Provider Responsibilities

In addition to meeting all other provider requirements set forth in 130 CMR 442.000 and 130 CMR 450.000: Administrative and Billing Regulations, the provider of orthotics must: (A) accept rates of payment established by the Executive Office of Health and Human Services as set forth in 101 CMR 334.00: Prostheses, Prosthetic Devices and Orthotic Devices for all orthotic services provided to MassHealth members, unless otherwise determined by the MassHealth agency or its designee through a selective contracting, preferred provider, or other process; (B) notify the MassHealth agency or its designee within 14 days prior to any changes in any of the information submitted in the provider application in accordance with 130 CMR 450.215: Provider Eligibility: Notification of Potential Changes in Eligibility and 130 CMR 450.223(B) including, but not limited to, change of ownership, change of address, change in scope of service, and additional service locations. The provider may not bill for new service locations until approved by MassHealth. The provider must maintain records of all such communications and transactions and make such records available to the MassHealth agency or its designee for review upon request; (C) ensure that the orthotic services provided are consistent with industry quality standards or any applicable standards established by the MassHealth agency, given the medical need for which the orthotics are prescribed and the member's functional limitations; (D) ensure prompt amelioration, repair or replacement of all orthoses or other orthotic services that have been provided to a member and which are subject to recall, in accordance with the specifications in the recall notice. The orthotics provider shall provide the member with a copy of the recall notice and fully address the recall as specified in the recall instructions no later than five business days from the date the orthotic provider receives the recall notice; (E) evaluate and access the member's need for orthotic services, and for delivery of the product(s) to the member either at the orthotic provider's service facility location or other setting as deemed appropriate by the member and the orthotics provider, including education of the member, or caregivers, as appropriate, in the use of the product; (F) ensure that all orthotic services are furnished to MassHealth members by employees of the orthotics provider, and that such employees are qualified in their respective disciplines to perform the orthotic services that they provide, consistent with 130 CMR 442.404(B)(8); (G) comply with MassHealth administrative and billing regulations at 130 CMR 450.000: Administrative and Billing Regulations, including any third party liability or member cost-sharing requirements; (H) comply with applicable state and federal third party liability requirements for MassHealth members with other insurance, including dually eligible members. This includes compliance with state and federal law and other subregulatory requirements necessary to obtain payment from other liable parties; (I) comply with all applicable Medicare billing and authorization requirements and make diligent efforts to identify and obtain payment from all other liable parties including Medicare, before billing MassHealth, in accordance with 130 CMR 450.316: Third-party Liability: Requirements. This includes appealing a denied claim when the service is payable in whole or in part by Medicare or other liable parties or payers; (J) report to the proper authorities any suspected abuse or neglect that staff may observe when providing service to a member, as mandated by M.G.L. c.19A, §15. M.G.L.c.19C, §10, M.G.L. c.111, §72G, M.G,L. c.119m §51A, , in addition to any other suspected abuse or neglect as required by other state and federal law; (K) adhere to the Medicare supplier standards set forth by CMS; (L) not alter any invoice or medical documentation; (M) not solicit members to purchase additional orthotic services; (N) submit prior-authorization requests, as specified by 130 CMR 442.412, to the MassHealth agency, or its designee. Prior authorization requests should only be submitted when the orthotic service is medically necessary and when prior-authorization is a prerequisite in accordance with 130 CMR 442.412, and when other MassHealth guidance requires it; (O) respond to members’ complaints or complaints made on behalf of a member within two business days; (P) not share a service facility or physical location (including a consignment closet, unless permitted by specific MassHealth guidance) with a provider who is authorized to prescribe orthotics, or with another orthotics provider, except as permitted by 42 CFR 424.57(C)(29)(ii) (Medicare Supplier Standard 29); (Q) have a complaint resolution protocol to promptly address members’ complaints and keep written complaints, related correspondence, and any notes of actions taken in response to written and oral complaints, and maintain such information in accordance with 130 CMR 442.423(I). This includes responding to any member complaints within two business days; (R) ensure that the member and the member’s caregivers, as appropriate, can use all orthotics provided safely and effectively in the settings of anticipated use; (S) comply with applicable CMS and MassHealth quality standards and any applicable quality measurement program requirements; and (T) provide MassHealth members, currently being serviced by the provider, with written notification at least 60 days in advance of any change in the orthotics provider’s scope of business or services (for example, if a provider decides to no longer provide certain products), or if the scope of the provider’s Medicare accreditation changes). Notification to the member must include: (1) a statement that the member can contact MassHealth Customer Service or other agency designee to request a list of MassHealth participating Orthotics providers in their area; 2) offer assistance to the member regarding transfer of services to another provider if appropriate; and (3) if prior authorization is required for the service: (a) information about any unbilled units remaining on the PA; and (b) a copy of the original PA approval from MassHealth for the member to provide to the new orthotics provider.