130 CMR, § 409.404

Current through Register 1536, December 6, 2024

Section 409.404 - Provider Eligibility

(A)Provider Participation Requirements. Payment for services described in 130 CMR 409.000 is made to DME providers who, as of the date of service, are participating in MassHealth; to providers also enrolled as MassHealth-participating OXY providers, orthotic services providers, or prosthetic services providers and who meet all program-specific requirements; and to MassHealth-enrolled pharmacy providers who have been assigned a DME specialty in accordance with 130 CMR 409.404(C) as of the date of service. Applicants must meet the requirements in 130 CMR 450.000: Administrative and Billing Regulations as well as the requirements in 130 CMR 409.000. Participating DME providers must continue to meet provider eligibility participation requirements throughout the period of their provider contract with the MassHealth agency.

(B)General Qualifications. To qualify as a MassHealth DME provider, all applicants and providers must enter into a provider contract or agreement with MassHealth, and:

(1) have a service facility that

(a) is open a minimum of 30 hours per week;

(b) is staffed with an employee during posted business hours;

(c) is available to members during regular, posted business hours;

(d) has available inventory for all products for which the DME provider has been accredited by an Accrediting Body, and for which the DME provider is enrolled in MassHealth, with the exception of items provided by subcontractors;

(e) is accessible to all members, including members with disabilities;

(f) has clear access and space for individualized ordering, returns, repair, and storing of business records;

(g) has a sign visible from outside the facility identifying the business name and hours that the service facility is open. If the DME provider's place of business is located within a building complex, the sign must be visible at the main entrance of the building where the service facility is located;

(h) has a primary business telephone number listed in the name of the business with a local toll-free telephone number that is answered by customer service staff during business hours, and that has TTY transmission and reception capability. During business hours, this number cannot be a pager, answering service, or voice message system; and

(i) during off hours, must maintain a voice message system and/or answering service;

(2) obtain separate approval from the MassHealth agency and a separate provider number for each service facility operated by the DME provider;

(3) engage in the business of providing DME or DME repair services to the public;

(4) be accredited by an Accrediting Body to participate or enroll in the Medicare program as a DME provider for the same business and service facility for which the applicant is applying to become a MassHealth provider, unless the provider supplies only items not covered by Medicare;

(5) meet all applicable federal, state, and local requirements, certifications, and registrations;

(6) conduct applicable Office of Inspector General (OIG) verifications on all staff;

(7) at the time of application and recredentialing, or any other time as requested by the MassHealth agency, provide all required documentation specified in 130 CMR 450.000: Administrative and Billing Regulations, and updated documentation in accordance with 130 CMR 450.223(B) and 130 CMR 450.215: Provider Eligibility: Notification of Potential Changes in Eligibility, including:

(a) a list of contracted manufacturers used for purchased products;

(b) a copy of all current liability insurance policies;

(c) a copy of the property lease agreement pertinent to the service facility, or a copy of the most recent property tax bill if applicant owns the business site; and

(d) for mobility providers only, a copy of current RESNA ATP certificate for each certified staff member.

1. DME providers who furnish mobility systems corresponding to one of the HCPCS codes for which CMS requires a certified ATP must employ at least one certified ATP at each service facility.

2. The ATP at each service facility must possess knowledge of the standards of acceptable practice in the provision of DME, including ordering, assembling, adjusting, and delivering DME, and providing ongoing support and services to meet a person's rehabilitation equipment needs;

(e) a copy of all current signed employee professional licenses, as applicable;

(f) a copy of current accreditation letters;

(g) a copy of the purchase and sale agreement if the applicant or DME provider has recently been purchased by another entity or has purchased the company for which they are applying to become a MassHealth DME provider;

(h) a copy of subcontracts, if applicable, as described in 130 CMR 409.412. For PERS providers, the subcontract must include the central monitoring station contract, if applicable;

(i) a copy of the applicant's emergency preparedness plan as approved by the accrediting body;

(j) a copy of written policies and procedures, including the customer service protocol, customer complaint tracking and resolution protocol, the protocol on transfer and discharge of members, staff training; and

(k) for PERS providers only, a copy of documentation demonstrating compliance with UL Standards 1637 in accordance with 130 CMR 409.429(C);

(l) Controlled Substances Registrations through the Commonwealth of Massachusetts Department of Public Health, Division of Food and Drug (if provider provides oxygen);

(m) a Sterilization/Sanitation of Bedding, Upholstered Furniture, and Filling Materials License through the Department of Public Health, Division of Food and Drug (if applicable);

(8) for a provider of home infusion services, be a licensed pharmacy in Massachusetts or in the state where the provider is located, and be accredited by an Accrediting Body, and be assigned a DME specialty by the MassHealth agency (see130 CMR 409.404(C));

(9) conduct pre-employment CORI checks on employees and subcontractors and keep CORIs on file at the DME provider's place of business;

(10) not accept prescriptions for MassHealth DME from any ordering practitioner who has a financial interest in the DME provider;

(11) cooperate with the MassHealth agency or its designee during the application and recredentialing process including, but not limited to, site visits or periodic inspections to ensure compliance with 130 CMR 409.000 and applicable state and federal laws and regulations; and

(12) comply with applicable CMS provider requirements, including supplier standards listed at 42 CFR 424.57(c) and any CMS or MassHealth quality standards.

(C)Providers Assigned DME Specialty. An applicant or provider enrolled as a MassHealth provider of pharmacy services under 130 CMR 406.000: Pharmacy Services may qualify to provide DME services if the following conditions are met:

(1) the applicant or provider meets all other conditions under 130 CMR 409.404 and 405 to provide DME services; and

(2) MassHealth has assigned a specialty of DME to the applicant's or provider's existing provider number for pharmacy services; or

(3) the MassHealth agency has determined that the applicant proposes to provide repairs of DME and meets the MassHealth agency requirements for participation as a DME repair provider.

(D)In State. To qualify as an in-state DME provider, the applicant or provider must have a service facility located in Massachusetts that meets the criteria described in 130 CMR 409.404(B)(1).

(E)Out of State. An applicant or provider of DME with a service facility located outside of Massachusetts may qualify as a MassHealth DME provider only if the following condition is met:

(1) all applicable requirements under 130 CMR 409.000 and 130 CMR 450.000: Administrative and Billing Regulations, and 42 CFR 431.52 are met;

(2) the out-of-state DME provider participates in the Medicaid program of the state in which the provider primarily conducts business;

(3) the DME provider participates in the Medicare program, unless the DME provider provides only PERS or absorbent products;

(4) the provider has a service facility that can readily replace and repair products when needed by the member; and

(5) the MassHealth agency has determined that the out-of-state applicant proposes to provide durable medical equipment or supplies that meet a need identified by the MassHealth agency.