MassHealth Provider Preventable Conditions (PPC)
Healthcare Acquired Conditions (HCAC)
The Acute Hospital RFA includes provisions for non-payment of services associated with fourteen hospital acquired conditions listed in the Appendix V MassHealth Billing Instructions for Provider Preventable Conditions.
Other Provider Preventable Conditions (OPPC)
Appendix V also contains provisions for non-payment of services associated with three national coverage determinations (surgical procedures on wrong patient, wrong site, or wrong surgery on a patient).
MassHealth PPC Billing
- The Acute Hospital RFA claims billing of services associated with HCAC and OPPC are automatically processed except for claims that include an HCAC and qualify for outlier payments. In the case of billing that includes outliers, MMIS will automatically suspend or be denied for Edit 6215. MMIS Notices post other instruction on reprocessing suspended or denied claims on the MassHealth provider remittance webpage. The ICD-10 codes that apply to HCAC and OPPC claims billing are updated by the Center for Medicare and Medicaid Services (CMS) each fiscal year. Hospitals can use the CMS updated ICD-10 codes lists that apply to each Acute RFA rate year billing.
Additional Resources
Additional Resources
MassHealth Serious Reportable Events
The Acute Hospital RFA includes provisions for non-payment of services associated with serious reportable events (SREs). Appendix U lists the specific events that are not Provider Preventable Conditions and instructions on how to submit preventability determination report for payment adjustment.
SRE Reports should be sent to: MassHealth Quality Office Serious Reportable Events Coordinator at MQO@mass.gov.
Additional Resources
Contact
| Date published: | September 27, 2023 |
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