130 CMR, § 450.211

Current through Register 1536, December 6, 2024

Section 450.211 - Medicaid Electronic Health Records Incentive Payment Program

(A)Applicability. The provisions set forth in 130 CMR 450.211 establish the MassHealth agency's review process for provider disputes concerning the Medicaid Electronic Health Records Incentive Payment Program established pursuant to § 4201 of the American Recovery and Reinvestment Act of 2009, P.L. 111-5 and 42 CFR Part 495.

(B)Medicaid Electronic Health Records Incentive Payment Program Notice. The MassHealth agency will notify the provider in writing of the agency's determination of the provider's Medicaid Electronic Health Records Incentive Payment Program eligibility and payment amount. The notice will identify the provider's eligibility, determination of payment amount, and right to review. The MassHealth agency will notify the provider by letter, report, computer printout, electronic transmission, or other format. This notification is the Medicaid Electronic Health Records Incentive Payment Program Notice referred to in 130 CMR 450.211.

(C)Requesting MassHealth Agency Review of Medicaid Electronic Health Records Incentive Payment Program Determinations.

(1) To preserve its right to an adjudicatory hearing and judicial review, a provider must request MassHealth agency review of the agency's determination specified in the Medicaid Electronic Health Records Incentive Payment Program Notice. A provider's request for review may be based on either an alleged error in the MassHealth agency's determination of the provider's Medicaid Electronic Health Records Incentive Payment Program eligibility and payment amount or on information that was not initially supplied during the application process. The provider's request for review must be made in writing and be received by the MassHealth agency within 30 calendar days of the date appearing on the Medicaid Electronic Health Records Incentive Payment Program Notice. Only those determinations specifically identified in dispute by the provider in its request for an agency review are subject to review.

(2) A provider's request for review may request reconsideration of the following findings:

(a) the provider's eligibility for incentive payments; and

(b) incentive payment amounts.

(3) Any request for agency review submitted pursuant to 130 CMR 450.211(C)(1) must

(a) identify with specificity all determinations with which the provider disagrees;

(b) specify in sufficient detail the basis for the provider's disagreement with those determinations;

(c) identify and address all issues in the Medicaid Electronic Health Records Incentive Payment Program Notice with which the provider disagrees; and

(d) include any documentary evidence and information that the provider wants the MassHealth agency to consider.

(D)MassHealth Agency's Final Determination.

(1) The MassHealth agency will review a provider's request for agency review only if it is submitted in compliance with the requirements of 130 CMR 450.211(C)(1) through (3). The MassHealth agency is not obligated to consider any information or documents that the provider failed to timely submit under time deadlines previously imposed by the MassHealth agency. The MassHealth agency will issue a final written determination of contested Medicaid Electronic Health Records Incentive Payment Program determinations based on its review, which will state the reasons for the determination, and inform the provider of the provider's right to file a claim for an adjudicatory hearing in accordance with 130 CMR 450.241.

(2) Any findings specified in the Medicaid Electronic Health Records Incentive Payment Program Notice that are not specifically identified as in dispute in a provider's request for agency review will, without further notice, constitute the MassHealth agency's final determination. The provider has no right to an adjudicatory hearing pursuant to 130 CMR 450.241 or judicial review of such findings because of the failure to exhaust its administrative remedies.

(3) If the provider does not submit a request for agency review, the Medicaid Electronic Health Records Incentive Payment Program Notice constitutes the MassHealth agency's final determination. If a provider requests agency review but fails to timely comply with the requirements of 130 CMR 450.211(C)(1) through (3), the request for agency review may be denied. In either case, the Medicaid Electronic Health Records Incentive Payment Program Notice constitutes the MassHealth agency's final determination, and the provider has no right to an adjudicatory hearing pursuant to 130 CMR 450.241 or judicial review because of the failure to exhaust its administrative remedies.