Section 409.405 - Provider ResponsibilitiesIn addition to meeting all other provider requirements set forth in 130 CMR 409.000 and 130 CMR 450.000: Administrative and Billing Regulations, the DME provider must:
(A) accept, as payment in full, rates of payment established by EOHHS through regulations at 101 CMR 322.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, including as determined by the MassHealth agency through a preferred supplier contracting process or by other means;(B) comply with all applicable Medicare billing and authorization requirements and make diligent efforts to identify and obtain payment from all other liable parties including Medicare, before billing MassHealth, in accordance with 130 CMR 450.316: Third-party Liability: Requirements through 130 CMR 450.318: Third-party Liability: Payment Limitations on Medicare Crossover Claim Submissions, and all subregulatory guidance. This includes appealing a denied claim, before filing a MassHealth claim, when the service is payable in whole or in part by Medicare or other liable parties or payers. If documentation requested by the MassHealth agency, or its designee, is not received within the timeframe specified by the MassHealth agency or its designee, or the documentation is incomplete or does not support coverage by MassHealth, the associated claims will be denied. Failing to seek payment from all other liable parties may result in an overpayment pursuant to 130 CMR 450.235(A)(4).(C) comply with Medicare Competitive Bid Provider requirements for items subject to the CMS competitive bid process, which require that only qualified Medicare Competitive Bid Providers may provide DME that is subject to Medicare's competitive bid process to members with both MassHealth and Medicare coverage. MassHealth reimbursement is pursuant to 130 CMR 450.318: Third-party Liability: Medicare Payment Limitations on Medicare Crossover Claim Submissions.(D) except as provided in 130 CMR 409.405(O) regarding change in scope of service or business, notify the MassHealth agency in writing within 14 days of any changes in any of the information submitted in the provider application in accordance with 130 CMR 450.223(B) and 130 CMR 450.215(A) including, but not limited to, change of ownership, change of address, change in scope of the provider's Medicare accreditation, and addition of, or reduction in service locations. The DME provider must maintain records of all such communications and transactions and make such records available to the MassHealth agency for review upon request;(E) ensure that the DME provided is from the least costly, reliable source, and are consistent with MassHealth and industry quality standards, given the medical need for which the DME is prescribed and the member's medical condition;(F) ensure that EOHHS-specified absorbent products meet the quality performance standards for disposable adult absorbent products used by the National Association for Continence (NAFC) or other such standards as EOHHS may adopt;(G) ensure that all DME are free from defects and are in proper working order. This includes, but is not limited to, prompt amelioration, repair or replacement of DME that has been provided to a member and is subject to recall, in accordance with the specifications in the recall notice. For recalls of potentially dangerous or defective DME that predictably could cause serious health problems or death, the DME provider must give the member a copy of the recall notice and fully address the recall as specified in the recall instructions no later than five business days from the date the DME provider receives the recall notice;(H) report to the proper authorities any suspected abuse or neglect that staff may observe when providing service to a member, as mandated by M.G.L. c. 111, § 72G, M.G.L. c. 119 § 51A, M.G.L. c. 19A § 15, M.G.L. c. 19C, § 10, and any regulations promulgated under these laws, as well as any other suspected abuse or neglect as required by state and federal law;(I) give employees a picture identification to be presented to a member when making a delivery;(J) not alter any invoice or medical documentation;(K) not solicit members to purchase additional DME;(L) submit prior authorization requests, as specified by 130 CMR 409.418, to the MassHealth agency or its designee, only when the DME is medically necessary and when prior authorization is a prerequisite in accordance with 130 CMR 409.418, or required by MassHealth agency guidance;(M) not share a service facility or physical location (including a consignment closet, unless permitted by specific MassHealth guidance) with an ordering practitioner, or other provider who is authorized to prescribe DME or with another supplier of DME, except as permitted by 42 CFR 424.57(c) (Medicare Supplier Standard 29);(N) have a complaint resolution protocol to promptly address members' complaints by responding to any member complaints within two business days, and keep written complaints, related correspondence, and any notes of actions taken in response to written and oral complaints, and maintain such information in accordance with 130 CMR 409.430(I). MassHealth may request a copy of the provider's complaint log/records and may specify the time period for the requested records in accordance with 130 CMR 409.426;(O) provide MassHealth members and the MassHealth agency with written notification at least 60 days in advance of any change in the DME provider's scope of business or services (for example, if a provider decides to no longer provide certain products, if the scope of the provider's Medicare accreditation changes, or if a provider will be disenrolling as a MassHealth provider. Notification to the member must include (1) a statement that the member can contact MassHealth Customer Service to request a list of DME providers in their area; and(2) if prior authorization is required for the service(a) the number of non-billed units remaining on the PA; and(b) a copy of the original PA approval from MassHealth for the member to provide to the new DME provider;(P) instruct the member, or the member's caregiver, in the appropriate use of the DME furnished to the member. Such instruction must include, but not be limited to, the provision of appropriate information related to setup, features, routine use, troubleshooting, cleaning, infection control practices, and other issues related to the use and maintenance of all DME provided. Instructions must be commensurate with the risks, complexity, and manufacturer's instructions and specifications for the DME. The DME provider must tailor training and instruction materials and approaches to the needs, abilities, learning preferences, and language of the member and caregivers, as appropriate. The DME provider must document the provision of such instruction in the member's record in accordance with 130 CMR 409.430(K);(Q) ensure that the member and the member's caregivers, as appropriate, can use all DME provided safely and effectively in the settings of anticipated use;(R) upon request, submit to the MassHealth agency or its designee a statement of fiscal soundness attesting to the financial viability of the DME provider supported by documentation to demonstrate that the provider has adequate resources to finance the provision of services in accordance with 130 CMR 409.000; and(S) upon request, submit to the MassHealth agency or its designee, data demonstrating the DME provider's performance related to customer service, delivery of equipment, supplies and timeliness of repairs in accordance with 130 CMR 409.426.Amended by Mass Register Issue 1449, eff. 8/6/2021.Amended by Mass Register Issue 1472, eff. 7/1/2022.Amended by Mass Register Issue 1494, eff. 4/28/2023.