Provider Eligibility

(A) Provider Participation Requirements. Payment for services described in 130 CMR 428.000 is made to providers who are participating in MassHealth as prosthetic providers; to providers also enrolled as MassHealth participating DME providers; OXY providers, or orthotic services providers and who meet all program-specific requirements. Applicants must meet the requirements in 130 CMR 450.000: Administrative and Billing Regulations as well as the requirements in 130 CMR 428.000. Participating prosthetic providers must continue to meet provider eligibility participation requirements throughout the period of their provider contract with the MassHealth agency. (B) In State. To participate in MassHealth, a provider with a service facility in Massachusetts must: (1) primarily engage in the business of providing prosthetic and repair services to the public; (2) meet all state and local requirements for engaging in such business; (3) be or employ a prosthetist currently certified by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics Inc. (ABC), or the Board of Certification/Accreditation, International (BOC), unless the provider intends to solely provide breast prostheses and accessories, in which case the provider must employ, for each service facility location, at least one full-time certified mastectomy fitter, who is currently certified by the ABC or BOC. (4) be a Medicare provider; (5) have a service facility that is physically accessible to MassHealth members during reasonable business hours; (6) maintain a visible sign identifying the business and hours of operation; (7) maintain a primary business telephone listed under the name of the business in a local directory. The exclusive use of a pager, answering machine, or cell phone is prohibited; and (8) obtain a provider number from MassHealth and, if the provider intends to solely provide breast prostheses and accessories, be designated by the MassHealth agency as a specialty provider of certified mastectomy fitter services. (C) Out of State. A provider with no service facility in Massachusetts may participate in MassHealth only if the provider participates in the Medicaid program of the state in which the provider primarily conducts business and otherwise meets the requirements of 130 CMR 428.404(A). Such a provider may receive payment for MassHealth services only as set forth in 130 CMR 450.109: Out-of-state Services.