130 CMR, § 450.210

Current through Register 1536, December 6, 2024

Section 450.210 - Pay-for-performance Payments: MassHealth Agency Review

(A)Applicability. The provisions set forth in 130 CMR 450.210 establish the MassHealth agency's review process for provider disputes concerning MassHealth pay-for-performance payment amounts for acute hospitals, MCOs, SCOs, ICOs, and the behavioral health contractor. For purposes of 130 CMR 450.210, "pay for performance" means a value-based purchasing program implemented by the MassHealth agency to pay providers to perform activities related to improving the quality of care delivered to MassHealth members.

(B)MassHealth Pay-for-performance Payment Notice. The MassHealth agency will notify the provider in writing of the agency's determination of the provider's pay-for-performance payment amount for the time period specified in the notice. The notice will identify the aggregate pay-for-performance payment amount calculated for the provider, and may separately identify the amount calculated for components of such payment amount. The MassHealth agency will notify the provider by letter, report, computer printout, electronic transmission, or other format; this notification is the "MassHealth Pay-for-performance Payment Notice" referred to in 130 CMR 450.210.

(C)Requesting MassHealth Agency Review of Pay-for-performance Amounts.

(1) To preserve its right to an adjudicatory hearing and judicial review, a provider must request MassHealth agency review of the provider's pay-for-performance payment amounts specified in the MassHealth Pay-for-performance Payment Notice. The request for agency review must be made in writing and be received by the MassHealth agency within 30 calendar days of the date appearing on the MassHealth Pay-for-performance Payment Notice. Only those payment amounts specifically identified as in dispute by the provider in its request for agency review are subject to review.

(2) Any request for agency review submitted pursuant to 130 CMR 450.210(C)(1) must

(a) identify with specificity all payment amounts and components of such payment amounts in dispute;

(b) specify in sufficient detail the basis of the provider's disagreement with those amounts as calculated;

(c) identify and address all issues in the MassHealth Pay-for-performance Payment Notice with which the provider disagrees; and

(d) include any documentary evidence and information it wants the MassHealth agency to consider.

(D)MassHealth Agency's Final Determination.

(1) The MassHealth agency will review a provider's request for agency review only if it is submitted in compliance with the requirements of 130 CMR 450.210(C)(1) and (2). The MassHealth agency is not obligated to consider any information or documents that the provider failed to timely submit under time deadlines previously imposed by the MassHealth agency. The MassHealth agency will issue a final written determination of contested payment amounts based on its review, which will state the reasons for the determination, and inform the provider of the provider's right to file a claim for an adjudicatory hearing in accordance with 130 CMR 450.241.

(2) Payment amounts and components of payment amounts specified in the MassHealth Pay-for-performance Payment Notice that are not specifically identified as in dispute in a provider's request for agency review will, without further notice, constitute the MassHealth agency's final determination of those amounts. The provider has no right to an adjudicatory hearing pursuant to 130 CMR 450.241 or judicial review of such amounts because of the failure to exhaust its administrative remedies.

(3) If the provider does not submit a request for agency review, the MassHealth Pay-forperformance Payment Notice constitutes the MassHealth agency's final determination of the provider's pay-for-performance payment amounts. If a provider requests agency review but fails to timely comply with the requirements of 130 CMR 450.210 (C)(1) and (2), the request for agency review may be denied. In either case, the MassHealth Pay-for-performance Payment Notice constitutes the MassHealth agency's final determination, and the provider has no right to an adjudicatory hearing pursuant to 130 CMR 450.241 or judicial review because of the failure to exhaust its administrative remedies.