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This page will be periodically updated. Below is a description of some of the program integrity provisions that affect MassHealth providers.
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.
The ACA allows states to request a temporary moratorium on enrollment from the Centers for Medicare & Medicaid Services (CMS). CMS granted Massachusetts’ request for moratoriums on Home Health Agencies and Adult Foster Care Providers. Here are the details:
The Affordable Care Act (ACA) mandates additional enrollment, re-enrollment, and revalidation screening for providers based on their risk level. Providers are assigned into one of three categories: 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 adopted those risk levels and assigned risk levels for Medicaid-only provider types. Enrollment requirements are based on the risk level for a particular provider type or provider.
Limited Risk Providers – verify that the provider complies with applicable federal and state requirements, verify licenses, and conduct database checks.
Moderate Risk Providers – activities listed above for limited-risk providers and unannounced site visits that may be conducted by Medicare, MassHealth, or both.
High Risk Providers – activities listed above for limited-risk and moderate-risk providers, and fingerprint based criminal background checks performed by Medicare, MassHealth, or both.
ACA Section 6401 requires MassHealth and/or Medicare to perform a fingerprint-based criminal background check on all High Risk providers and all persons with a 5% or greater direct or indirect ownership interest in such providers. See 42 CFR 455.434 and 455.450. We will be performing local and national background checks. Fingerprinting is required in order to complete the background checks. Providers who need to be fingerprinted or need to have their owners fingerprinted will be notified by MassHealth. For more information, please see All Provider Bulletin 267: Fingerprint Based Criminal Background Checks.
If you are applying or reapplying to become a MassHealth provider, you may be required to submit an application fee. The application fee is $560 for Calendar Year 2017 (effective January 1, 2017). 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.
The state Medicaid agency must revalidate the enrollment of all providers, regardless of provider type, at least every five years. MassHealth revalidation is currently underway.
For more information, visit: http://www.mass.gov/eohhs/provider/insurance/masshealth/provider-enrollment/provider-revalidation.html
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.
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 6401—Ordering, Referring, and Prescribing Provider Requirements
Nonbilling Provider Contract and Application
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.