Sanctions: General

(A) Introduction. All providers are subject to the rules, regulations, standards, and laws governing MassHealth. 130 CMR 450.238 through 450.240 set forth the MassHealth agency’s procedures for imposing sanctions for violations of those rules, regulations, standards, and laws. Such sanctions may include, but are not limited to, administrative fines, provider service restrictions, and suspension or termination from participation in MassHealth. The MassHealth agency determines the amount of any fine and may take into account the particular circumstances of the violation. The MassHealth agency may assess an administrative fine whether or not overpayments have been identified based on the same set of facts. (B) Instances of Violation. Instances of violation include, but are not limited to (1) billing a member for services that are payable under MassHealth, except copayments as provided in 130 CMR 450.130; (2) submitting claims under an individual provider’s MassHealth provider number for services for which the provider is entitled to payment from an employer or under a contract or other agreement; (3) billing the MassHealth agency for services provided by someone other than the provider, unless expressly permitted by the applicable regulations; (4) billing the MassHealth agency before delivery of service, unless permitted by the applicable regulations; (5) failing to comply with recordkeeping and disclosure requirements; (6) overstating or misrepresenting services, including submitting separate claims for services or procedures provided as components of a more comprehensive service for which a single rate of payment is established; (7) failing to return credit balance funds to the MassHealth agency within 60 days of their receipt; (8) failing to obtain or provide a physician's order, prescription, or referral when required by the applicable regulations; (9) failing to comply with MassHealth enrollment, licensure, or certification requirements; and (10) misapplication or misappropriation of personal needs allowance funds.