Quality Management and Utilization Review

(A) A hospice 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 hospice provider’s place of business upon request by MassHealth or its designee. (B) A hospice 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 certification of terminal illness and other records to determine if services are medically necessary in accordance with 130 CMR 437.000. The hospice 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. (C) Upon request, a hospice provider must submit to the MassHealth agency or its designee a statement of fiscal soundness attesting to the financial viability of the hospice provider supported by documentation to demonstrate that the provider has adequate resources to finance the provision of services in accordance with 130 CMR 437.000.