Section 456.420 - Case-mix Classification(A) MassHealth pays for nursing facility services based on per diem rates that correspond to the nursing care needs of members in a facility using a case-mix classification system.(B) To determine the member's nursing care needs, a nursing facility must complete a case-mix classification assessment to be specified by EOHHS and in accordance with sub-regulatory guidance. Based on the assessment, each member is assigned a case-mix classification rating, which corresponds to a rate of payment established by MassHealth.(C) MassHealth or its designee may periodically audit medical records to ensure that the nursing facility's documentation supports the per diem case-mix classification rating. MassHealth or its designee must be permitted access to the facility's records and the facility's premises for an audit pursuant to 130 CMR 456.420(C).(D) As part of the review under 130 CMR 456.420(C), if it is determined that the case-mix classification rating is not supported, MassHealth or its designee will notify the nursing facility of any re-classification by MassHealth through the issuance of audit findings. If MassHealth's case-mix classification rating differs from that of the nursing facility, MassHealth's case-mix classification rating will supersede the facility's and the facility must bill for the member's payment cycle at the MassHealth audited case-mix classification per diem rate.(E) If in the course of conducting audits MassHealth determines that any of the regulations, rules, instructions, or procedures of MassHealth have been violated by the nursing facility, MassHealth may implement an overpayment action and/or impose sanctions against the nursing facility in accordance with MassHealth's administrative and billing regulations at 130 CMR 450.000: Administrative and Billing Regulations.Amended by Mass Register Issue 1505, eff. 10/1/2023.