409.404 - Requirements for Provider Participation

409.404. Requirements for Provider Participation

(A) Provider Participation Requirements. Payment for services described in 130 CMR 409.000 is made only to providers who are participating in MassHealth as a DME provider or have been assigned a DME specialty in accordance with 130 CMR 409.404(D) as of the date of service. Applicants must meet the requirements in 130 CMR 450.000 as well as the requirements in 130 CMR 409.000. Participating providers must continue to meet provider eligibility participation requirements throughout the period of their provider contract with the MassHealth agency.

(B) Letter of Intent. All applicants must submit a letter of intent prior to receiving and completing a MassHealth provider application for DME. The letter of intent must describe

(1) the applicant's primary scope of business, including which DME services and products the applicant intends to provide;

(2) a list of any subcontractors the applicant intends to use and for what purpose;

(3) existing contracts with other payers; and

(4) the service areas in which services will be provided.

(C) General Qualifications. To qualify as a MassHealth DME provider, all applicants and providers must

(1) have a service facility that

(a) is available to members during regular, posted business hours;

(b) is physically accessible to members with disabilities;

(c) has clear access and space for individualized ordering, returns, repair, and storing of business records;

(d) has a sign visible from outside the facility identifying the business name and hours that the service facility is open. If the provider's place of business is located within a building complex, the sign must be visible at the main entrance of the building where the service is located;

(e) has a primary business telephone number listed in the name of the business with a local toll-free telephone number that is answered by customer service staff during business hours, and that has TTY transmission and reception capability. During business hours, this number cannot be a pager, answering service, voice message system, or cell phone; and

(f) maintains a 24-hour voice message system;

(2) obtain separate approval from the MassHealth agency and a separate provider number for each service facility operated by the provider.

(3) except for specialty providers described in 130 CMR 409.404(D), primarily engage in the business of providing DME, or durable medical equipment repair services, to the public;

(4) participate in the Medicare program as a DME provider, unless the provider supplies only PERS or absorbent products;

(5) have a Medicare provider number that is assigned to the same business and service facility and location for which the applicant is applying to become a MassHealth provider;

(6) be accredited by an accrediting body that is acceptable to the Centers for Medicare & Medicaid Services unless the provider supplies only PERS or absorbent products;

(7) meet all applicable federal, state, and local requirements, certifications, and registrations;

(8) at the time of application and recredentialing, or any other time as requested by the MassHealth agency, provide all required documentation specified in 130 CMR 450.000 as well as the following:

(a) a list of contracted manufacturers used for purchased products

(b) a copy of all current liability insurance policies;

(c) copy of the property lease agreement pertinent to the service facility, or a copy of the most recent property tax bill if applicant owns the business site;

(d) for mobility providers only, a copy of current RESNAATP certificate for each certified staff member. DME providers who furnish mobility systems must employ at least one certified ATP at each service facility. The ATP must possess knowledge of the standards of acceptable practice in the provision of DME including ordering, assembling, adjusting, and delivering DME, and providing ongoing support and services to meet a person's rehabilitation equipment needs;

(e) a copy of all current signed employee professional licenses, as applicable;

(f) a copy of current accreditation letters;

(g) a copy of the purchase and sale agreement if the applicant or provider has recently purchased the company for which they are applying to become a MassHealth provider;

(h) a copy of subcontracts, if applicable, as described in 130 CMR 409.412. For PERS providers, the subcontract must include the central monitoring station contract, if applicable;

(i) a copy of the applicant's emergency preparedness plan as approved by the accrediting body;

(j) a copy of written policies and procedures, including the customer service protocol, customer complaint tracking and resolution protocol, the protocol on transfer and discharge of members, staff training; and

(k) for PERS providers only, a copy of documentation demonstrating compliance with UL Standards 1637 in accordance with 130 CMR 409.429(C);

(9) for a provider of home infusion services, be a licensed pharmacy in Massachusetts and be accredited by an accrediting body, as approved by the Centers for Medicare & Medicaid Services, and be assigned a DME specialty by the MassHealth agency. See130 CMR 409.404(D);

(10) conduct CORI checks on employees and subcontractors in accordance with procedures outlined in EOHHS CORI regulations at 101 CMR 15.00et seq.;

(11) not accept prescriptions for MassHealth DME from any prescribing provider who has a financial interest in the DME provider; and

(12) cooperate with the MassHealth agency or its designee during the application and recredentialing process, including participation in a site visit.

(D) Providers Assigned DME Specialty. Applicants or providers whose primary business is not DME may qualify to provide DME services if the following conditions are met:

(1) the applicant or provider is enrolled as a MassHealth provider of oxygen and respiratory therapy equipment services under 130 CMR 427.000 or pharmacy services under 130 CMR 406.000;

(2) the applicant or provider meets all other conditions under 130 CMR 409.404 to provide DME services; and

(3) MassHealth has assigned a specialty of DME to the applicant's or provider's existing provider number for oxygen and respiratory therapy equipment services or pharmacy services.

(E) In-state. To qualify as an in-state provider of DME, the applicant or provider must have a service facility located in Massachusetts that meets the criteria described in 130 CMR 409.404(C)(1).

(F) Out-of-state. An applicant or provider of DME with a service facility located outside of Massachusetts may qualify as a MassHealth DME provider only if the following additional conditions are met:

(1) all requirements under 130 CMR 409.000 and 450.000, and 42 CFR 431.52 are met;

(2) the out-of-state DME provider participates in the Medicaid program of the state in which the provider primarily conducts business, unless the out-of-state DME provider solely provides PERS;

(3) the DME provider participates in the Medicare program of the state in which the provider primarily conducts business, unless the DME provider provides only PERS or absorbent products; and

(4) the provider has a service facility that can readily replace and repair products when needed by the member.

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