MassHealth claims have new stipulations

In order to comply with a section of the Affordable Care Act that went into effect in 2011, Massachusetts recently changed its regulations to require that claims to MassHealth must include the NPI (National Provider Identifier) of the provider as well as that of any provider who ordered or referred the patient for a service.

The new ruling took effect on September 1, although MassHealth will not immediately deny claims not properly completed. Instead, providers will receive an informational notification with the paid claim. After November 1, claims will be denied that do not include the proper information.

“The initial target date was September,” said Alison Kirchgasser director of federal and state relations at the Massachusetts Office of Medicaid, “but given the fact that providers are also moving from ICD-9 to 10 on October 1, we were asked to delay.”

In addition, in accordance with ACA regulations, MassHealth can not pay the claim unless all providers listed, including those who referred or ordered the service, are enrolled with MassHealth.
In many cases, this stipulation means that providers who have no billing relationship with MassHealth must be enrolled.

The second part of the new regulation, however, may cause a bit more concern for psychologists. The state legislature, Kirchgasser explained, decided that all providers must be enrolled with MassHealth in order to have their state licenses renewed.

“The legislature felt that this was the only way to ensure that people who order services would be enrolled,” said Kirchgasser. “There was no way to parse out who that would involve because you never know a scenario where you could be ordering something for someone who is going to seek coverage under MassHealth for that service.”

In order to encourage providers to enroll with MassHealth, the legislature decided that it would require enrollment for license renewals. This part of the law has yet to take effect, however.

“The requirement that professionals sign up as MassHealth providers in the non-billing or billing categories as a condition of renewing their licenses has yet to be promulgated and is many months off,” said James Leffert, Ed.D, chair of the advocacy committee of the Massachusetts Psychological Association.

To ease the transition, the state has created a simplified form for enrolling and is doing outreach to provider organizations.

“We are trying to encourage providers to enroll in MassHealth ahead of time so that licensure issues do not apply,” said Kirchgasser.

According to Leffert, one section of the non billing provider contract, however, may give psychologists pause.

“I can foresee professional organizations complaining about a provision that is overly broad,” he said.

According to the contract, providers must “permit the Federal Centers for Medicare and Medicaid Services and the MassHealth agency and their agents and designated contractors, to conduct unannounced on-site inspections of any and all provider locations.”

In a letter to Kirchgasser, Leffert explained that professionals will be “forced to choose between granting the government unfettered and wholesale access to their records and facilities on an unannounced basis or losing their professional licenses.”

The state is looking at the language to see if it is possible for it to be more clearly written.

“There are general rules for when we or Medicaid are required to do site visits on a provider,” said Kirchgasser. “The question is: can we tweak the language to clarify the limited scenarios where we would need to do them? The legal team is looking at this now.”