Quality Management and Utilization Review

(A) A therapy provider must participate in any quality management and program integrity processes as required by the MassHealth agency, including making any necessary data available and providing access to visit the therapy provider’s place of business upon request by MassHealth or its designee. (B) A therapy provider must submit requested documentation to the MassHealth agency or its designee for purposes of utilization review and provider review and audit, within the MassHealth agency’s or its designee’s time specifications. The MassHealth agency or its designee may periodically review a member’s plan of care and other records to determine if services are medically necessary in accordance with 130 CMR 450.204: Medical Necessity. The therapy provider must provide the MassHealth agency or its designee with any supporting documentation the MassHealth agency or its designee requests, in accordance with M.G.L. c. 118E, § 38 and 130 CMR 450.000: Administrative and Billing Regulations.