130 CMR, § 450.238 - Sanctions: General
(A)
Introduction. All providers are subject to the rules,
regulations, standards, and laws governing MassHealth. 130 CMR 450.238 through
450.240
set forth the MassHealth agency's procedures for imposing sanctions for
violations of those rules, regulations, standards, and laws. Such sanctions may
include, but are not limited to, administrative fines, provider services
restrictions, and suspension or termination from participation in MassHealth.
The MassHealth agency determines the amount of any fine and may take into
account the particular circumstances of the violation. The MassHealth agency
may assess an administrative fine whether or not overpayments have been
identified based on the same set of facts.
(B)
Instances of
Violation. Instances of violation include, but are not limited to
(1) billing a member for services that are
payable under MassHealth, except copayments as provided in
130 CMR
450.130;
(2) submitting claims under an individual
provider's MassHealth provider number for services for which the provider is
entitled to payment from an employer or under a contract or other
agreement;
(3) billing the
MassHealth agency for services provided by someone other than the provider,
unless expressly permitted by the applicable regulations;
(4) billing the MassHealth agency before
delivery of service, unless permitted by the applicable regulations;
(5) failing to comply with recordkeeping and
disclosure requirements;
(6)
overstating or misrepresenting services, including submitting separate claims
for services or procedures provided as components of a more comprehensive
service for which a single rate of payment is established;
(7) failing to return credit balance funds to
the MassHealth agency within 60 days of their receipt;
(8) failing to obtain or provide a
physician's order, prescription, or referral when required by the applicable
regulations;
(9) failing to comply
with MassHealth enrollment, licensure, or certification requirements;
and
(10) misapplication or
misappropriation of personal needs allowance funds.
Notes
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