Provider Application - Medical Practitioner.pdf

| page 1 |PE-MP_2026-01 PROVIDER APPLICATION: Medical Practitioner

PROVIDER APPLICATION

MEDICAL PRACTITIONER

Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth

APPLICATION TRACKING NUMBER (ATN)

This application will not be processed if any sections are left unanswered.

CONTACT INFORMATION FOR INDIVIDUAL COMPLETING THIS APPLICATION (MassHealth may contact you if there are questions about this application.)

Name Tel.

Email

REASON FOR APPLICATION

New enrollment Reactivation – Provider ID Service Location (PID/SL)

SECTION 1: APPLICANT INFORMATION

Note: Should this or any other information on this application change, you must notify MassHealth prior to the change.

Please go to MassHealth Provider Self-Service (https://masshealth.ehs.state.ma.us/ProviderSelfService/).

1.1 APPLICATION TYPE

Is the applicant enrolling as An individual practitioner practicing independently Part of a group practice organization Both

Note: This application is for individual practitioners of the provider types listed below, who practice independently or as part of a group practice, and who wish to enroll as a participating MassHealth practitioner. This application should not be completed by other salaried or contracting providers, ordering and referring applicants, or managed care entities (MCE) applicants. Indicate your provider type below (select one).

Physician (PT–01)*

Optometrist (PT–02)

Optician (PT–03)

Ocularist (PT–04)

Psychologist (PT–05)

Podiatrist (PT–06)

Certified nurse midwife (PT–08)

Chiropractor (PT–16)

Certified nurse practitioner (PT–17)*

Physician assistant (PT–39) (Must be a part of a group practice organization with at least one physician)

Hearing Instrument Specialist (PT–44)

Audiologist (PT–50)

Certified registered nurse anesthetist (PT–51)

Clinical nurse specialist (PT–57)

Psychiatric clinical nurse specialist (PT–78)

Qualified Medicare Beneficiary (QMB)-only provider (PT–86) (Cannot be part of a group practice organization)

Acupuncturist (PT–A9)

Licensed independent behavioral health clinicians

(LIBHC) (PT–B6)

Licensed marriage and family therapists (LMFT)

Licensed mental health counselors (LMHC)

Licensed independent clinical social worker (PT–92)

*These providers can enroll as independent PCCs. PCC-qualifying providers must specialize in: family medicine, internal medicine, pediatrics, OB/GYN, or GYN, and otherwise satisfy PCC Plan participation requirements.

Does the applicant wish to participate in the Primary Care Clinician (PCC) Plan? Yes No

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.

1.2 APPLICANT INFORMATION

Legal Name of Applicant: Last First Middle Initial

Individual (SSN) Sole Proprietor ( SSN or EIN)

Applicant’s National Provider Identification (NPI) Date of Birth

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Applicant’s Professional License Number (MA) State/License Number

DEA Number (if issued) Do not have a DEA in practice state Check box if prescribing only Schedule VI drugs

Applicant Legal Address/Home Street Address

City State Zip

ATTN/Title Email

Tel. Fax

1.3 MEDICAID INFORMATION FOR OTHER STATES

Does the applicant currently participate, or have they previously participated, in another state’s Medicaid program? Yes No

List Other State Medicaid Number Effective Date End Date (if applicable)

List Other State Medicaid Number Effective Date End Date (if applicable)

List Other State Medicaid Number Effective Date End Date (if applicable)

1.4 PROVIDER DIRECTORY

Please complete each of the following questions, which will be used in the MassHealth Provider Directory on Mass.gov.

Per program regulations, out-of-state providers are exempt from completing this section.

1. What languages, other than English, does the provider speak?

2. Does the provider offer telehealth services? Yes No If Yes, make sure that telehealth offered for MassHealth-covered services meets the requirements detailed in All-Provider Bulletin 379 at mass.gov/lists/all-provider-bulletins, or any subsequent guidance from EOHHS.

3. Accepting New Patients? Yes No If No, please explain.

Selecting 'No' must be declining all new patients, and not only MassHealth members. Qualified Medicare Beneficiary-only providers may enroll only for the purpose of submitting crossover claims for QMB members.

1.5 CERTIFIED SPECIALTY

Board Certifications (as certified by your board of professional licensure)

Area of Certifications (if applicable)

Other Area of Certifications (if applicable)

1.6 MEDICARE INFORMATION

Is the applicant enrolled in Medicare as a provider? Yes No In process

Note: Medicare participation is required for certain provider types, including 05- psychologist, 16- chiropractor, 86- Qualified Medicare Beneficiary (QMB)-only (individual), 92- licensed independent clinical social worker, and B6- licensed independent behavioral health clinician (licensed marriage and family therapist and licensed mental health counselor).

MassHealth requires Medicare enrollment for any provider that files claims for services provided to MassHealth members who are also enrolled in Medicare (dual eligible members). Refer to MassHealth's all-provider regulations and all applicable program-specific regulations. You can access these publications mass.gov/masshealth-and-eohhs-regulations.

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SECTION 2: INDIVIDUAL PRACTITIONER PRACTICING INDEPENDENTLY

Note: This section applies ONLY to individual practitioners practicing independently and practitioners BOTH practicing individually AND as part of a group practice organization. If applying to participate ONLY as part of a group practice organization, proceed to Section 3.

2.1 ELECTRONIC FILE SUBMISSION METHOD

Indicate which transactions will be submitted electronically and what method will be used to transmit electronic files. (With limited exceptions, MassHealth does not accept paper claims (see 130 CMR 450.302)). You must submit a Trading Partner Agreement (TPA) if completing this section.

TRANSACTION TYPES: Check the type of transaction that the applicant will be submitting or receiving. Also check who will be submitting or receiving on behalf of the applicant and how they will be submitting or receiving the transactions.

835 Health Care Claims Payment/Advice

837P Professional Health Care Claim

837P COB Professional Health Care Claim for Secondary Insurers

270 Health Care Eligibility Benefit Inquiry

271 Health Care Eligibility Benefit Response

276 Health Care Claims Status Request

277 Health Care Claims Status Response

VOID or REPLACE claims

* DDE = Direct Data Entry ** EDI = Electronic Data Interchange

VENDOR INFORMATION: If you checked the "Vendor" box one or more times in the preceding "transaction types" section, you must complete this section.

Check the box that describes the vendor: Billing vendor/Provider intermediary Software vendor In order for the vendor to submit transactions on your behalf, the vendor must also be an approved MassHealth provider with a valid MassHealth provider ID.

Vendor Name

Doing Business As (DBA) Name (if applicable)

MassHealth PID/SL Number (if applicable) Vendor Contact Name

Vendor Tel. Vendor Email

Note: Vendors must apply for a MassHealth relationship entity number before they can submit claims on behalf of the applicant. For more information, email MassHealth at edi@mahealth.net.

2.2 BILLING ADDRESS (Address of the entity that submits claims)

Is the billing address the same as the legal address in Section 1.2? Yes No If Yes, you do not have to complete the remainder of Section 2.2.

Number/Street Building, Suite, or PO Box if applicable

City State Zip

ATTN/Title Email

Tel. Fax

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2.3 SERVICE LOCATION (SL) INFORMATION (Correspondence will be mailed to this address.)

Enter the applicant’s street address, and all other information requested below that is applicable to this SL where services will be provided to MassHealth members. Post-office box (PO box) addresses are not acceptable. Enrollment will not be approved if only a PO box address is entered in this space.

Number/Street Building, Suite (if applicable)

City State Zip

ATTN/Title Email

Tel. Fax

2.4 OTHER SERVICE LOCATION (SL) INFORMATION NUMBER OF

PLEASE MAKE A COPY OF SECTION 2.4 IF YOU NEED TO LIST MORE THAN FIVE SERVICE LOCATIONS.

Note: Failure to list on the application all locations where services will be provided to MassHealth members is a violation of MassHealth regulations at 130 CMR 450.222 and 450.223. Attach each completed copy of Section 2.4 to the signed application. Each such copy will become part of the application.

Number/Street Building, Suite (if applicable)

City State Zip

ATTN/Title Email

Tel. Fax

Number/Street Building, Suite (if applicable)

City State Zip

ATTN/Title Email

Tel. Fax

Number/Street Building, Suite (if applicable)

City State Zip

ATTN/Title Email

Tel. Fax

Number/Street Building, Suite (if applicable)

City State Zip

ATTN/Title Email

Tel. Fax

Number/Street Building, Suite (if applicable)

City State Zip

ATTN/Title Email

Tel. Fax

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SECTION 3: GROUP AFFILIATION

This section applies ONLY to applicants seeking to participate with a group practice organization currently enrolled with MassHealth or a group practice organization that is concurrently applying to enroll with MassHealth. Note: Applicants enrolling ONLY with a group practice organization do not need to submit a W-9, EFT, TPA, or ERA, as the group practice organization will be paid for services performed by the individual medical practitioner.

PLEASE MAKE A COPY OF SECTION 3 IF YOU NEED TO LIST MORE THAN FOUR GROUP AFFILIATIONS.

Attach each completed copy of Section 3 to the signed application. Each such copy will become part of the application.

3.1 GROUP AFFILIATION NUMBER OF

List the name(s) of each MassHealth-participating group practice organization, the NPI, and the MassHealth Provider ID and the Service Location (PID/SL). The first group practice organization listed will serve as the Primary Service Location.

Group Practice Organization Name

Check here if group practice organization enrollment is pending or is being submitted concurrently.

Group Practice Organization NPI MassHealth PID/SL

Group Practice Organization Address (number/street)

City State Zip

Group Practice Organization Name

Check here if group practice organization enrollment is pending or is being submitted concurrently.

Group Practice Organization NPI MassHealth PID/SL

Group Practice Organization Address (number/street)

City State Zip

Group Practice Organization Name

Check here if group practice organization enrollment is pending or is being submitted concurrently.

Group Practice Organization NPI MassHealth PID/SL

Group Practice Organization Address (number/street)

City State Zip

Group Practice Organization Name

Check here if group practice organization enrollment is pending or is being submitted concurrently.

Group Practice Organization NPI MassHealth PID/SL

Group Practice Organization Address (number/street)

City State Zip

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SECTION 4: APPLICANT DISCLOSURES

4.1 CRIMINAL CONVICTION(S) INFORMATION

Has the applicant ever been convicted of any state or federal crime in Massachusetts or any other U.S. state, including but not limited to any criminal offense relating to the applicant’s involvement in any program established under Title XVIII, XIX, or XXI of the Social Security Act (i.e., Medicare, Medicaid, or CHIP)?

Yes No

If Yes, provide the following information for each such conviction. Note: Convictions for criminal offenses other than offenses relating to the applicant’s involvement in any program established under Title XVIII, XIX, or XXI of the Social Security Act may be omitted if such conviction(s) 1) occurred more than 10 years before the date of this application, or 2) were punishable by imprisonment of less than one year, regardless of the date of such conviction.

Name of the Offense

Date of Conviction Court/State Case or Record Number

Name of the Offense

Date of Conviction Court/State Case or Record Number

Name of the Offense

Date of Conviction Court/State Case or Record Number

4.2 SANCTION(S) INFORMATION

Has the applicant ever been subject to any disciplinary action, sanction, or other limitation or restriction of any nature imposed with or without consent by any state (including Massachusetts) or federal agency, board, or other regulatory/licensing agency including, but not limited to, revocation, suspension, reprimand, censure, admonishment, fine, probation agreement, practice limitation, practice monitoring, remedial training, or other educational or public service activities?

Yes No

If Yes, for each such action provide the following information.

Agency or Board Action Taken Date of Action

Agency or Board Action Taken Date of Action

Agency or Board Action Taken Date of Action

4.3 PENDING PROCEEDINGS

Is the applicant subject to any proceeding(s) currently pending that could result in a conviction, sanction, or other action reportable in Sections 4.1 or 4.2?

Yes No

If Yes, provide the following information for each such proceeding.

Court/State, Agency, or Board

Charge or Allegation Case or Record Number

Court/State, Agency, or Board

Charge or Allegation Case or Record Number

Court/State, Agency, or Board

Charge or Allegation Case or Record Number

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4.4 ADDITIONAL EXPLANATION

The applicant may use the space below to provide additional information regarding the applicant’s answers in Sections 4.1, 4.2, or 4.3.

Attach additional pages if necessary.

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SECTION 5: CERTIFICATION

PLEASE READ CAREFULLY AND SIGN

I certify that I am a medical practitioner applying to enroll as a participating provider in MassHealth.

I certify under the pains and penalties of perjury that the information on this provider application and any attachments are true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein, and that the failure to provide true, accurate, and complete information in this provider application may result in the denial of my enrollment as a participating provider in MassHealth or the termination of any provider agreement resulting from or related to this provider application. I understand that I must notify the MassHealth Provider Enrollment unit of any change in any of the information submitted in this Provider Application, and its attachments in accordance with and within the time specified in

130 CMR 450.223(B).

I hereby authorize MassHealth and its designees to access, and I agree to furnish to MassHealth upon request, any information MassHealth deems relevant to my eligibility and qualifications to be a participating provider in MassHealth, including otherwise privileged or confidential information. I understand and agree that I have the burden to produce adequate information to MassHealth to permit evaluation of my eligibility and qualifications to be a participating provider in MassHealth, and for resolving any doubts that MassHealth may have about my eligibility and qualifications.

The Applicant hereby releases from any liability MassHealth and all representatives of MassHealth for any acts performed in good faith in connection with the evaluation of the Applicant’s eligibility and qualifications to be a participating provider in MassHealth.

I understand that I am obligated to cooperate with MassHealth during this application process, any revalidation of enrollment (including, but not limited to, revalidation required by Section 6401 of the Affordable Care Act and occurring at least every five years), or other review process.

Printed Legal Name of Applicant

Signature of Applicant Date

The form can either be signed traditionally and then scanned, or it can be signed electronically using DocuSign or Adobe Sign. For electronic signatures, the signer can upload a picture of their wet signature. The typed text of a signature is not an acceptable form of an electronic signature.

Return your completed application packet by fax or mail to MassHealth.

If you have any questions, email PEC@maximus.com, or you can verify the status of this application at https://masshealth.ehs.state.ma.us/ProviderSelfService. For general questions, you may contact MassHealth by email at provider@masshealthquestions.com. 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 or personally identifiable information. You may also call (800) 841-2900, TDD/TTY: 711.