Massachusetts Association of
Medical Staff Services
34th Annual Education
Conference
MassHealth / Executive Office of Health &
Human Services
May 12, 2017
Agenda
I.
Payment Reform / ACO Development
II. Regulation Overview
I. Ordering & Referring & Prescribing
II. Mid-level enrollment
III. Revalidation
IV. Fingerprinting
III. Primary Clinician Care (PCC) Plan
IV. Question & Answers
2
I. Payment Reform / ACO Development
3
Current Choices for Managed Care
Members (cont’d)
 Currently, managed care members can choose:
•
Primary Care Clinician Plan
‒ Behavioral health is by the Massachusetts
Behavioral Health Partnership (MBHP)
‒ All other services (medical and Long Term Services
and Support (LTSS) are provided directly by
MassHealth
•
Managed Care Organization (MCO) in their region:
‒ Manages medical and behavioral health services
‒ LTSS is provided directly by MassHealth
•
Fee for Service
4
New Health Plan Choice
Definition
Accountable Care
Partnership Plans
A group of PCPs who have exclusively
partnered with a Managed Care Organization
(MCO) to use their provider network to provide
integrated and coordinated care for members
Primary Care ACOs
A group of PCPs who contract directly with
MassHealth to use it’s provider network to
provide integrated and coordinated care for
members
MCO’s and MCO
Administered ACO
Managed Care Organization (MCO) that has a
network of providers to deliver care. MCO’s
may contract with an ACO to provide more
integrated and coordinated care
PCC Plan
MassHealth’s statewide managed care option
that uses the MassHealth provider network to
deliver care
5
Future Choices for Managed Care
Members
This winter 2017 MassHealth will now offer a new choice of
health plan for member’s called an Accountable Care
Organization (ACO)
• An ACO is a group of Primary Care Providers (PCP) who work
together to make sure a member’s overall health care needs are
met. When they are part of an ACO, their doctors will work with
the member and each other to coordinate their care and help
them meet their health goals
•
In an ACO, a PCP is responsible for working with the member and
the ACO’s network of providers to help better coordinate their care
and connect them with available services and supports. This
coordination can help them get the right care at the right time to
improve their health and keep them healthy
6
MassHealth ACO Goals and Principles
 Materially improve member experience–ACOs are expected to
innovate and engage members differently (e.g., better transitions of
care, improved coordination between a member’s various providers)
 Strengthen the relationship between members and Primary Care
Providers by attributing members to an ACO through their selection of
a primary care provider
 Encourage ACOs to develop high value, clinically integrated
provider partnerships by expecting and allowing ACOs to define
coordinated care teams and, for some ACOs, to establish preferred
networks
 Increase Behavioral Health / Long Term Service and Support
integration and linkages to social services in ACO models through
explicit requirements for partnering with BH and LTSS Community
Partners
7
ACO Responsibilities include:
 Direct investment in their PCPs and requirements for performance
management and value-based payment arrangements
 Screening members to identify care needs
 Coordinating care, managing discharges and transitions, and
operating a clinician advice and support line for members
 Performing comprehensive assessments and developing personcentered care plans, as appropriate
 Team-based care management, including a care coordinator or
clinical care manager as appropriate
 Governance that is provider-led (75% of board) and includes a voting
consumer board member as well as a Patient and Family Advisory
Committee
 Processes to accept member grievances and requirements to protect
member rights (e.g., access to medical records, choice of providers,
non-discrimination)
8
Why Members May Choose an ACO
 Members may choose an ACO because:
• ACO’s are PCP-driven with a team-focused approach that
can allow providers to care for their overall health and
wellness including coordination of physical, behavioral, and
social health care needs
• They want to increase their engagement in their care and work
with their health team to meet their health goals and stay
healthy
• ACO’s networks have referral circles that make referrals
faster and easier for them
• ACO’s can help them find the right care during difficult times
with their health, such as during hospitalizations or a
discharge from a hospital stay
• ACO’s can help connect them to services in their community to
improve their health
• If they meet certain criteria they may have access to additional
services such as Community Partners and Flexible Services
depending on eligibility standards and availability of services
9
MassHealth Restructuring
MassHealth
Accountable
Care
Partnership
Plan
Primary
Care
ACO
Provider
Provider
Accountable Care
Partnership Plan
▪ MCO and ACO
have significant
integration and
provide covered
services through a
provider network
▪ Risk-adjusted,
prospective
capitation rate
▪ Takes on full
insurance risk
Primary Care ACO
▪ ACO contracts directly
with MassHealth for
overall cost/ quality
▪ Based on MassHealth
provider network/MBHP
▪ ACO may have referral
circles
▪ Choice of level of risk;
both include two-sided
performance (not
insurance) risk
MCOOptions
Options
MCO
MCO
Options
PCC Plan
MCOACO
Administered
ACO
MCOAdministered
ACO
ProviderProvider
Provider
Provider
Provider
Provider
Provider
Provider
Provider
MCO-Administered ACO
▪ ACOs contract and work with
MCOs
▪ MCOs play larger role to
support population health
management
▪ Various levels of risk; all include
two-sided performance (not
insurance) risk
PCC Plan
▪ Primary care
Providers based on
the PCC Plan
network
▪ Specialists based on
MassHealth network
▪ Behavior Health
administered by
Massachusetts
Behavioral Health
Partnership (MBHP)
10
Accountable Care Partnership Plan
• Either an MCO with a separate, designated ACO partner, or a single,
integrated entity that meets the requirements of both.
• A single MCO may participate in more than one ACO, each with a different
ACO Partner.
• All enrolled members receive primary care from PCPs in the ACO.
• Each ACO’s PCPs can only serve MassHealth managed care eligible
members on their panel if those members are enrolled in their ACO.
• Members can see any providers in the Partnership Plan’s network.
• Must meet all MassHealth requirements for MCOs and ACOs, including
provider-led governance and Health Policy Commission (HPC) certification.
• Must provide the same administrative functions as MCOs do today, such as:
- paying claims
- maintaining an adequate provider network within service area
- prior authorization, etc.
• Communicate directly with enrollees about benefits of participating, provider
network, and how to access services.
• Will be selected for defined service area.
• May serve areas different than the geographical area under the MCO
contract (i.e., a “Region”).
11
Primary Care ACO
• Contracts directly with MassHealth.
• All enrolled members receive primary care from the Primary Care
ACO’s PCPs.
• Each ACO’s PCPs can only serve MassHealth managed care eligible
members on their panel if those members are enrolled in their ACO.
• Aside from their PCP, members can see any provider in the
MassHealth network.
• Primary Care ACOs may establish “Referral Circles”—a list of
specialists who members can access without needing a referral.
• Members enrolled in Primary Care ACOs are also automatically
enrolled with MassHealth’s behavioral health contractor (currently
MBHP).
12
MCO-Administered ACO
• For members who choose an MCO.
• MCO enrollees may choose or may be attributed to an MCOAdministered ACO, based on their PCP choice or assignment.
• Contracts directly with one or more MassHealth MCOs. In the first
year MCOs must contract with each MCO-Administered ACO
operating within their region. In Years 2 - 5, MCOs must contract
with at least one MCO- Administered ACO per region.
• Each MCO-Administered ACO’s PCPs can only serve MassHealth
managed care eligible member on their panel if those members are
enrolled in an MCO with which the ACO has a contract.
• MCO enrollees may see any providers in their MCO's network
(subject to their MCO's rules) regardless of their attribution to an
MCO-Administered ACO.
13
Member Perspective
“If I am enrolled in ___, which providers can I see for ___?”
PCC Plan
Primary Care ACO
MCO
MCO-Administered
ACO
Partnership Plan
Primary Care
Hospital/
Specialists
Behavioral
Health (BH)
Long-Term
Services and
Supports (LTSS)
Pharmacy
MassHealth
PCPs
MassHealth
Hospital/
Specialists
MBHP
providers
MassHealth LTSS
providers
MassHealth
network
Pharmacies
Primary Care
ACO’s PCPs
MassHealth
Hospital/
Specialists
MBHP
providers
MassHealth LTSS
providers
MassHealth
network
Pharmacies
PCPs in the
MCO’s network
Hospitals/
specialists in
the MCO’s
network
BH Providers in
the MCO’s
network or the
network of its
BH vendor
Year 1 & 2 –
MassHealth LTSS
providers
Pharmacies in
the MCO’s
network
Hospitals/
specialists in
the Partnership
Plan’s network
BH Providers in
the Partnership
Plan’s network
or the network
of its BH
vendor
Year 1 & 2 –
MassHealth LTSS
providers
MCOAdministered
ACO’s PCPs
PCPs in the
Partnership
Plan’s network
Year 3 or 4 –
LTSS Providers in
the MCO’s
network
Pharmacies in
the Partnership
Plan’s network
Year 3 or 4 –
LTSS Providers in
the Partnership
Plan’s network
14
Member Enrollment in New MCOs and ACOs
• To ensure that all managed care eligible members are enrolled in MCOs
and ACOs (or PCC Plan) by December 18, 2017, certain members will
have a “Special Assignment” to plans.
• Special Assignment will be based on keeping members with their PCP to
the extent possible.
- Members who will be Specially Assigned will receive a notice and
an enrollment guide from MassHealth in October 2017.
- All MCO and ACO options will be presented in the Enrollment
Guide.
- Members who are Specially Assigned will have the option to
change plans.
• MCO and ACO enrolled members will have
- a 90-day Plan Selection Period beginning December 18, 2017, and
- the Fixed Enrollment Period beginning March 19, 2018.
15
Member Support
Member support covers three categories—each focused on a different goal
Global Awareness & Education
Trainings, communication, and materials
Goal Awareness
and information
Education
that
share broad
to mass
Trainings,
communication,
and
materials
thatprogram
support payment
audiences to educate them about
reform initiatives, with the goal of establishing and
changes
communicating a consistent message to members, memberfacing staff, and advocacy groups
Member Engagement and Support
Notices, publications, and instructional content aimed at
helping members throughout the payment reform transition,
including with complex topics such as special assignment and
selecting a health plan
Customer
Support Material & Member
Engagement
Targeted communication
materials and engagement
activities designed to provide
Customer Service Center (CSC)
individual and focused
Enhancements to the Customer Services Center to provide
information to audiences effective customer service to members by answering
questions, providing resources, and resolving issues
Service Center
(CSC)*
Enhancements to the Customer
Services Center to provide
effective customer service to
members by answering
questions, providing resources,
and resolving issues
* CSC is responsible for enrolling members into health plans, including ACOs and MCOs.
16
Member Support Materials & Events
In anticipation of new enrollment options, MassHealth is actively seeking avenues to
educate and engage members.
Global Awareness &
Education
• Staff Training: MassHealth Enrollment Center (MEC)
• MassHealth Training Forum (MTF) Presentations
• EOHHS Website Updates
• Sister Agency & Advocacy Training
• Certified Application Counselor (CAC) & Navigator training
• Navigator Feedback Sessions
• Advertising
Support Material
• Enrollment Guide presenting all available MCO, ACO, and
PCC Plan options
• Member-specific letters with information about Special
Assignment, Plan Selection Period, and Fixed Enrollment
Period
• Choice Counseling Tool
• Member Booklet
• Video/Animation “How to Enroll”
Member Engagement
Customer Service
Center
• Community Health Worker (CHW) Training
• Ombudsman
• Community Enrollment Events throughout the Commonwealth
• Searchable Provider Directory
• Enhanced Call Center Staff
17
Provider Communication and Education
• To support the goals of MassHealth Restructuring, MassHealth is focused on strategies that bring
awareness of payment reform activity and delivery system change to the provider community.
• Providers will need information about how and when MassHealth restructuring will impact them,
including network contracting choices, payments and accountability, and administrative changes,
as well as changes for members
• MassHealth will develop messaging tailored for specific provider groups, including:
- Primary Care Providers
– Specialists
- Hospitals
– Behavioral Health Providers
- Community Health Centers
– Long-Term Services and Supports Providers
• MassHealth will use a variety of communication strategies and methods to share information with
providers, including:
Resources and Information:
Collaboration Strategies:

Webinars


Provider bulletins
Work with ACOs/MCOs to provide consistent
messaging

MassHealth website

Work closely with Provider Associations

MassHealth regulations

Proactive outbound calls from MassHealth

Message text (POSC)

Knowledgeable MassHealth Provider Services staff,
available to answer providers’ questions as needed
18
Provider Perspective (1 of 2): PCPs
“What are my ACO participation options and their implications?”
My options for ACO
participation are . . .
And what it means for the MassHealth managed careeligible members I can serve is . . .
Do not participate in an ACO
I need to contract with the PCC Plan and/or MassHealth MCOs in
order to have any of their enrollees on my primary care panel*
Join a Partnership Plan as a
Network PCP
I serve a panel of members who are all enrolled in my ACO. I
cannot simultaneously have a PCP panel in any other products (i.e.,
the PCC Plan, an MCO, another ACO)
Join a Primary Care ACO as a
Participating PCP
Join an MCO-Administered ACO as a
Participating PCP
My ACO will partner with one or more MCOs (in year 1, my ACO will
partner with all the MCOs operating in its geography). I will be
required to contract with those MCOs as a Network PCP for their
enrollees, and all of their enrollees who are assigned to my panel will
be considered part of my ACO’s attributed population
• Primary care exclusivity is only with respect MassHealth managed care-eligible members. PCPs may provide primary care services to
MassHealth Fee-For-Service members, including Dually Eligible MassHealth members, and they may also provide specialty services
to MassHealth members in any delivery system.
• Primary care exclusivity is site- /practice-level, similar to PCC Plan enrollments or participating in the ACO Pilot.
• MassHealth will provide additional operational details of primary care provider enrollment/ACO affiliation to those providers
participating with ACOs over the coming months.
19
Provider Perspective (2 of 2): non-PCP providers
“What does ACO reform mean for my contracts and who I can see?”
I want to see members enrolled in . . .
The PCC
Plan
Hospital
A Primary
Care ACO
Be in MassHealth’s
hospital network (via the
MassHealth hospital RFA)
Professional
(e.g.,
specialist)
Be a MassHealthparticipating provider (via
MH professional reg/fee
schedule)
Behavioral
Health (BH)
Provider
Be an in-network provider
for MassHealth’s BH
Vendor (via contract with
the BH Vendor)
Long-Term
Services and
Supports
(LTSS)
Provider
Contract with MassHealth
as an LTSS provider at the
MassHealth fee schedule;
LTSS is “wrapped”
coverage directly by
MassHealth
Pharmacy
Contract with MassHealth
as an in-network
pharmacy provider
I am a…
An MCO
(regardless of whether or not they
are attributed to an MCOAdministered ACO)
A Partnership Plan
Contract with each MCO whose
enrollees I want to see (negotiated
rate)
Contract with each Partnership Plan
whose enrollees I want to see
(negotiated rate)
Contract with each MCO (or that
MCO’s BH Vendor if they have one)
whose enrollees I want to see
(negotiated rate)
Contract with each Partnership Plan
(or that Plan’s BH Vendor if they have
one) whose enrollees I want to see
(negotiated rate)
For years 1 and 2, contract with MassHealth as an LTSS provider at the
MassHealth fee schedule; LTSS is “wrapped” coverage directly by
MassHealth for all members, regardless of model
Starting on or about year 3, contract
with each MCO whose enrollees I
want to see (negotiated rate)
Starting on or about year 3, contract
with each Partnership Plan whose
enrollees I want to see (negotiated
rate)
Contract with each MCO (or that
MCO’s pharmacy benefit manager
as applicable) whose enrollees I
want to see
Contract with each Partnership Plan
(or that Plan’s pharmacy benefit
manager as applicable) whose
enrollees I want to see
20
Visit us at:
www.mass.gov/hhs/masshealth-innovations
E-mail us at
[email protected]
21
II. Regulation Overview
Ordering & Referring & Prescribing
Mid-level enrollment
Revalidation
Fingerprinting
22
Ordering, Referring and
Prescribing Update
23
Ordering and Referring (O&R) Requirements
Background
 ACA Section 6401 (b)
 States must require:
•
•
All ordering or referring physicians and other professionals be
enrolled under the State [Medicaid] Plan…as a participating provider;
and
The NPI of any ordering or referring physician or other
professional…be specified on any claim for payment that is based on
an order or referral of the physician or other professional.
 These requirements were effective March 25, 2011. Final Rule (42
CFR 455.410(b) and 42 CDR 455.440) was published in the
Federal Register on Feb. 2, 2011. Subregulatory guidance was
given to states on December 23, 2011.
 MassHealth is continuing its implementation efforts. In March 2016
we began providing informational messaging on certain impacted
claims.
24
O&R Requirements
Provider Types (including interns and residents in
those provider types) authorized to be included on a
claim as the ordering, referring or prescribing
provider
‒ Certified Nurse Midwife
‒ Certified Registered
Nurse Anesthetist
‒ Pharmacist (if authorized
to prescribe)
‒ Clinical Nurse
‒ Physician Assistant
Specialist
‒ Podiatrist
‒ Psychiatric Clinical
Nurse Specialist
‒ Dentist
‒ Licensed Independent
Clinical Social Worker
‒ Physician
‒ Psychologist
‒ Nurse Practitioner
‒ Optometrist
25
O&R Requirements (continued)
 MassHealth is implementing the O&R requirements in several
phases.
 On 2/26/16 MassHealth posted Provider Bulletin 259 for billing
providers regarding the ordering, referring and prescribing
provider requirements and the implementation phases.
 Phase 1A
• MassHealth began providing informational messages on
certain claims for dates of service on or after March 7,
2016 that do not meet the O&R requirements listed below:
-
The ORP provider’s NPI must be included on the claim.
The ORP provider must be one of the provider types listed on
the previous slide.
The ORP provider must be enrolled with MassHealth, at least
as a nonbilling provider.
26
O&R Requirements (continued)
 Claims impacted in Phase 1B (informational messaging
is anticipated to begin in spring 2017).
• All claims (professional and institutional - 837P, 837I, CMS 1500
and UB-04) that currently require a PCC referral, regardless of
billing provider.
• All professional claims (837P and CMS 1500) from certified
Independent Labs and Diagnostic Testing Facilities.
 Phase 2
• In Phase 2, effective date TBD, the claim types impacted in
Phase 1 will not be payable if they do not meet O&R
requirements.
27
O&R Requirements (continued)
 Phase 3
• Phase 3A (Informational Messaging is anticipated to begin in
spring 2017, claims denial date TBD) will impact the following
claims:
- Institutional claims (837I and UB-04) for home health
services
- Professional claims (837P and CMS 1500) for certain PCA
related procedure codes.
• Phase 3B – (Informational Messaging begin date TBD)
-
Institutional claims (837I & UB-04) for labs and diagnostic
testing
-
All professional claims (837P and CMS 1500) for labs and
diagnostic testing codes(such claims were included in
Phase 1 only when billed by Labs and Diagnostic testing
facilities).
28
O&R Requirements (continued)
 Next Steps
• Providers that order, refer or prescribe services for
MassHealth members will need to include their NPI on and
written orders, referrals and prescriptions.
• Effective June 1, 2017 MassHealth will update the process
for entity PCC referrals to ensure they meet the O&R
requirements. See Provider Bulletin #265 for more
information.
• MassHealth will implement Phase 1B and 3A (informational
messaging on claims for services that require a PCC referral,
claims from labs and diagnostic testing facilities, institutional
claims for home health services and certain PCA claims)
during the spring of 2017.
29
O&R Requirements (continued)
 Entity PCCs referrals
• ORP providers included on a claim must be individual providers
• The POSC referral panel has been updated so that entity PCCs can
identify an individual provider within the PCC entity as the PCC plan
referring provider when entering a referral. All Provider Bulletin #265
about this update was posted on March 3, 2017.
• Effective June 1, 2017 , entity PCC referrals will not go through unless
an affiliated, enrolled individual provider has been selected
• The PCC referral letter has been updated to include the name and NPI
of the individual referring provider within the PCC entity
• The customer service team has been reaching out to entity PCCs to
collect lists of their individual referring providers in order to add them to
the entity PCC’s list on the POSC panel
• Entity PCCs should ensure that their individual referring providers are
enrolled with MassHealth, at least as nonbilling providers, so that their
PCC referrals can go through and so that claims based on their PCC
referrals can be payable
30
POSC Referrals Page
Required Fields
Enter the Member’s MassHealth
ID Number
Enter the Referring
Provider which could be
an Organization or an
Individual Provider
Enter the Individual Provider within the above
Organization that is making the referral.
(*Note: this is a required field if the Referring Provider
above is a Group or Organization)
Enter the provider which will be
performing the requested service
Choose the service to be
rendered from the dropdown
Enter the start date, end date,
and number of visits authorized
for this service
31
POSC New Error Messaging You May See
This Error Message will
appear when you entered
a PROVIDER
ORGANIZATION as the
REFERRING PROVIDER
but have not entered an
INDIVIDUAL
REFERRING PROVIDER
within that organization
32
POSC New Error Messaging You May See
These are examples of messaging you may see if there is a mismatch between the
Referring Provider and the Individual Referring Provider.
If the Individual Referring Provider is
not affiliated with the selected
Referring Provider Organization you
will get this error message.
If you list an Individual as the Referring Provider
the Individual Referring Provider field below that
is not required.
If you enter an additional referring
provider you will receive this error
message.
33
Mid-Level Enrollment
34
NOTICE OF PROPOSED AMENDMENT OF REGULATIONS
April 21, 2017
The proposed midlevel practitioner amendments to 130 CMR 433.000, 450.000, and
508.000 will allow physician assistants (PAs) in a group practice with at least one physician
to participate in MassHealth and as a primary care clinician, and for the group practice to
bill for the PA’s services. The proposed amendments will allow certified registered nurse
anesthetists (CRNAs), psychiatric clinical nurse specialists (PCNSs), and clinical nurse
specialists (CNSs) to participate in MassHealth, and for certified nurse practitioners (NPs)
and certified nurse midwives (NMWs) to continue to participate in MassHealth. NPs,
NMWs, CRNAs, PCNSs, and CNSs can bill for their own services, or a group practice can
bill for their services. Only NP services will also be billable by a physician employer
pursuant to 42 CFR 441.22. The regulations will allow physicians to be paid for medical
direction of both community-based CRNAs and CRNAs employed by hospitals and
ambulatory surgery centers (ASCs) under specified circumstances, and will exempt CRNA
services from the primary care clinician referral requirement. They also update language to
conform to Board of Registration in Nursing regulations, clarify requirements for out-ofstate midlevel practitioners, and make conforming changes to service descriptions and
other areas to align with enrollment of midlevel practitioners.
35
Midlevel Provider Enrollment

Background:
•
With an anticipated effective date of August 1, 2017
MassHealth will require all Physician Assistants (PAs),
Certified Registered Nurse Anesthetists (CRNAs), Nurse
Midwives (NMWs), Clinical Nurse Specialists (CNSs) and
Psychiatric Clinical Nurse Specialists (PCNSs) to enroll in
MassHealth in order to receive payment for services
rendered.
•
Under these new regulations there is no change for Nurse
Practitioners (NPs). NPs may enroll as an independent
clinical nurse practitioner or simply be “known” to
MassHealth under the ORP regulations and act as a nonindependent nurse practitioner.
36
Key Points

Anticipated on 8/1/17, groups that employ a PA, CRNA, and NMW can
no longer bill for services under the supervising physician’s NPI.
•
The following claim modifiers, billed under a supervising physician,
will be deactivated, anticipated on 8/1/17:
‒
HN - billed for physician assistants
‒
SB – billed for nurse midwives

Payment for Physician Assistants will be made to MassHealth
participating group practices that have at least one physician as a
member. Group practices without a physician member cannot bill for
PA services.

Physician Assistants can participate in the PCC program as PCCs.
37
Key Points (cont.)

Independent Nurse Practitioners remain eligible to participate in the
PCC program as PCCs.

All anesthesia codes between procedure codes 00100-00199 require a
modifier or will be denied anticipated on 9/1/16.
•

Payable modifiers are AA, QK, QY, QX, QZ
The SA modifier, used for a physician billing the services of a NP, will
remain as a payable modifier.
38
Provider Enrollment Procedures

MassHealth has revised the Medical Practitioner enrollment application
(PE-MP) and checklist (PE-MP-CL) and the Group Practice
Organization enrollment application (PE-GPO) and checklist (PE-GPOCL) in preparation for the new Mid-Level provider implementation.

New mid-level providers are encouraged to submit their enrollment
applications prior to the anticipated effective date of 8/1/17.
39
Revalidation
40
Revalidation Background
In March of 2014, MassHealth began its revalidation initiative as required
by Section 6401 of the Affordable Care Act.
Providers enrolled in MassHealth on or prior to March 25, 2011 eligible
for revalidation (32,546 total providers).
Each month a new 30-day “wave” was launched.
Revalidation evolved from as a provider file update, but has evolved into
an extensive recredentialing process to ensure provider file integrity.
November 2015, MassHealth introduced a streamlined approach for
providers that are active with Medicare and can be verified through the
PECOS system.
Round 1 revalidation was completed in September 2016 and each month
200-300 providers are launched for revalidation based on their original
enrollment date with MassHealth.
41
Helping Providers to Complete Revalidation
Bimonthly
Webinar
Phone
and Email
Outreach
Job Aids
and FAQs
Tools and
Techniques
Program
Manager
Outreach
Message
Text
Webpage
on
Mass.gov
Provider
Bulletins
42
Revalidation – Phase 2
Revalidation will continue on a 5-year cycle based on the providers
enrollment date with MassHealth. Example: May 2017 wave will be for
those providers enrollment in May 2012.
90 DAYS PRIOR TO PROVIDER’S ENROLLMENT DATE
Research
Revalidation
Type (PECOS
versus
Traditional)
Research
Credentialing
Contacts
Document
additional
materials
required by
provider and
include in
launch letters
Continue
focused
outreach and
maintain regular
Communication
channels with
Corporate
Entities
Launch Wave
43
Fingerprinting
44
Fingerprint Based Criminal Background
Checks
Section 6401 of the Affordable Care Act requires a fingerprint-based
criminal background check as part of new screening requirements for all
“high” risk providers and all persons with a 5% or greater direct or indirect
ownership interest in such providers.
The following is a list of the provider types that have been classified as
high risk.
 Adult Foster Care Providers
 Group Adult Foster Care Provider
 New enrollees in the following provider types:
• Durable Medical Equipment Providers & Personal Emergency Response
System (PERS) Providers (newly enrolling on or after August 1, 2015 only)
• Home Health Agencies (newly enrolling between August 1, 2015 and
February 10, 2016)
Due to the moratorium, we haven’t enrolled any since that date
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Fingerprint Based Criminal Background
Checks (continued)
 New enrollees in the following provider types: (continued…)
• Orthotics Providers (newly enrolling on or after August 1, 2015 only)
• Oxygen & Respiratory Therapy Equipment Providers (newly enrolling on or
after August 1, 2015 only)
• Prosthetics Providers (newly enrolling on or after August 1, 2015 only)
 Any provider that meets one of the following criteria:
• Have a payment suspension based on a credible allegation of fraud,
waste, or abuse on or after August 1, 2015;
• Excluded by OIG or another state Medicaid program within the past 10
years;
• Had a qualified overpayment and is enrolled or revalidated on or after
August 1, 2015; or
• In a provider type that was previously subject to an enrollment moratorium
who applies to enroll during the first six months after the moratorium is
lifted.
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Fingerprint Based Criminal Background
Checks (continued)
Notification and Process
 MAXIMUS has been outreaching to all affected providers during March.
 Providers will receive written notification from MassHealth that they and/or
their owners are required to be fingerprinted through the Statewide
Fingerprint Identification Services (SAFIS) for a fingerprint-based check of
state and national criminal history databases.
 We are targeting to send letters out prior to implementation.
 Each person is required to schedule an appointment and have their
fingerprints scanned within 30 days of notification.
 Providers must ensure that each of their qualifying owners have an
appointment within this timeframe.
 The notification letter will include information on how to schedule an
appointment by visiting the MorphoTrust USA IdentoGo™
 The website contains information about the fingerprint services, locations,
hours of operation, and acceptable forms of identification.
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Fingerprint Based Criminal Background
Checks (continued)
Notification and Process Continued
 The appointment has been scheduled when the individual receives a
registration ID number from MorphoTrust.
 Each individual should bring this ID number to the appointment.
 Failure to have the fingerprints of each individual on the notification
letter scanned within thirty (30) days may result in denial of an
enrollment application or termination of enrollment with MassHealth.
 To avoid a denial or termination, providers may be required to remove
any owners who fail to have their fingerprints scanned within 30 days, or
are found to have a criminal history unacceptable to the MassHealth
agency.
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III. Primary Clinician Care Plan
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Background
 Separate enrollment plan from MassHealth fee-for-service (FFS).
 Members are enrolled to a PPC site for primary care services.
 Requires a separate application from the FFS application (medical
practitioner application).
 Physicians and Nurse Practitioners are eligible to be primary care
providers at a PCC site. These providers need to be identified under the
PCC application and enrolled specifically as a PCC affiliation provider.
 Providers under a group setting (PT97) must have a PCC affiliation to
be identified as a primary care provider. Providers under a CHC or
hospital OPD setting must have a RI (referral information) affiliation.
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IV. Questions and Answers
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