Group Links
Each MassHealth provider must notify the MassHealth agency of any change to their
information within 14 days. Failure to do so is a breach of the provider contract. Group practices cannot file a claim for services provided by an individual practitioner until the individual practitioner is enrolled and approved by the MassHealth agency as a member of the group. (For more information, see 130 CMR 450.223 (B)).
When working with a group practice, the following individual provider types must be linked.
- Physician (PT-1)
- Optometrist (PT-2)
- Optician (PT-3)
- Ocularist (PT-4)
- Psychologist (PT-5)
- Podiatrist (PT-6)
- Certified Nurse Midwife (PT-08)
- Chiropractor (PT-16)
- Certified Nurse Practitioner (PT-17)
- Physician Assistant (PT-39)
- Hearing Instrument Specialist (PT-44)
- Audiologist (PT-50)
- Certified Registered Nurse Anesthetist (PT-51)
- Clinical Nurse Specialist (PT-57)
- Psychiatric Clinic Nurse Specialist (PT-78)
- Acupuncturist (PT-A9)
- Licensed Independent Clinical Social Worker (PT-92)
- Doula Provider (PT-C5)
Please note: A provider enrolled exclusively as a PT86 (Qualified Medicare Beneficiary) cannot be linked to a group or affiliated to an organization. Licensed Clinical Social Workers are now eligible to enroll as fee-for-service (FFS), so these applicants should confirm whether they should enroll as FFS to link with their workplace. FFS providers are also eligible for Medicare crossovers.
If an individual is enrolled as a No Bill- No Pay provider, and is not linked to any group practices, they must link to a new group or convert to an Ordering, Referring, and Prescribing (ORP) non-billing status, if an eligible provider type.
If a group practice organization bills through an administrative location, individual providers must be linked to the administrative location and all locations where the provider provide services.
Group practice organizations can use the Provider Online Service Center (POSC) to submit a request to link an individual. Please refer to the “Update Provider Profile - Group Link Requests” job aid on Mass.gov.
Unlinking from a Group
Each MassHealth provider must notify the MassHealth agency of any change to their information within 14 days. Failure to do so is a breach of the provider contract. As it is required to report a group link to MassHealth, it is also required to notify MassHealth when a provider is no longer participating in a group practice.
If a provider was paid for a date of service AFTER the provider left the group practice, claims will be adjusted.
If an individual is enrolled as a No Bill- No Pay provider, and is not linked to any group practices, they must link to a new group or convert to an Ordering, Referring, and Prescribing (ORP) non-billing status, if an eligible provider type.
Group practice organizations can use the Provider Online Service Center (POSC) to submit a request to unlink an individual. Please refer to the “Update Provider Profile - Group Unlink Requests” job aid on Mass.gov.
Affiliations
An individual may be affiliated with an enrolled entity to confirm their relationship with MassHealth, and the request to affiliate may be made by either party. Individuals who are eligible to be enrolled in MassHealth, and who are employed at hospitals, clinics and other entity locations, need to be enrolled as an ORP provider, at a minimum. Affiliations can be requested on page four of the Ordering, Referring, and Prescribing Provider application or by sending a request to MassHealth.
MassHealth should be notified within 14 days when an individual is no longer participating at their affiliated workplace. Failure to do so is a breach of the provider contract.
A provider will be affiliated in MassHealth’s system under the following circumstances.
- Nurse practitioners working at a Limited Services Clinic (PT-96), and who are listed on the application or newly employed by the clinic.
- Individuals who practice as a Primary Care Practitioner who are referring members for other services under the Primary Care Clinician (PCC) plan or the Primary Care Accountable Care Organization (PCACO).
- Homeless Medical Respite Services (PT-88) will be affiliated with a Community Support Programs for Homeless Individuals (CSP-HI) provider (C3 provider type) as a requirement of their enrollment in MassHealth. Homeless Medical Respite Services will also be affiliates with a licensed medical provider as a requirement of their enrollment in MassHealth.
Managed Care Requirements
Individual providers participating as Primary Care Practitioners (PCP) under a Primary Care Clinician (PCC) plan or Primary Care Accountable Care Organizations (PCACO) should be aware of the distinct scenarios where links vs. affiliations will be required.
Links
- Group Practices (PT-97s) enrolled as a PCP with MassHealth are required to have individuals linked and listed on claims as rendering providers in order to receive payment for rendering services.
Affiliations
- Individual providers enrolled as PCP with MassHealth will be affiliated to the organization where they participate.
- Individuals practicing as a PCP who refer members for other services under the PCC plan or the PCACO will be affiliated.
Please refer to MassHealth’s regulations to verify the requirements of PCP participation (450.118 for PCC Plan & 450.119 for ACO B).
Billing Error Codes Due to Linkages
Only group practices should list rendering providers on claims.
Entities and clinics will receive a 1010 error code when listing someone who is not eligible/enrolled.
Resources
To verify if an individual provider is linked to a group practice, use the Self-Service Tools for MassHealth Providers, and search under Check Provider Enrollment Status.
| Date published: | February 4, 2025 |
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