MassHealth
Commonwealth of Massachusetts
Executive Office of Health and Human Services
www.mass.gov/masshealth

Physician Certification and Attestation Form
for ACA Section 1202 Rates for Physicians
Who Provide Primary Care Services

SECTION I: Instructions
Please complete the information in sections II and IV (or V), sign and return the form by fax to 617-988-8974 or mail it
to the MassHealth Customer Service address in Section IV. All information is subject to audit.

SECTION II: Physician Information
NAME
BUSINESS NAME (If applicable or employed by a group practice)
STREET ADDRESS
CITY
STATE 		ZIP CODE
BUSINESS TELEPHONE NO. 
BUSINESS FAX NO. 
BUSINESS E-MAIL ADDRESS
CONTACT NAME 
CONTACT PHONE NUMBER 
CONTACT E-MAIL ADDRESS
MASSHEALTH PROVIDER ID 
PROVIDER NPI 
TAX ID
List any subspecialties:
Are you enrolled in the MassHealth Primary Care Clinician Program? .  .  .  .  .  .  .  .  .  .  .  .  .   ____Yes  ___No

Section III: Information
For calendar years 2013 and 2014, Section 1202 of the federal Affordable Care Act requires Medicaid agencies to provide 
payment for certain primary care services delivered by eligible physicians who specialize in family medicine, general internal 
medicine, and/or pediatric medicine, or a subspecialty recognized by the American Board of Medical Specialties (ABMS), the 
American Osteopathic Association (AOA), or the American Board of Physician Specialties (ABPS).

In order to be eligible for the Section 1202 Rates, one of the following requirements must be met. Such physicians must:
• self-attest to being board-certified in one of the qualified specialties or subspecialties referenced above; and/or
• self-attest that at least 60% of the Medicaid codes he or she has billed during the most recently completed 
calendar year were for the services eligible for the Section 1202 Rates. (Newly eligible physicians must provide self-
attestation based on the Medicaid codes billed during the prior month.)

The following billing codes are eligible for the Section 1202 Rates.
• E&M codes 99201-99499
• Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473, 90474, 
or their successor codes

Section IV: American Board of Medical Certification
If you have a certification in an eligible specialty or subspecialty from the American Board of Medical Specialties (ABMS), the
American Osteopathic Association (AOA), or the American Board of Physician Specialties (ABPS), and would like to be 
eligible for the Section 1202 Rates, you may update your specialty by going to the MassHealth Provider Online Service Center 
(POSC) at https://newmmis-portal.ehs.state.ma.us/EHSProviderPortal/appmanager/provider/desktop, or you may also fax 
this form to (617) 988-8974 or mail it to the following address.
MassHealth Customer Service
Attn: Provider Enrollment
PO Box 9118
Hingham, MA 02043

Section V: Attestation

1. Complete section V, Part 1 if you are practicing in internal medicine, pediatrics, or family medicine, and are attesting that 
you are certified by the ABMS, AOA, or ABPS in one of the following specialties:
Check specialties in which you have board certification: 
Family Medicine 
General Internal Medicine 
Pediatric Medicine
Provide the date of such certification:

2. Complete Section V, Part 2 only if you are attesting that you are practicing in internal medicine, pediatrics, or family 
medicine, you do not have a certification from the ABMS, AOA, or ABPS, but at least 60% of your total billings are for 
evaluation and management E&M services and vaccine administration codes.

Note: You may check your physician profile with MassHealth Customer Service or online at the POSC to see if MassHealth 
has an eligible certified specialty attestation or certificate on file for you.

Current Enrolled Physicians only
___I attest that at least 60% of my total billings for the previous calendar year were for the E&M and vaccine administration 
codes as published in the final federal regulation implementing section 1202 of the Affordable Care Act and meet the 
requirements to receive the Section 1202 Rates.

New Physicians only
___I attest that at least 60% of my total billings during the previous month are for qualified E&M and vaccine 
administration codes as published in the final federal regulation implementing section 1202 of the Affordable Care Act, and 
meet the requirements to receive the Section 1202 Rates.

I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have 
provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand 
that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any 
material fact contained herein.

Printed legal name of provider 
Printed legal name of individual signing (if the provider is a legal entity)

Provider’s signature (Signature and date stamps, or the signature of anyone other than the provider or a person legally authorized to 
sign on behalf of a legal entity, are not acceptable.)

Date

ACA-1202 (01/13)