Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth	

MASSHEALTH
TRANSMITTAL LETTER ALL-130 
February 2005

	TO:	All Providers Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director 

	RE:	All Provider Manuals (Revision to Hearings)

The amendment to 130 CMR 450.243(B) clarifies that MassHealth can postpone an adjudicatory proceeding before the Board of Hearings because a provider has been referred to, or is under investigation by, the Attorney General's Medicaid Fraud Control Unit or other criminal investigatory agency or professional licensing board.  It also clarifies that a provider may not request that a hearing be postponed under this subsection.     

This regulation is effective March 1, 2005.

NEW MATERIAL
(The pages listed here contain new or revised language.)

All Provider Manuals

Pages 1-3 and 1-4
Pages 2-25 and 2-26

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)

All Provider Manuals

Pages 1-3 and 1-4 — transmitted by Transmittal Letter ALL-125

Pages 2-25 and 2-26 — transmitted by Transmittal Letter ALL-113

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION
(130 CMR 450.000)	
PAGE

1-3	

ALL PROVIDER MANUALS	
TRANSMITTAL LETTER

ALL-130	
DATE

03/01/05	

MassHealth Agency — the Executive Office of Health and Human Services’ Division of Medical Assistance.

MassHealth Enrollment Center (MEC) — a regional office of MassHealth that determines MassHealth eligibility of individuals and families who do not receive cash assistance (TAFDC, EAEDC, SSI).

MassHealth Managed Care Provider — a Primary Care Clinician participating in the Primary Care Clinician Plan or a managed care organization that has contracted with the MassHealth agency to provide and coordinate primary care and certain other medical services to certain MassHealth members.

Medicaid — see “MassHealth.”

Medical Services — medical or related care, including goods and services provided to members, the cost of which is paid or payable by the MassHealth agency.

Medicare — a federally administered health insurance program for persons eligible under the "Health Insurance for the Aged Act," Title XVIII of the Social Security Act (42 U.S.C. 1395-1395pp).

Member — a person determined by the MassHealth agency to be eligible for MassHealth.

Multiple-Source Drug — a drug marketed or sold by two or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer or labeler under two or more different names.

Nonlegend Drug — any drug for which no prescription is required by federal or state law.

Overpayment — a payment made by the MassHealth agency to or for the use of a provider to which the provider was not entitled under applicable federal and state laws and regulations.  

Party in Interest — a person with an ownership or control interest.  

Peer Review — an evaluation of the quality, necessity, and appropriateness of medical services provided by a provider, to determine compliance with professionally recognized standards of health care or compliance with laws, rules, and regulations under which MassHealth is administered.

Primary Care — the provision of coordinated, comprehensive medical services, on both a first-contact and a continuous basis, to members enrolled in managed care.  Services include:  an initial medical history intake, medical diagnosis and treatment, communication of information about illness prevention, health maintenance, and referral services.

Primary Care Clinician (PCC) Plan — a managed care option administered by the MassHealth agency through which enrolled members receive primary care and certain other medical services.  

Provider — an individual, group, facility, agency, institution, organization, or business that furnishes medical services and participates in MassHealth under a provider contract with the MassHealth agency.  For purposes of applying 130 CMR 450.235 through 450.240, the term "provider" includes formerly participating providers.  

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION
(130 CMR 450.000)	
PAGE

1-4	

ALL PROVIDER MANUALS	
TRANSMITTAL LETTER

ALL-130	
DATE

03/01/05	

Provider Contract (also referred to as “Provider Agreement”) — a contract between the MassHealth agency and a contractor for medical services.

Provider Type — a provider classification specifying and limiting the kinds of medical services for which the provider may be paid under MassHealth. 

Provider under Common Ownership — two or more providers in which a person or corporation has or had, at any time, an ownership or control interest, whether concurrently, sequentially, or otherwise.  See 130 CMR 450.221(A)(9)(a), (b), (c), or (f).

Recipient Eligibility Verification System (REVS) — the member eligibility verification system accessible to providers.

Sanction — an administrative penalty imposed by the MassHealth agency pursuant to M.G.L. c. 118E, § 37 against a provider found to have violated MassHealth laws, regulations, or contract requirements.  Sanctions include, but are not limited to, administrative fines, suspension, and termination from participation in MassHealth.  

Statutory Prerequisite — any license, certificate, permit, or other requirement imposed by state or federal law or regulation as a precondition to the practice of any profession or to the operation of any business or institution in or by which medical services are provided.  Statutory prerequisites include, but are not limited to, licenses required by the Massachusetts Department of Public Health or the Massachusetts Department of Mental Health, licenses and certificates issued by the Massachusetts boards of registration, and certificates required by the Massachusetts Department of Public Safety.

Third Party — any individual, entity, or program other than MassHealth that is or may be liable to pay all or part of the costs for medical services.

Transitional Aid to Families with Dependent Children (TAFDC) — a federally funded program administered by the Massachusetts Department of Transitional Assistance that provides cash assistance to certain low-income families.

Urgent Care — medical services that are not primary care, and are needed to treat a medical condition that is not an emergency medical condition.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION
(130 CMR 450.000)	
PAGE

2-25	

ALL PROVIDER MANUALS	
TRANSMITTAL LETTER

ALL-130	
DATE

03/01/05	

450.240:  Sanctions:  Determination

(A)  Sanction Notice.  When the MassHealth agency believes that sanctions should be imposed, the MassHealth agency will notify the provider in writing of the alleged violations and the proposed sanctions.  The notice will be sufficiently detailed to reasonably inform the provider of the acts that the MassHealth agency alleges constitute such violations.

(B)  Suspension or Termination upon Sanction Notice.  If the MassHealth agency seeks to suspend or terminate a provider’s participation in MassHealth and finds, on the basis of information it has before it that a provider’s continued participation during the pendency of the administrative process could reasonably be expected to endanger the health, safety, or welfare of its members or compromise the integrity of MassHealth, it may suspend or terminate participation at the same time the sanction notice described in 130 CMR 450.240(A) is sent to the provider.  Said suspension or termination will remain in effect until either the MassHealth agency, pursuant to 130 CMR 450.240(D), issues a final determination removing or revising said suspension or termination, or the Medicaid Director, pursuant to 130 CMR 450.248, issues a final agency decision removing or revising said suspension or termination.

(C)  Timely Reply.  To preserve its right to an adjudicatory hearing and judicial review, the provider must reply in writing to the MassHealth agency and such reply must be received by the MassHealth agency within 30 calendar days of the date on the sanction notice.  The reply must specifically identify and address all allegations in the sanction notice with which the provider disagrees and explain any objections to the proposed sanctions.  The provider must also include any additional documentary evidence it wants the MassHealth agency to consider.

(D)  Sanction Determination.  The MassHealth agency will consider and review only information submitted with a timely reply.  If, after reviewing the provider’s reply, the MassHealth agency determines that sanctions should be imposed because the provider has committed one or more violations of any rule, regulation, standard, or law governing MassHealth, the MassHealth agency will notify the provider in writing of its final determination, which will state any sanctions that the MassHealth agency will impose against the provider.

(E)  Adjudicatory Hearing.  If the provider submits a timely reply, the provider may claim an adjudicatory hearing to appeal the MassHealth agency’s final determination, in accordance with 130 CMR 450.241 and 450.243.  The MassHealth agency may amend or supplement the sanction notice at any time before the commencement of an adjudicatory hearing as long as any additional findings have been identified in a notice or amended notice.  Once an adjudicatory hearing has commenced, the hearing officer may permit amendment of the sanction determination upon proper motion by the MassHealth agency and will permit amendment, where necessary, to conform the sanction determination to the evidence.

(F)	Consequences of Failure to Submit a Timely Reply.  The provider has no right to an adjudicatory hearing if it fails to submit a timely reply.  The MassHealth agency will take appropriate action to implement the proposed sanctions.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION
(130 CMR 450.000)	
PAGE

2-26	

ALL PROVIDER MANUALS	
TRANSMITTAL LETTER

ALL-130	
DATE

03/01/05	

450.241:	Hearings:  Claim for an Adjudicatory Hearing

A provider may challenge the findings set forth in the MassHealth agency’s final determination, issued pursuant to 130 CMR 450.209(C)(3), 450.237(C), or 450.240(D), by filing a claim for an adjudicatory hearing (claim) with the Board of Hearings and the MassHealth agency within 30 calendar days of the date on the final determination, pursuant to 130 CMR 450.243.  A claim is filed on the date actually received by both the Board of Hearings and the MassHealth agency.  Failure to file a timely claim will result in implementation of the action identified in the final determination.

450.242:	Hearings:  Stay of Suspension or Termination

A timely claim will stay any suspension or termination described in the final determination  until there has been a final agency action pursuant to 130 CMR 450.243(D) or 450.248; provided, however, that if the MassHealth agency finds on the basis of information it has before it that a provider’s continued participation in MassHealth during the pendency of the administrative appeal could reasonably be expected to endanger the health, safety, or welfare of members or compromise the integrity of MassHealth, suspension or termination will not be stayed.  A timely claim will not stay any withholding of payments under 130 CMR 450.249.

450.243:	Hearings:  Consideration of a Claim for an Adjudicatory Hearing

(A)  A timely claim must specifically identify each issue and fact in dispute and state the provider's position, the pertinent facts to be adduced at the hearing, and the reasons supporting that position.

(B)  If a matter has been referred to or is under investigation by, the Attorney General’s Medicaid Fraud Control Unit or other criminal investigation agency, or if a question of quality of care has been referred to a professional licensing board for investigation, the Board of Hearings, upon notice from the MassHealth agency, will postpone the hearing until the conclusion of such investigation and the final disposition of any criminal complaint, indictment, or order to show cause that ensues, or until the MassHealth agency notifies the Board to schedule the hearing.  A provider may not request a postponement of the hearing under 130 CMR 450.243(B).

(C)  The Board of Hearings will grant a hearing only if the claimant demonstrates all of the following.
(1)  The claim was filed within the time limits set forth in 130 CMR 450.241.
(2)  There is a genuine and material issue of adjudicative fact for resolution.  
(3)  The factual issues can be resolved by available and specifically identified reliable evidence as set forth in M.G.L. c. 30A, § 11(2).  A hearing will not be granted on the basis of general allegations or denials or general descriptions of positions and contentions.
(4)  The allegations of the provider, if established, would be sufficient to resolve a factual dispute in the manner urged by the provider.  A hearing will not be granted if the provider’s submissions are insufficient to justify the factual determination urged, even if accurate.
(5)  Resolution of the factual dispute in the way sought by the provider is relevant to and would support the relief sought.