Provider Application Cover Letter and Check List - Independent Clinic.pdf

PE-ICC-CL (Rev. 02/24)

Dear Applicant:

Thank you for your interest in participating in MassHealth. Enclosed is a checklist of required application documents and an enrollment packet.

Before submitting your application, you should review MassHealth's all-provider regulations (130 CMR 450.000) and all applicable program-specific regulations. You can access these regulations from the MassHealth website at www.mass.gov/masshealth-and-eohhs-regulations.

Note: Provider payment rates that are applicable to MassHealth-covered services can be accessed on the Executive Office of Health and Human Services website at www.mass.gov/service-details/eohhs-regulations.

To ensure that your application is processed in a timely manner, you must return to the following address or by fax all of the required application documents listed on the checklist.

MassHealth will notify you in writing on its decision about your application. You are not a participating MassHealth provider until you have satisfied the enrollment requirements and have been notified that your enrollment has been approved. Payment will not be made for any claims submitted for services, care, or supplies furnished before the enrollment date authorized by MassHealth.

If you have any questions about the enrollment process, please email PEC@Maximus.com. For general questions, you may contact MassHealth by email at provider@masshealthquestions.com. Please note: These email boxes are only for general questions. They are not secure. Please do not send documents to these email boxes, or include any personal health information (PHI) or personally identifiable information (PII). You may also call (800) 841-2900, TDD/TTY: 711.

Sincerely, MassHealth

PROVIDER ENROLLMENT CHECKLIST: INDEPENDENT CLINIC/CENTER

Providers who participate in MassHealth are responsible for delivering crucial services to MassHealth members with disabilities and other vulnerable populations. Providers should be aware of the Americans with Disabilities Act (ADA) and its requirements. The U.S. Department of Justice, which enforces the ADA, has issued guidelines for providers on providing individuals with mobility disabilities access to medical care. Please see www.ada.gov/medcare_mobility_ta/medcare_ ta.htm. Please review these guidelines and determine if changes to your facilities, programs, and services are necessary.

Please carefully review the following list of items that you need to include with your application. This list is designed to help ensure that your application is complete. Submitting an incomplete application may result in the delay or denial of your application. Each of these documents has been included in the application packet you received.

Commonwealth of Massachusetts

Executive Office of Health and Human Services www.mass.gov/masshealth www.mass.gov/masshealth-and-eohhs-regulations www.mass.gov/service-details/eohhs-regulations www.ada.gov/medcare_mobility_ta/medcare_ta.htm www.ada.gov/medcare_mobility_ta/medcare_ta.htm

PE-ICC-CL (Rev. 02/24)

If you are enrolling as a non-billing site, you must list in Section 2 a billing site PID/SL that is actively enrolled under the same FEIN, NPI, provider type, and license number (if applicable) as the non-billing site. Claims submitted for a non-billing site must have the service location list the correct address in the appropriate loop/segment of the 837.

A. ALL applicants must submit the following:

PE-ICC application.)

B. If you are enrolling as a billing site, you must submit:

1. A Request for Taxpayer Identification Number and Certification (Massachusetts Substitute W-9 form) (Refer to Tips for Completing the Massachusetts Substitute W-9 Form (APP-2) when completing this form.) MassHealth does not accept the federal W-9 form.

C. CERTAIN providers, as indicated below, must submit the following:

1. A signed Provider Contract for Entities (GEN-16), if applicable (The following provider types listed in Section 1.1 of the Independent Clinic/Center Provider Application require a GEN-16: B8, 20, 21, 22, 25, 26, 28, 45, 46, 65, 84, 85, 87, and 96.)

28, 46, 65, 84, 85, and 96. Provider types 45 and 87 may require a license.)

4. A copy of the applicant’s current accreditation or certification (provider type 84). A copy of the BSAS certification (BSAS certification optional for Mental Health Center (PT-26) and required for PT-28: Substance Use providers billing for substance use codes.)

5. Provider type 85 (freestanding birth center) must (1) submit with their application their agreement with a nearby hospital providing obstetrical and newborn services for the transfer of their patients for emergency treatment beyond that provided by the FBC, and (2) be accredited by the Commission for the Accreditation of Birth Centers (CABC) by the later of the date of application or April 21, 2022.

6. A completed Independent Clinic/Center Supplemental Application for Mental Health Centers (PE-ICC-SUPP-26) for each service location if applicable, including all required attachments

7. A completed Independent Clinic/Center Supplemental Application for Limited Service Clinic (PE-ICC-SUPP-96) for each service location if applicable, including all required attachments Note: Nurse practitioners who provide services to members must be enrolled as a full provider.

8. Providers who are qualified Medicare beneficiary (QMB)-Only providers must submit a MassHealth Contract for QMB-Only Providers (QMB-1) only.

9. CHCs that are interested in enrolling in the PCC plan must submit a completed Primary Care Clinician (PCC) Plan Provider Application (APP-PCC), a Primary Care Clinician (PCC) Plan Signature Page CON-PCC-SP, and the PCC Contract.

10. If applying as a result of a merger, acquisition, closure, or change in corporate structure, include a copy of Purchase of Sale or other documentation of changes.

Please note that this list is only a guide and is not intended to alter or supersede any application requirements set forth in the applicable state or federal regulations.

Forms, with the exception of the Independent Clinic/Center Provider Application (PE-ICC) and supplements (PE-ICC-SUPP-26 and PE-ICC-SUPP-96), are available for download at www.mass.gov/masshealth-provider-forms. The Independent Clinic/Center Provider Application (PE-ICC) the Primary Care Clinician (PCC) Plan Provider Application (APP-PCC), and the PCC Contract and supplements (PE-ICC-SUPP-26 and PE-ICC-SUPP-96) are available from MassHealth upon request.