Only MassHealth providers are reimbursed for services provided to MassHealth members, therefore, providers must be approved as a participating provider before claims can be submitted for payment.
To apply to become a MassHealth provider or to become a PCC provider, contact our Provider Enrollment and Credentialing department to receive an enrollment package.
Out-of-state providers may apply for enrollment to provide certain emergency services within 90 days from the date of service. It is necessary for a completed application to be submitted and approved before an out-of-state provider submits claims to MassHealth. MassHealth must receive a completed application within 90 days of the date of service. Please contact MassHealth Customer Service as soon as possible, before or after providing services. For specifics, please refer to MassHealth regulations at 130 CMR 450.109 .
Before you return your completed MassHealth provider application, please review the Provider Enrollment Checklist to verify that you have all the required documentation. We suggest printing a copy of the Provider Enrollment Checklist to assist you when assembling all the required documentation.
About the Application Fee
- The application fee is $542 for calendar year 2014. The fee may change from year to year based on adjustments to the Consumer Price Index for Urban Areas (CPI-U).
- The application fee applies to certain provider applicants who are enrolling or reenrolling, and to providers adding a new service location.
Providers who are required to pay the fee but enrolled in Medicare or another state’s Medicaid or CHIP program, and have paid the application to the Medicare contractor or the other state’s program, are also exempt (see below: Payment and Documentation of the Application Fee).
- The fee is nonrefundable. If a provider applicant does not meet participatory requirements or does not submit the appropriate documentation required within time frames requested, the fee will not be refunded. Any subsequent submissions of an application for enrollment or reenrollment to MassHealth would require payment of a new application fee.
Payment and Documentation of the Application Fee
Provider types subject to the fee are:
- ICF-MR State Schools
- Acute In-Patient Hospitals
- Chronic In-Patient Hospitals
- Psychiatric In-Patient Hospitals
- Semi-Acute In-Patient Hospitals
- Skilled Nursing Facilities
All other providers are exempt from the fee.
Unless you are exempt or have an approved hardship request, MassHealth will not process your application until the application fee has been paid. To pay the application fee, provider applicants must use the secure payment site linked below.
If you believe that you are exempt due to enrollment with Medicare or another state’s Medicaid program or the Children’s Health Insurance Plan (CHIP), please see MassHealth’s Attestation of Application Fee Payment document. If you would like to request a financial hardship waiver, please see MassHealth’s Hardship Exception Request.
Section 1202 Rates for Physicians Who Provide Primary Care Services
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.
For additional information:
- General Information About National Health Care Reform (the Affordable Care Act (ACA)) (www.mass.gov/nationalhealthreform
Information for MassHealth Providers About ACA Program Integrity Provisions
This information is provided by MassHealth.