Provider Eligibility

Payment for the services described in 130 CMR 423.000 will be made only to in-state and out-of-state surgical centers participating in MassHealth on the date of service. The MassHealth agency has established the provider eligibility requirements listed below for in-state and out-of- state providers. Providers must meet all of these requirements to participate in MassHealth as a surgical center. (A) Procedures for Hospitalization. An in-state or out-of-state surgical center must have established procedures to ensure the transfer of a member to a hospital if an emergency occurs that requires treatment beyond the capabilities of the surgical center. Either the surgical center must have a written transfer agreement with a hospital, or all the dentists, physicians, and podiatrists with surgical privileges at the surgical center must have admitting privileges at the hospital. The hospital must be a MassHealth-participating provider, and must be licensed to operate as a hospital in accordance with 105 CMR 130.000: Hospital Licensure or with its own state's licensing agency. (B) In-State Providers. To participate in MassHealth, an in-state surgical center must: (1) obtain a MassHealth provider number from the MassHealth agency; (2) operate under a clinic license issued by the Massachusetts Department of Public Health, in accordance with regulations at 105 CMR 140.000; Licensure of Clinics; (3) participate in the Medicare program as an ambulatory surgery center; (4) be accredited by a national accrediting body for ambulatory surgery centers; and (5) have a minimum of two dedicated operating rooms. (C) Out-of-State Providers. (1) To participate in MassHealth, an out-of-state surgical center must (a) obtain a MassHealth provider number from the MassHealth agency; (b) participate in its own state’s Medicaid program; (c) operate as a provider of surgical center services as authorized by the governing or licensing agency in its state; (d) participate in the Medicare program as an ambulatory surgery center; (e) be accredited by a national accrediting body for ambulatory surgery centers; and (f) have a minimum of two dedicated operating rooms. (2) Out-of-state surgical center services provided to an eligible MassHealth member are payable only when (a) the surgical services are provided to a member who resides in a community located within a 50-mile radius of the Massachusetts border in Connecticut, Maine, New Hampshire, New York, Rhode Island, or Vermont and for whom the out-of-state freestanding ambulatory surgical center is nearer than a facility in Massachusetts providing equivalent surgical services; or (b) an out-of-state surgical center that is more than 50 miles from the Massachusetts border obtains prior authorization from the MassHealth agency to provide any surgical center services to a member. This prior authorization is required in addition to the prior- authorization requirements found at 130 CMR 423.406. All requests for prior authorization must be submitted in accordance with the instructions found in Subchapter 5 of the Freestanding Ambulatory Surgery Center Manual. No payment will be made for such services unless prior authorization has been obtained from the MassHealth agency before the delivery of service. The MassHealth agency does not grant retroactive prior- authorization requests.