Excluded individuals and entities prohibited from participating in MassHealth are identified in the list above. They are listed according to the provider type at the time of exclusion.
In accordance with the Patient Protection and Affordable Care Act (Pub. L. 111-148) enacted on March 23, 2010, as revised by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) enacted on March 30, 2010, together known as the Affordable Care Act (ACA), the MassHealth program is required to terminate enrollment of any provider that is excluded under Medicare or by any other state Medicaid agency.
MassHealth suspends or excludes a provider when the
- provider's license or authorization to provide services is made inactive, terminated, suspended, or revoked by any authorizing board or entity;
- provider has been convicted of health-care fraud;
- provider has been suspended or excluded from another state’s Medicaid program;
- Medicare program has initiated an exclusion of a provider that is binding upon the Medicaid program;
- provider has pleaded guilty to, or was convicted of, a criminal activity materially related to the Medicare or Medicaid programs; or
- U.S. Department of Health and Human Services initiates an action that is binding on a provider's participation in the Medicaid program.
In addition, it is important to note that MassHealth, at its discretion, may suspend a provider who fails to comply with participatory requirements of the MassHealth program.
An excluded provider is prohibited from providing or participating in the provision of any services, in any capacity, to any MassHealth member in all categories of services. Pursuant to Section 1128 and Section 1902(a)(39) of the Social Security Act, the MassHealth program will not reimburse a provider for any services or items that were rendered, ordered, or prescribed by a sanctioned (i.e., suspended, excluded) provider. The provider's sanction precludes them from furnishing, ordering, or prescribing services or items to a MassHealth member.
On a monthly basis, any provider participating or applying to participate in the MassHealth program must search the list on this page, as well as the list of excluded individuals and entities (LEIE) of the federal Office of Inspector General available at https://oig.hhs.gov/fraud/exclusions.asp, to determine if any existing employee, contractor, owner, or board member has been suspended or excluded from participation in the Medicaid program. In addition, the provider must immediately report any discovered exclusion of an employee or contractor to the Executive Office of Health and Human Services Compliance Office by telephone at 855-326-8966, by fax at 617-210-5452, via e-mail at firstname.lastname@example.org, or by mail at Compliance Office, 600 Washington Street, #5276, Boston, MA 02111.
Also, providers participating or applying to participate in the MassHealth program must search both the lists mentioned above before hiring staff, to ensure that any potential employees, contractors, owners, or board members have not been excluded from participating in the Medicaid program.
If the period of suspension or exclusion expires, reinstatement into the MassHealth program is not automatic. The individual or entity must submit an application for re-enrollment and cannot submit claims for services provided to MassHealth members until they are notified that their application has been approved.
If you have any questions about the information on this page, please contact MassHealth Customer Service Quality Assurance Team via e-mail at email@example.com or by mail at MassHealth Customer Service Team, ATTN: PEC QC/PRC, 55 Summer Street, 8th Floor, Boston, MA 02110.