101 CMR, § 613.07 - Reporting Requirements

(1) General. Each Provider must file or make available information that the Health Safety Net Office deems necessary to verify that a service for which a Provider submits a claim is an Eligible Service.

(a) The Health Safety Net Office may revise the data specifications, the data collection scheduled, or other administrative requirements by administrative bulletin.

(b) Providers must maintain records sufficient to document compliance with all screening and documentation requirements of 101 CMR 613.00. Providers must maintain records documenting claims for Reimbursable Health Services to Low Income Patients, Bad Debt for Emergency or Urgent Care services, and Medical Hardship.

(c) The Health Safety Net Office may deny payment for claims by any Provider that fails to comply with the reporting requirements of 101 CMR 613.00 or 614.00: Health Safety Net Payments and Funding until such Provider complies with the requirements. The Health Safety Net Office will notify such Provider of its intention to withhold payment.

(2) Medical, Dental and Professional Claims Submission Deadlines. The Health Safety Net pays only for claims that are submitted within the time frames listed in 101 CMR 613.07(2)(a) through (f).

(a) Unless otherwise specified in 101 CMR 613.07(2)(b) through (f), claims must be submitted within 90 days of the date of service. If a service is provided continuously on consecutive dates, the date from which the 90-day deadline is measured is the latest date of service.

(b) If the Health Safety Net is the primary payer, and Low Income Patient status is determined after services are provided, claims must be submitted within 90 days of Low Income Patient determination. A waiver may be requested if the Patient was determined to be a Low Income Patient after services are provided, and the claim cannot be submitted within 90 days of service.

(c) For claims that are not submitted within the 90-day period but that meet one of the exceptions specified in 101 CMR 613.07(2)(c)1. through 3., a Provider must request a waiver of the billing deadline pursuant to the billing instructions provided by the MassHealth Agency. The exceptions are as follows.

1. A medical service was provided to a person who was not a Low Income Patient on the date of service, but was later determined to be a Low Income Patient for a period that includes the date of service.

2. A medical service was provided to a Patient who failed to inform the Provider in a timely fashion of the member's eligibility for MassHealth or status as a Low Income Patient.

3. A medical service was provided to a Patient with health insurance and the Provider delayed submission of the claim in order to bill the Patient's insurer. Claims must be submitted by the later of 90 days of the date of service or 90 days after the date of the primary insurer's explanation of benefits, but no later than 18 months after the date of service.

(e) Claims for Emergency or Urgent Care Bad Debt may be written off by the Provider no earlier than 120 days after services are provided. Such claims must be submitted within 90 days after the date on which the claim is written off as uncollectible.

(f) Claims related to Medical Hardship must be submitted to the Health Safety Net Office by the deadline specified in 101 CMR 613.05(6).

(3) Final Deadline for Submission of Claims.

(a) If the Health Safety Net Office has denied a claim that was initially submitted within the 90-day deadline, the Provider may resubmit the claim with appropriate corrections or supporting information.

(b) The Health Safety Net does not pay any claim submitted or resubmitted for services provided more than 12 months before the date of submission or resubmission, except as provided in 101 CMR 613.07(2).

(4) Pharmacy Billing Deadlines. Pharmacy claims must be submitted to POPS by the later of 90 days after services are provided or 90 days after the date of the primary insurer's explanation of benefits.

(5) Other Acute Hospital Claim Requirements.

(a) Each Acute Hospital claim must contain a site-specific identification number as assigned by the Health Safety Net Office. The Health Safety Net Office assigns individual identification numbers to each Acute Hospital, Hospital Licensed Health Center, Satellite Clinic, and school-based health center that provides Eligible Services.

(b) The Health Safety Net Office may require Acute Hospitals to submit interim data on revenues and costs to monitor compliance with federal upper payment limits and Safety Net Care pool payment limits, including cost limits. Such data may include, but not be limited to, gross and net patient service revenue for Medicaid non-managed care, Medicaid managed care, and all payers combined; and total Patient service expenses for all payers combined.

(6) Other Community Health Centers Claim Requirements.

(a) Each Community Health Center must submit claims to the Health Safety Net Office according to the requirements of 101 CMR 613.00 and 614.00: Health Safety Net Payments and Funding and the data specification requirements of the Office.

(b) Each Community Health Center must, upon request, provide the Health Safety Net Office with Patient account records and related reports as set forth in 101 CMR 613.03(1)(b).

(7) Audits. The Health Safety Net Office or its agent may audit claims and may adjust claims that are not in compliance with the provisions of 101 CMR 613.00.

(a) The Health Safety Net Office may adjust claims for services covered by MassHealth, another program of public assistance, or other Health Insurance Plan in which the Patient is enrolled, or may adjust claims for services that do not meet the criteria for Eligible Services including claims for Reimbursable Health Services to Low Income Patients, Bad Debt, or Medical Hardship.

(b) The Health Safety Net Office may adjust claims for which the Provider cannot provide documentation required by 101 CMR 613.00 or 614.00: Health Safety Net Payments and Funding.

(c) The Health Safety Net Office may adjust payments using a methodology to appropriately extrapolate the audit results of a representative sample of accounts.

(d)

1. Notification. The Health Safety Net Office will notify the Provider of its proposed audit adjustments. The notification will be in writing and will contain a complete listing of all proposed adjustments.

2. Objection Process.

a. A Provider may file a written objection to a proposed audit adjustment within 15 business days of the mailing of the notification letter.

b. The written objection must, at a minimum, contain

i. each adjustment to which the Provider is objecting;

ii. the Fiscal Year for each disputed adjustment;

iii. the specific reason for each objection; and

iv. all documentation that supports the Provider's position.

c. Upon review of the Provider's objections, the Health Safety Net Office will notify the Provider of its determination in writing. If the Health Safety Net Office disagrees with the Provider's objections, in whole or in part, the Health Safety Net Office will provide the Provider with an explanation of its reasoning.

d. The Provider may request a conference on objections after receiving the Health Safety Net Office's explanation of reasons. The Health Safety Net Office will schedule such conference on objections if it determines that further articulation of the Provider's position would promote resolution of the disputed adjustments.

(8) Grievances. A Provider must provide any information or documentation requested by the Health Safety Net Office related to a grievance request filed in accordance with 101 CMR 613.04(5) within 30 days of the request from the Office.

Notes

101 CMR, § 613.07

Amended by Mass Register Issue 1271, eff. 10/10/2014. Amended by Mass Register Issue 1304, eff. 1/15/2016. Amended by Mass Register Issue 1310, eff. 4/8/2016. Amended by Mass Register Issue 1329, eff. 10/1/2016.