Provider Application Cover Letter and Check List - Medical Practitioner.pdf

PE-MP-CL_2026-01

Dear Applicant:

Thank you for your interest in participating in MassHealth. Enclosed are an enrollment packet with the required application forms and a checklist on the reverse side of this letter for all required application documents.

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/eohhs/gov/laws-regs/masshealth/.

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/eohhs/gov/laws-regs/hhs/provider-payment-rates.

html.

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

MassHealth will notify you in writing of 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. Applicants can also verify the status of an application that has already been submitted by using MassHealth Provider Self-Service at https://masshealth.ehs.

state.ma.us/ProviderSelfService.

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

Commonwealth of Massachusetts

Executive Office of Health and Human Services www.mass.gov/masshealth https://masshealth.ehs.state.ma.us/ProviderSelfService https://masshealth.ehs.state.ma.us/ProviderSelfService

PE-MP-CL_2026-01

PROVIDER ENROLLMENT CHECKLIST: MEDICAL PRACTITIONER

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 guidance for providers on providing access to medical care for individuals with mobility disabilities. Please review this guidance and determine whether changes to your facilities, programs, and services are necessary. Please see www.ada.gov/medcare_mobility_ ta/medcare_ta.htm.

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. 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 and federal regulations. All but two of the forms referenced on this checklist are available for download at www.mass.gov/masshealth-provider-forms.

A. ALL applicants must submit the following:

1. A completed Medical Practitioner Provider Application (PE-MP)

2. A signed MassHealth Provider Contract for Individuals (GEN-15)

3. A completed Data Collection Form (POSC-DC-PE)

4. A completed Federally Required Disclosure Form for Individual Practitioners (PE-FRD-IN)

B. Individual practitioners practicing independently, and individual practitioners practicing BOTH independently AND as part of a group practice or other organization, must submit the following. Individual practitioners practicing ONLY as part of a group practice or other organization are NOT required to submit the following:

1. Massachusetts Substitute W-9 Form (MA-W-9) (Refer to the Tips for Completing the Massachusetts Substitute W-9 Form (APP-2) when completing this form.) MassHealth does not accept the federal W-9 Form.

2. An Electronic Funds Transfer Enrollment/Modification Form (EFT-1) (Please include a voided check with your EFT-1 form.)

3. An Electronic Remittance Advice Enrollment/Modification Form (ERA-1)

4. A signed Trading Partner Agreement (TPA)

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

1. Providers who are interested in enrolling in the PCC plan must submit a completed Primary Care Clinician

(PCC) Plan Provider Application (APP-PCC) along with a Primary Care Clinician (PCC) Plan Signature Page CON-PCC-SP, and the PCC Contract.

2. Providers who are Qualified Medicare Beneficiary (QMB)-Only Providers must submit a MassHealth Contract for QMB-Only Providers (QMB-1).

The Medical Practitioner Provider Application (PE-MP), the Primary Care Clinician (PCC) Plan Signature Page (CON-PCC-SP), the Primary Care Clinician Plan Provider Application (APP-PCC), and the PCC Contract are available by request from MassHealth at www.mass.gov/how-to/apply-to-become-a-masshealth-provider. Other forms related to this application are available for download at www.mass.gov/masshealth-provider-forms.

www.ada.gov/medcare_mobility_ta/medcare_ta.htm www.ada.gov/medcare_mobility_ta/medcare_ta.htm https://www.mass.gov/masshealth-provider-forms https://www.mass.gov/how-to/apply-to-become-a-masshealth-provider www.mass.gov/masshealth-provider-forms