Determination of Compliance with Medical Standards

Violations of 130 CMR 450.204 may be determined by peer review. Except as otherwise required by law, the MassHealth agency will decide the level and manner of peer review in each instance. Such peer review may be conducted by a qualified MassHealth agency employee or consultant or by one or more qualified persons provided by health-care foundations, professional societies, or such other professional organizations as the MassHealth agency may select. In appropriate cases, the MassHealth agency may rely in part or in whole upon reviews conducted by a utilization and quality-control review organization or a board of registration. In the event that the MassHealth agency decides to pursue any sanction or recovery of overpayment as a result of a peer-review recommendation, the provisions of 130 CMR 450.235 through 450.260 apply.