Provider Eligibility

The MassHealth agency pays for the services described in 130 CMR 431.000 only when performed by eligible providers of IDTF services who are participating in MassHealth on the date of service. The participating provider is responsible for the quality of all services for which payment is claimed, the accuracy of such claims, and compliance with all regulations applicable to IDTF services under MassHealth. In order to claim payment, the participating provider must be the IDTF that actually performed the service. An IDTF must have one or more supervising physicians who are responsible for the personal, direct, or general supervision of the facility and its personnel in accordance with Medicare requirements at 42 CFR §410.323 (b)(3), the operation and calibration of the equipment, and the quality of the testing performed. (A) Participating Providers: The following diagnostic testing facilities are eligible to participate in MassHealth as IDTF providers: (1) diagnostic imaging centers: centers that perform a variety of tests, including ultrasounds, positron emission tomography (PET) scans, and other imaging studies; (2) freestanding MRI centers: independent MRI centers that perform MRI or magnetic resonance angiography (MRA) services in accordance with standards developed by the American College of Radiology (ACR); (3) portable X rays: all suppliers of portable X ray services who are in compliance with 42 CFR 486 Part C and are certified under the Medicare program; (4) sleep centers: clinics that perform diagnostic tests to determine the existence and type of sleep disorders; and (5) mammography vans: mobile facilities that provide radiological tests for breast cancer. (B) In-State Providers. To be eligible to participate as a MassHealth provider, an IDTF must: (1) be located and doing business in the Commonwealth of Massachusetts; (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) when required, obtain a determination of need, issued by the Massachusetts Department of Public Health; (4) participate in the Medicare program as an independent diagnostic testing facility; and (5) have all radiology equipment used to provide services inspected and certified by the Massachusetts Department of Public Health. (C) Out-of-State Providers. An out-of-state IDTF provider that does not meet the requirements of 130 CMR 431.404(B)(1), (2), and (3), may participate in MassHealth only if the IDTF is licensed in its own state and it meets the requirements of 130 CMR 431.404(B)(4) and 450.109: Out-of-State Services.