442.404 - Provider Eligibility

442.404. Provider Eligibility

(A) Provider Participation Requirements. Payment for services described in 130 CMR 442.000, is only to providers who, as of the date of service, are participating in MassHealth as an orthotics provider or are a MassHealth prosthetics provider that has been assigned an orthotics specialty in accordance with 130 CMR 442.404(C).

(B) General Qualifications. To qualify as a MassHealth orthotics provider, all applicants and providers must enter into a provider contract or agreement with MassHealth and

(1) have a service facility that:

(a) is open a minimum of 30 hours per week;

(b) is staffed with an employee during posted business hours;

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

(d) is physically accessible to members with disabilities, and complies with all ADA guidelines;

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

(f) has the space and capability for evaluating/assessing, repairing, modifying, adjusting and customizing products to meet members' needs;

(g) the provider can demonstrate their ability to fill orders, fabricate, or fit items from its own inventory or by direct purchase of items necessary to fill the order.

(h) has a sign visible from outside the service 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 with the business name both at the main entrance of the building and the location where the service facility is located. The hours must be posted within the business complex where the service facility is located;

(i) 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 exclusively be a pager, answering service, voice message system, or cell phone; and

(j) maintains a 24-hour voice message system and/or answering service.

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

(3) primarily engage in the business of providing orthotics, or orthotic repair services to the public, except for specialty providers described in 130 CMR 442.404(C), (a MassHealth prosthetics provider that has been assigned an orthotics specialty);

(4) participate in the Medicare program as a provider;

(5) have a Medicare provider number for each business and service facility and location for which it is applying to participate or participating in MassHealth:

(6) be accredited by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. (ABC), or the Board of Certification/Accreditation International (BOC) as a comprehensive orthotics facility, and display such accreditations at service facility locations;

(7) for each service facility, maintain fulltime coverage by an ABC- or BOC-certified orthotist or orthotists responsible for overall patient care and for providing or supervising the noncertified orthotists for the provision of, comprehensive orthotic services at that service facility. A noncertified orthotist must be employed by the MassHealth-enrolled Orthotics provider;

(8) ensure that any professional staff from the disciplines listed in 130 CMR 442.404(B)(8)(a) through (d), who provide orthotic services to members meet the requirements set forth in 130 CMR 442.404(B)(8)(a) through (d), for their respective disciplines, and that the services provided are within their scope of practice and training.

(a) An orthotics fitter must be ABC- or BOC-certified or work under the supervision of an ABC- or BOC-certified orthotist, and be employed by the MassHealth Orthotics provider.

(b) A fitter of therapeutic shoes for diabetics must be ABC- or BOC-certified or work under the supervision of an ABC- or BOC-certified orthotist or ABC- or BOC-certified pedorthist, and be employed by the MassHealth Orthotics provider.

(c) An Orthotic assistant must be ABC- or BOC-certified or work under the supervision of an ABC- or BOC-certified orthotist, and be employed by the MassHealth Orthotics provider.

(d) A pedorthist may be ABC- or BOC-certified or may be noncertified. A non- certified pedorthist must work under the supervision of an ABC- or BOC-certified orthotist or ABC- or BOC-certified pedorthist. All pedorthists must be employed by the MassHealth-enrolled Orthotics provider.

(9) meet all applicable federal, state, and local requirements, including requirements for certifications and registrations;

(10) at the time of application and recredentialing, or any other time as requested by the MassHealth agency or its designee, and provide all required documentation specified in 130 CMR 450.000: Administrative and Billing Regulations and 130 CMR 450.215: Provider Eligibility: Notification of Potential Changes in Eligibility, including:

(a) all current liability insurance policies;

(b) the property lease agreement(s) for each service facility, or a copy of the most recent property tax bill if applicant owns the business site;

(c) all current signed employee professional credentials, as applicable;

(d) the current facility ABC or BOC accreditation letter; and

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

(11) provide, or make available upon request, a copy of written policies and procedures, including the customer service protocol, customer complaint tracking and resolution protocol, and staff training;

(12) conduct Criminal Offender Record Information (CORI) checks on employees and subcontractors in accordance with procedures outlined in EOHHS CORI regulations at 101 CMR 15.00: Criminal Offender Record Checks, and conducting applicable Office of Inspector General (OIG) verifications on all personnel;

(13) not accept prescriptions from any prescribing provider who has a financial interest in the orthotics provider or any prescribing provider who is employed by an entity that has a financial interest in the orthotics provider;

(14) cooperate with the MassHealth agency or its designee during the application and recredentialing process and record reviews, including agreeing to periodic inspections to ensure compliance with 130 CMR 442.000 and applicable state and federal laws and regulations;

(15) establish, maintain, and comply with written policies and procedures in accordance with 130 CMR 442.000 and 130 CMR 450.000: Administrative and Billing Regulations; and

(16) agree to participate in any orthotic provider orientation or any other training required by EOHHS.

(C) Providers Assigned Orthotics Specialty. Applicants or providers whose primary business is not orthotics or orthotic repair services for the public may qualify to provide orthotic services if the following conditions are met:

(1) the applicant or provider is enrolled as a MassHealth provider of prosthetic services in accordance with 130 CMR 428.000: Prosthetic Services;

(2) the applicant or provider meets all other conditions under 130 CMR 442.404 to provide Orthotic services; and

(3) MassHealth has assigned a specialty of Orthotics to the applicant's or provider's existing provider number for prosthetic services.

(D) In-state. To participate in MassHealth as an in-state orthotics provider, the applicant or provider of orthotics must have a service facility in Massachusetts that meets the criteria described in 130 CMR 442.404(B), and must meet all other criteria described in 130 CMR 442.404.

(E) Out-of-state. To participate in MassHealth as an out of state orthotics provider, an applicant or provider of orthotics must meet all of the following conditions:

(1) the provider participates in the Medicare program, and participates in the medical assistance program of the state in which the provider primarily conducts business;

(2) the provider meets all applicable requirements under 130 CMR 442.000 and 130 CMR 450.000: Administrative and Billing Regulations, and 42 CFR 431.52; and

(3) The MassHealth agency or its designee has determined that the out-of-state provider provides orthotics that meets a MassHealth-identified agency need.

(Amended by Mass Register Issue 1395, eff. 7/12/2019.)

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