation, or Similar Hospitals with Both Out-of-state Inpatient Facilities and In-state Outpatient Facilities .. 2-27 : Overpayments .. 2-27 : Overpayments: Calculation by Sampling .. 2-28 : Overpayments: Determination .. 2-28 : Sanctions: General .. 2-29 : Sanctions: Calculation of Administrative Fine .. 2-30 : Sanctions: Determination.
8 2-31 : Hearings: Claim for an Adjudicatory Hearing .. 2-32 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page ii-a All Provider Manual Transmittal Letter All-220 Date 06/16/17 2. ADMINISTRATIVE REGULATIONS (cont.) : Hearings: Stay of Suspension or Termination .. 2-32 : Hearings: Consideration of a Claim for an Adjudicatory Hearing .. 2-33 : Hearings: Authority of the Hearing Officer .. 2-33 : Hearings: Burden of Proof .. 2-34 : Hearings: Procedure .. 2-34 : Hearings: Hearing Officer s Decision.
9 2-34 : Medicaid Director s Decision .. 2-34 : Withholding of Payments .. 2-34 (130 CMR through Reserved) : Overpayments Attributable to Rate Adjustments .. 2-37 : Monies Owed by Providers .. 2-37 : Member and Provider Fraud .. 2-39 (130 CMR through Reserved) : Individual Consideration .. 2-40 (130 CMR through Reserved) Teaching Physicians: Documentation Requirements .. 2-41 (130 CMR through Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iii All Provider Manuals Transmittal Letter ALL-220 Date 06/16/17 3.
10 BILLING REGULATIONS : Claims .. 3-1 : Claim Submission .. 3-1 : Prior Authorization .. 3-2 : Claim Submission: Signature Requirement .. 3-3 (130 CMR and Reserved) : Unacceptable Billing Practices .. 3-4 (130 CMR Reserved) : Time Limitation on Submission of Claims: General Requirements .. 3-5 (130 CMR through Reserved) : Time Limitation on Submission of Claims: Claims for Members with Health Insurance .. 3-6 : Final Deadline for Submission of Claims .. 3-6 (130 CMR Reserved) : Third-party Liability: Requirements .. 3-7 : Third-party Liability: Payment Limitations on Other Health Insurance Claim Submissions.
