National Health Care Reform, also known as the Affordable Care Act (ACA), improves government-wide efforts to fight Medicaid fraud and waste through many new initiatives that affect providers. This page will be periodically updated. Below is a description of some of the program integrity provisions that affect MassHealth providers.
ACA Section 2702: Payment Adjustment for Provider-Preventable Conditions (PPC) including Health Care-Acquired Conditions (HCAC)
Under the rule, providers must report PPCs to state Medicaid agencies, and state Medicaid agencies are prohibited from paying providers for PPCs in violation of the rule. See Appendix V of your provider manual for billing instructions for PPCs.
ACA Section 6401:
Enhanced provider screening and enrollment requirements
National Health Care Reform (ACA) mandates additional enrollment, re-enrollment, and revalidation screening for providers based on their risk level. Providers are assigned into one of three categories: these are limited risk, moderate risk, and high risk.
The final rule for Section 6401 assigned risk levels for provider types that are recognized by Medicare. MassHealth assigned risk levels for Medicaid-only provider types.
Enrollment requirements are based on the risk level for a particular provider type.
- Limited Risk Providers – verify that the provider complies with applicable federal and state requirements, verify licenses, and conduct database checks
- Abortion/Sterilization Clinics
- Acute Inpatient Hospitals
- Acute Outpatient Hospitals
- Adult Day Health Providers
- Ambulatory Surgery Centers
- Case Management
- Chronic Inpatient Hospitals
- Chronic Outpatient Hospitals
- Community Health Centers (CHC)
- Day Habilitation Programs
- Dental Clinics
- Dental School Clinics-Graduate
- Dental School Clinics-Undergraduate
- DPH Transportation Providers (& DPH waivers)
- Early Intervention Providers
- Family Planning Agencies
- Fiscal Intermediaries (for personal care attendants)
- Group Practice Organizations
- Health Maintenance Organizations
- Hearing Instrument Dispensers
- Home Care Corporations
- Hospital Licensed Health Centers (HLHC)
- ICF - MR - State School
- Independent Living Centers
- Independent Nurses
- Indian Health Services
- Intensive Residential Treatment Programs (IRTP)
- Nurse Midwives
- Nurse Practitioners
- Nursing Facilities
- Optometry Schools
- Personal Care Management Agencies
- Psychiatric Day Treatment Programs
- Psychiatric Inpatient Hospitals (all ages)
- Psychiatric Outpatient Hospitals
- Public Health Dental Hygienists
- Radiation Oncology Treatment Centers
- Rehabilitation Clinics
- Renal Dialysis Clinics
- School-Based Medicaid Providers
- Semi-Acute Inpatient Hospitals
- Semi-Acute Outpatient Hospitals
- Special Programs – Wigs
- Special Programs – Certified Mastectomy Fitters
- Speech and Hearing Clinics
- Substance Abuse Programs
- State Agency Services
- Transportation Providers
- Volume Purchasers
- Moderate Risk Providers** – activities listed above for limited-risk providers and unannounced site visits that may be conducted by Medicare, MassHealth, or both
- Certified Independent Laboratories
- Diagnostic Testing Facilities (IDTF)
- Group Practice Organizations with Physical Therapy
- Hospice Care Providers
- Mental Health Clinics
- Physical Therapists
- Transportation-Ambulance Providers
** All providers or supplies that are publicly traded on the NYSE or NASDAQ are considered ‘‘limited’’ risk.
- High Risk Providers – activities listed above for limited-risk and moderate-risk providers, and potentially, criminal background checks, and fingerprinting
- Adult Foster Care Providers
- Durable Medical Equipment Providers &
Personal Emergency Response System (PERS) Providers
- Group Adult Foster Care Provider
- Home Health Agencies
- Orthotics Providers
- Oxygen & Respiratory Therapy Equipment Providers
- Pharmacies-DME Specialty
- Prosthetics Providers
If you are applying or reapplying to become a MassHealth provider, you may be required to submit an application fee. The application fee is $532 for calendar year 2013. Federal law generally requires provider applicants for enrollment or reenrollment into a Medicaid program to pay an application fee. See 42 CFR 455.460 implementing Section 6401 of the National Health Care Reform (ACA). Individual physicians and non-physician practitioners, including dentists, providers of Home- and Community-Based Waiver Services, group practices, and local public health providers participating in MassHealth's Flu Vaccine Program, are exempt. Also exempt are providers who are enrolled in Medicare or another state’s Medicaid program or CHIP, and have paid the application fee to a Medicare contractor or another state’s Medicaid program.
Revalidation of enrollment
The state Medicaid agency must revalidate the enrollment of all providers, regardless of provider type, at least every five years. MassHealth revalidation planning is in process.
Federally required disclosures
State agencies must collect certain required information, such as the date of birth and social security number (or other tax identification number for legal entities) of all persons with an ownership or control interest in an entity applying for enrollment and for enrolled providers, upon reenrollment/revalidation or when certain entity information changes. MassHealth collects this information on the
Federally Required Disclosure Form [PE-FRD]
ACA Section 6401(b): Enrollment and NPI of Ordering or Referring Providers
All ordering or referring physicians and other professionals must be enrolled under the State (Medicaid) Plan as an ordering and referring provider or as a servicing provider; and the national provider identifier (NPI) of any ordering or referring physician or other professional must be specified on any claim for payment that is based on an order or referral of the physician or other professional.
ACA Section 6402: General Program Integrity Provisions
- Overpayment Requirements – Providers must generally return overpayments within 60 days and report the reason for the overpayment. See All Provider Bulletin 224: Provider Overpayment Disclosure Process
- The provider’s NPI must be included on all enrollment applications and claims (only those who qualify for NPI).
- Payments to providers must generally be withheld pending the investigation of a credible allegation of fraud and completion of any associated enforcement proceedings. See Transmittal Letter ALL-192: Revised Administrative Regulations
ACA Section 6411: Medicaid Recovery Audit Contractor (RAC) Program
ACA Section 6507: National Correct Coding Initiative
National Health Care Reform (ACA) requires state Medicaid agencies to incorporate compatible methodologies of the National Correct Coding Initiative (NCCI). NCCI was implemented by CMS to promote national correct coding methodologies and to control improper coding to minimize inappropriate payment. Refer to All Provider Bulletin 209, dated April 2011, and All Provider Bulletin 227, dated July 2012, for additional information.
- All Provider Bulletin 209: Medicaid National Correct Coding Initiative
- All Provider Bulletin 227: Modifier Coverage and National Correct Coding Initiative (NCCI) Updates
This information is provided by MassHealth.