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Providers

Section 8: Provider Responsibilities

We are your partners in delivering the best possible care to our members, and we know that delivering excellent care comes with many responsibilities. If you have questions or need help verifying a member’s enrollment, check the Providers page at bmchp.org or call us; the table below lists contact numbers.

For information about… …contact … …at this number
Enrollment verification/ member eligibility
  • Provider line—select the member eligibility option
  • Our website: bmchp.org
 1-888-566-0008, 8 a.m. to 5 p.m., Monday through Friday (except holidays)
Member benefits, eligibility, and primary care provider (PCP) assignment
  • Provider line (after using the automated system, you can ask a Plan staff member)
  • Our website: bmchp.org
 1-888-566-0008, 8 a.m. to 5 p.m., Monday through Friday (except holidays)
Behavioral health issues
  • Beacon Health Strategies (BMC HealthNet Plan contracts with Beacon Health Strategies to manage the Plan’s behavioral health program.)
  • Beacon’s website: beaconhealthstrategies.com
 1-866-444-5155 (24 hours a day, seven days a week)
Care Management evaluations Care Management department 1-866-853-5241 from 8:30 a.m. to 5 p.m., Monday through Friday (except holidays)
Contracting or Provider Relations
(if you are a contracted medical/surgical provider) 		Provider line— select the appropriate option
or
Your assigned Provider Relations Representative 		1-888-566-0008 , 8 a.m. to 5 p.m., Monday through Friday (except holidays)

8.1 Overview

This section outlines your obligations as a Plan network provider. You are responsible for verifying member eligibility, adhering to our administrative and clinical guidelines, following access to care and office waiting time standards, complying with provider contract terms, following cultural and linguistic requirements, and adhering to our quality and utilization management programs. You must meet our credentialing and recredentialing standards to participate in our provider network. See the table above for contact information if you have any questions or issues.

Unless otherwise specified in this manual or your contract with us, provider responsibilities described in this section apply to the following types of providers:

  • Contracted physicians
  • Contracted healthcare clinicians, including medical/surgical providers
  • Contracted healthcare facilities, including health centers, acute care hospitals, skilled nursing facilities and rehabilitation hospitals
  • Contracted ancillary providers (e.g., durable medical equipment vendors, home healthcare agencies, laboratory facilities, radiology/imaging centers, physical therapy vendors, speech therapy vendors, and occupational therapy vendors)
  • Contracted community-based providers, facilities, and agencies

For information on maintaining positive provider/member relationships, PCP selection and assignments, transfers and confidentiality issues, see sections 12.7 and 12.9.

8.2 Verifying Member Status

8.2.1 MassHealth: Two Member Identification Cards Issued

Each Plan MassHealth member receives two member identification (ID) cards: a MassHealth member ID card and a Plan member ID card. Our member ID card includes a Plan member ID number, the member’s MassHealth-issued ID number, the name of the primary care provider (PCP) and important phone numbers. Presentation of the member’s ID cards does not ensure member eligibility; you must verify that the member is currently enrolled with both MassHealth and the Plan on each date of service.

8.2.2 Commonwealth Care and Commercial Plans: One Member Identification Card Issued

Each Commonwealth Care and Commercial plans member receives a member identification (ID) card from us. This card includes a member ID number and important phone numbers. We tell members to present this card to you on each date of service. Presentation of the member’s ID card does not ensure member eligibility. For Commonwealth Care members, you must verify that the member is currently enrolled with both Commonwealth Care and the Plan on each date of service. For Commercial members, you must verify that the member is currently enrolled with the Plan on each date of service.

8.2.3 Verifying MassHealth, Commonwealth Care and Commercial Plan Eligibility

You must check member eligibility for all Plan members on the date of service and daily for inpatient admissions and 24-hour level of care.

8.2.3.1 MassHealth and Commonwealth Care Options for Checking Eligibility

  • Use WebEVS and/or Automated Voice Response (AVR). Note that this is the preferred and most accurate/up-to-date option. See Section 1 for MassHealth telephone numbers and website information.
  • Go to our online eligibility lookup at bmchp.org. Click on ‘Provider Login’ and enter your user name and password. Once logged in, click on ‘Provider e-services’ in the left column, then click on Member Eligibility. 
  • Call our provider line at 1-888-566-0008.

8.2.3.2 Commercial Plans Options for Checking Eligibility

  • Go to our online eligibility lookup at bmchp.org. Click on ‘Provider Login’ and enter your user name and password. Once logged in, click on ‘Provider e-services’ in the left column, then click on Member Eligibility. 
  • Call our provider line at 1-888-566-0008.

For MassHealth members, member eligibility may change from day to day. For Commonwealth Care and Commercial plans members, eligibility is generally effective on the first day of a given month and terminates on the last day of the appropriate month.

It is your responsibility to verify member eligibility at the time of service to ensure that services rendered are eligible for reimbursement. You may deny services if the member is not eligible on the date of service. You may verify member eligibility after providing emergency services to determine the member’s insurer(s).

AVR and WebEVS only verify eligibility for the date of service; they do not authorize services requiring Plan prior authorization. Further, if you are a PCP, AVR and WebEVS do not verify that the Plan member is assigned to your panel. See section 3 (Prior Authorization and Utilization Management), section 5 (Behavioral Health Management) and section 7 (Pharmacy Administration) for instructions on how to obtain Plan prior authorization. Section 8.6.2 includes instructions on how a provider may assist a member in changing his/her PCP assignment, if requested by the member. Follow the step-by-step instructions included in section 8.2.6.1 to verify MassHealth enrollment and member eligibility in the Plan.

8.2.4 Summary of Plan Eligibility Verification Process

Contact our provider line at 888-566-0008 to verify Plan member benefits and eligibility, determine which benefit plan applies to a member, confirm the member’s PCP assignment, and determine provider participation status before services are rendered. We also provide this information when you complete the Plan prior authorization process.

See section 13 for a list of covered benefits for our members. There are also certain additional benefits that are covered directly by MassHealth for MassHealth members; bill MassHealth directly for these additional “wraparound” benefits. Follow the step-by-step instructions included in sections 8.2.5 and 8.2.6 (immediately below) to verify member eligibility in the Plan.

8.2.5 Newborn Eligibility Guidelines

We automatically cover any newborn child of an eligible Plan member/mother on the newborn’s date of birth. To ensure continuity of care and enrollment of the newborn into the Plan, the admitting hospital or hospital where the newborn delivery occurred must notify our Enrollment Department by fax at 617-897-0838 within one business day of each new birth for any Mass Health or Commonwealth Care members. See section 8.8.1.5 for a summary of notification guidelines for newborn deliveries and newborn care.

This fax should include the following information:

  • Newborn mother’s first and last name
  • Newborn mother’s member ID number
  • Newborn mother’s address and phone number
  • Newborn’s first and last name
  • Birth weight (in grams)
  • Gender
  • Gestational age
  • Date of delivery

To ensure a smooth and efficient process for reporting all newborn deliveries and billing for services provided, we assign a temporary ID number (T number) to each newborn upon notification of birth to our Enrollment department. For MassHealth and Commonwealth care members, providers may use the T number to submit claims to us if the MassHealth recipient ID number (RID) is not available.

When the facility notifies us of the newborn birth, we give the facility the T number. The T number is a Plan-specific, temporary member ID number and may be used only for claims submitted to the Plan. We use the newborn’s given name to generate the T number; if this information was not sent to us, we use the mother’s last name and BabyBoy or BabyGirl as the first name until notified of the newborn’s given name. Follow the step-by-step instructions included in section 8.2.6 to verify member eligibility of the mother and the newborn in the Plan.

Hospitals treating the Plan’s MassHealth and Commonwealth Care members must complete a MassHealth Notification of Birth (NOB-1) form and submit it directly to the MassHealth Enrollment Center Notification of Birth Unit in a timely manner, no later than 30 calendar days after the delivery. Please indicate birth weight and gestational age on this form. MassHealth will generate a ZZ number for a newborn of an eligible mother after it receives a completed NOB-1 form, if the newborn’s social security number is not available. We automatically assign the newborn to the mother’s primary care site if the PCP specialty is appropriate for the newborn (such as a family medicine site), a sibling’s PCP, or randomly assign a primary care pediatric or family medicine site unless the mother requests another PCP assignment. The mother may request a PCP assignment by calling our Member Services department or faxing a completed Primary Care Provider Selection Form to our Enrollment department. See section 15 for a sample Primary Care Provider Selection Form (which includes the appropriate fax number for the Enrollment department).

We encourage providers to deliver prenatal, third-trimester and post-partum visits as appropriate.

  • See section 3.2.2 for more maternity program guidelines and requirements.
  • See section 4 for a description of how our Care Management program is involved with pregnant members and their babies.

8.2.6 Step-by-Step Instructions for Verifying Member Eligibility

8.2.6.1 Verifying Member Eligibility (Except Newborns)

STEP ONE
For MassHealth and Commonwealth Care members, providers must verify enrollment in MassHealth or Commonwealth Care before determining membership in the Plan. A member may only participate in our network if the state has determined she/he is eligible in MassHealth or Commonwealth Care. To verify eligibility for MassHealth or Commonwealth Care, call MassHealth’s automated voice response (AVR) or use the MassHealth WebEVS website, using the member identification number or certain personal attributes (gender, name, date of birth). See section 1.2.2 for a list of MassHealth telephone numbers and contact information if you have questions about MassHealth enrollment.

STEP TWO
If an individual is enrolled in MassHealth or Commonwealth Care, you may check member eligibility for the Plan using any of the following ways:

  • Use WebEVS and/or Automated Voice Response (AVR). Note that this is the preferred and most accurate/up-to-date option.
  • Go to our online eligibility lookup at bmchp.org.
  • Call our provider line at 1-888-566-0008.

You may check your member panel reports, but member eligibility may change daily so the reports may not accurately reflect member eligibility. If you find a discrepancy in eligibility between MassHealth and the Plan, use the MassHealth eligibility information lookup and notify us of the discrepancy. We will update the membership information to reflect the information provided by MassHealth.

  • For members through our Commercial plans, providers must verify enrollment via one of the following options:
    • Go to our online eligibility lookup at bmchp.org.
    • Call our provider line at 1-888-566-0008.

8.2.6.2 Verifying Newborn Member Eligibility

STEP ONE
Check the mother’s eligibility for the Plan on the date of birth of the newborn (following all of the step-by-step instructions listed in the previous section).

STEP TWO
For MassHealth and Commonwealth Care members, hospitals must submit a completed NOB-1 form to the MassHealth Enrollment Center Notification of Birth Unit in a timely manner, no later than 30 calendar days after the delivery. MassHealth will generate a permanent ID for the newborn. There will be no record of the newborn on MassHealth WebEVS until MassHealth creates a permanent ID for the member.

STEP THREE
If the mother is enrolled in the Plan on the newborn’s date of birth, the hospital or treating provider must complete Plan notification within one business day of the newborn’s date of birth. We will generate a T number for the newborn within one business day of the notification, and give you a reference number after receiving clinical information from you. Include the T number or MassHealth ID on the claim form when billing the Plan for newborn services.

STEP FOUR

  • For MassHealth and Commonwealth Care members, MassHealth will generate an ID number after it receives the completed NOB-1 form from the hospital. When the ID number is assigned to the newborn, the baby may be listed in WebEVS as a MassHealth member without a managed care plan or PCP assignment.
  • MassHealth then assigns the newborn to a managed care plan. If the mother is a member of BMC HealthNet Plan, the newborn will be retroactively enrolled in our MassHealth product from the newborn’s date of birth. Therefore, it is essential that the hospital completes the Plan notification process even though the newborn is not initially documented in WebEVS as a Plan member. The newborn may have multiple RIDs in MassHealth WebEVS. Please contact our provider line at 888-566-0008 and select the member eligibility option if you have questions or need clarification on newborn member eligibility.

See section 8.2.6.1 for instructions on how to check the eligibility of Plan members who are not newborns.

8.3 Access to Care Guidelines for Medical/Surgical Services

We perform quality assessments of provider practices to ensure they meet our appointment availability guidelines. We monitor access using provider self-reported data and validated with site audits. Locate access to care guidelines for behavioral health providers as well as consumer satisfaction measurement guidelines for behavioral health providers by contacting Beacon Health Strategies at beaconhealthstrategies.com or by calling 1-866-444-5155. A Plan member must receive medical/surgical services within the following timeframes from the date of the member’s request for the service (if the service is applicable to the provider).

8.3.1 Access to Care Guidelines for Emergency Services

Provide emergency services immediately upon member presentation at the service delivery site, including at non-network and out-of-area facilities.

8.3.2 Access to Care Guidelines for Outpatient Primary Care Services

  • A routine (non-symptomatic) appointment occurs within 45 calendar days of the member’s request, unless otherwise required by the EPSDT Periodicity Schedule; this includes a non-symptomatic health assessment or general physical exam if one has not been performed within the prior year.
  • Provide non-urgent, symptomatic care within 10 calendar days of the member’s request.
  • Provide an urgent visit within 48 hours of the member’s request.

8.3.3 Access to Care Guidelines for Outpatient Specialty Services and Newborn Care

Members need to be seen for:

  • Non-symptomatic care within 60 calendar days of the member’s request.
  • Non-urgent, symptomatic care within 30 calendar days of the member’s request.
  • Urgent care within 48 hours of the member’s urgent care request.
  • Initial prenatal visit within 21 calendar days of the member’s request.
  • Initial family planning visit within 10 calendar days of the member’s request.
  • Initial newborn care visit within 14 calendar days of the hospital discharge.

8.3.4. Access to Care Guidelines for Members affiliated with the Massachusetts Department of Mental Health (DMH) Children in Care or Custody of Department of Children and Families (DCF) (formerly DSS) and Youth Affiliated with the Massachusetts Department of Youth Services (DYS)

  • A DCF or DYS medical screening must occur within seven calendar days of receiving a request from a DCF or DYS social worker at a reasonable time and place. Such screening will attempt to detect life threatening conditions, communicable diseases, and/or serious injuries, or indication of physical or sexual abuse.
  • An initial comprehensive medical evaluation (including EPSDT screens appropriate for the child’s age) must occur within 30 calendar days of receiving a request from a DMH, DCF or DYS social worker, unless otherwise required by the EPSDT Periodicity Schedule.
  • Communicate with DMH, DYS and DCF caseworkers assigned to members and inform them of services provided through BMC HealthNet Plan that can support the member.

8.3.5 Access to Care Guidelines for Other Healthcare Services

For MassHealth members, provide other healthcare services in accordance with MassHealth standards and guidelines. Please contact us for eligibility and benefit eligibility. All Plan rules and policies apply.

8.4 Office/Service Waiting Time Standard

To ensure member satisfaction, we have established an average office/service waiting time standard that all participating providers must follow. A member’s wait time for an appointment is expected to be 20 minutes or less from the member’s scheduled appointment time. On occasion, longer waiting times may be understandable and acceptable when you are treating members with difficult problems, or you encounter unanticipated urgent visits; however, if there is a delay, inform the member promptly.

8.5 Requirements for All Contracted Providers

We work with MassHealth and Commonwealth Care to serve these special populations. For these members, you must work with them to promote, to the greatest extent possible, self-care, independent living and the minimization of secondary disabilities for Plan members. We contract with PCPs and specialists who have experience working in multidisciplinary teams to provide care management for high-risk members.

We expect you to comply with the obligations specified in your provider agreements and the latest version of this manual (including subsequent Network Notifications located at bmchp.org/providers/network-notifications). We will take appropriate action with providers who are not in compliance with Plan requirements and will work cooperatively with you on corrective actions, as appropriate. Best efforts are made to notify you in writing 60 calendar days in advance of changes in our policies or procedures.

Ask your assigned Provider Relations representative if you have questions or requests for provider training. You can also call the provider line at 888-566-0008.

8.5.1 Cultural and Linguistic Responsibilities of All Contracted Providers

We work with you to serve a diverse population representing multiple racial, ethnic and language groups. Our goal is to meet the healthcare needs of our members by providing high-quality, comprehensive care consistent with the racial, cultural and linguistic needs of all members. The following guidelines can help you work effectively with diverse populations.

  • Try to determine how the family members interact and the impact these interactions have on the member. Ask if the family has faced significant illness/hardship in the past in order to determine how the family copes with crises. His discussion will demonstrate interest in learning more about the member’s culture, and it will help to develop an effective care plan and/or discharge plan.
  • Consider how long the family has been in the United States. This information is important in understanding the degree to which the family has assimilated into American culture. If a family has been in the United States for less than a year, it is likely that much of the native culture remains intact.
  • Avoid making assumptions based solely on the member’s country of origin. Stereotypes often do not hold true. Cultures and beliefs vary according to regional and demographic differences. It may be more useful to determine whether a member comes from a city or rural area.
  • Be aware that some behaviors are based purely on culture. For example, in some cultures avoiding eye contact is a sign of respect. This should not be interpreted as a sign of indifference. If there is something you don’t understand about the member’s culture, ask about it. As long as questions are posed respectfully, members and families will most likely appreciate your wanting to understand their culture.
  • In general, family members should not serve as interpreters. A trained medical interpreter is in a much better position to provide accurate, objective interpretation. Also, it may be uncomfortable for both the member and the interpreting family member to be put in this situation.
  • Assist non-English speaking members with interpreter services. You should have a list of available interpreters and coordinate interpreter services, if requested by the member. The list of interpreters should include the following information: name of interpreter, languages spoken, and phone number for each interpreter. Be prepared to describe the interpreter’s fee and any related costs.
  • Learn some basic phrases you can use with members and families. Members will most likely be pleased to hear you say “hello,” “how are you” and “goodbye” in their native language.
  • Consider keeping a list of cultural issues that affect care management. For example, in cultures where women are allowed to make few decisions, asking the mother to sign a consent form for pediatric care may breach a fundamental cultural belief. It may be legally acceptable to have either parent sign, but in such cases it may be better to obtain the father’s signature.
  • Use resources that will educate you on cultural competency (e.g., material obtained in bookstores, libraries or international programs).
  • Research the behaviors associated with the cultures with which you interact. By doing so you will find out, for example, that Chinese people tend not to say “no” as they consider this disrespectful. Rather, if they disagree with something, they tend to remain silent. Therefore, while prodding an American member to answer a question may be acceptable behavior, it may offend a Chinese member.
  • At all times treat the member and family with respect, and show that you care about them. You don’t need to be an expert on a specific culture to communicate effectively with a member and his/her family. By demonstrating your interest in their beliefs, especially as they relate to health and wellness, you will build a relationship with members based on mutual respect and trust.

8.5.2 General Provider Contract Requirements for All Providers

Below are listed some of the most important contractual obligations for participating PCPs, specialty physicians, health centers, ancillary providers, hospitals, and vendors affiliated with us. This is only a partial list of your contractual obligations and supplements those within your contract. Please become familiar with all of the terms of your contract with us.

8.5.2.1 Care Coordination Requirements for All Contracted Providers

  • Supervise, coordinate, and provide medically necessary Plan-covered services, and for MassHealth and Commonwealth Care members, associated covered services in accordance with accepted standards of clinical practice by provider type.
  • Request a benefit exception if you believe that a member’s health is jeopardized because a particular service or item is medically necessary but not covered. See section 3.2 for guidelines on submitting a request for a benefit exception.
  • Upon initial contact with a member, complete a behavioral health assessment to identify a member’s need for behavioral health treatment. If a member requires behavioral health services, promptly direct him/her to a behavioral health provider according to Beacon Health Strategies guidelines at beaconhealthstrategies.com or by calling 866-444-5155.
  • Maintain the confidentiality of member information and records at all times.
  • Make best efforts to provide foster parents with current medical information about members placed in their care in a timely manner.
  • Treat members promptly and courteously in a clean, comfortable environment, with staff that is mindful of members’ needs for dignity and respect.
  • Accept and treat members without regard to race, age, gender, sexual preference, national origin, religion, health status, economic status, or physical disabilities. No provider may engage in any practice, with respect to any Plan member, that constitutes unlawful discrimination under any state or federal law or regulation.
  • Freely communicate with members about their treatment options, regardless of the benefit coverage limitations.
  • Maintain complete medical records consistent with all statutory and regulatory requirements and Plan policies. Medical records must be available to us to fulfill our quality management responsibilities. (See section 9.7 for medical record charting standards for participating physicians.)
  • Comply with any advance directive instructions that a member or his/her proxy has given you, and note it in the member’s medical record as mandated by state law.
  • Comply with our authorization and notification guidelines by service type for:
    • Medical/surgical services (specified in section 3)
    • Pharmacy services (outlined on our website click on 'Pharmacy' on the task bar just below our logo).  
    • Behavioral health services (beaconhealthstrategies.com or 866-444-5155)
  • Notify us as soon as possible, but no later than within three business days of each confirmed pregnancy of a Plan member by contacting our Prior Authorization department; call the provider line at 888-566-0008 and select the medical prior authorization option. Please note: this guideline does not apply to ancillary providers.
  • Immediately report to the Plan any adverse medical incident, and to Beacon Health Strategies any behavioral health reportable adverse incident related to a Plan member. See section 9.6 for a description of the adverse incidents and beaconhealthstrategies.com description of the behavioral health reportable adverse incidents, including policy information and instructions on the appropriate notification process by incident category.
  • Direct members to other participating providers unless required medical/surgical or behavioral health services are unavailable through a participating provider. You must seek prior authorization from us prior to referring members to non-participating providers. You must agree to notify the Plan no later than the next business day following an emergency referral if we require notification.
  • Assist Plan staff with care coordination and care management activities for members.
  • If applicable, review our utilization reports related to care management, care coordination or quality improvement activities. Work collaboratively with our staff to evaluate level of care, appropriateness of service or treatment for a member’s condition, and under and over utilization of services for a Plan member.
  • For MassHealth members, you may not refuse to provide services to members who have missed appointments or who have an outstanding debt to you from a time prior to the time that individual became a Plan member. You should work with MassHealth members and the Plan to help members keep their appointments.
  • With regard to MassHealth, Commonwealth Care and Commercial plan members, provide member clinical information, with lawful member consent, to other providers as necessary to ensure proper coordination and behavioral health treatment of members who express suicidal or homicidal ideation or intent.

8.5.2.2 Credentialing, Coverage and Administrative Requirements for All Contracted Providers

  • You must comply with our credentialing and recredentialing criteria as outlined in section 11 of this Manual. Providers must be credentialed in all locations and practices where Plan members will be treated. You must complete and submit a BMC HealthNet Plan Provider Data Form as well as an HCAS Enrollment Form to the Plan; see section 15 for sample forms.
  • All covering providers and new providers must be credentialed with the Plan; this includes temporary and permanent coverage arrangements. Any change in provider coverage arrangements must be submitted and approved by us prior to coverage occurring. See section 8.5.2.6 for our policy on the use of locum tenens physicians. Section 11.9 includes instructions on how to add a new provider to our network when the provider is affiliated with a contracted entity. The new provider must complete and submit a BMC HealthNet Plan Provider Data Form as well as an HCAS Enrollment Form to the Plan to begin the notification process; see section 15 for sample forms.
  • You must be able to assist a member who would like to select a PCP or is requesting a PCP transfer. See section 12.7 for PCP transfer guidelines, including the effective date of new PCP assignments. Your responsibilities related to PCP assignment are:
    • Instructing the member to call our Member Services department at 888-566-0010 (MassHealth), 877-957-5300 (Commonwealth Care) or 877-492-6967 (Commercial plans)); or
    • Asking the member to complete and sign a Primary Care Provider Selection Form. Immediately fax the completed form to our Enrollment department using the fax number listed on the form; see section 15 for a sample form (Form 15.5.2 'PCP selection Form') .
  • You must accept our reimbursement and the member cost-sharing (copayments, coinsurance and deductibles, as applicable) as payment in full for covered services. See section 2 for reimbursement guidelines of approved services.
  • Submit completed claims within the required filing timeframe from the date of service or discharge date using all necessary data fields on the required claim forms. (See section 2).
  • Collaborate with us to obtain coordination of benefits (COB) and subrogation recoveries from other payers. (See section 2.7 for guidelines.)
  • Notify us in writing no later than 30 calendar days before the effective date, or within the timeframe specified in your participating provider agreement, of a provider change related to any of the following:
    • Practice location(s)
    • Specialty
    • Service(s) provided
    • Coverage status
    • Hospital affiliation
    • Delivery of school-based care
    • Termination if a provider is leaving a practice
    • Termination of an entire provider group or contracting entity
      The provider or his/her designee (e.g., office manager) should specify the reason a provider is leaving a practice and/or terminating a contract and include a list of contracted providers who are available to treat members when the provider is no longer available to Plan members.
  • Once forms are completed, please submit in one of the following ways:
    • Email the documents to BMCHP.providerprocessingcenter@bmchp.org
    • Fax the documents to 1-617-897-0818
    • Mail the documents to:
      Boston Medical Center HealthNet Plan
      Provider Processing Center
      Two Copley Place, Suite 600
      Boston, MA 02116
  • Follow all of the administrative guidelines in this manual and your participating-provider contract, including cooperation with our quality improvement activities.

8.5.2.3 New Provider Requesting Participation in the Network

A provider not affiliated with a Plan-contracted entity may request participation in our provider network by submitting a written request to the Provider Relations department. You may request participation by forwarding a letter which must include the following information:

  • Reason you are interested in participating in our network
  • Your specialty
  • Your practice location(s)
  • Your hospital affiliation(s)
  • Number and percentage of MassHealth recipients treated in your practice per year
  • Language(s) you speak and other cultural competencies

Letters should be mailed to:

BMC HealthNet Plan
Provider Relations Department
Two Copley Place, Suite 600
Boston, MA 02116

8.5.2.4 If a New Provider Joins a Plan-Contracted Entity

All providers treating Plan members must be credentialed with the Plan. We (or our credentialing designee) must credential any provider joining a practice, facility, or ancillary site contracted with us before treating members. A provider joining a Plan-contracted entity must:

  • Complete the BMC HealthNet Plan Provider Data Form as well as an HCAS Enrollment Form (for a new individual professional medical/surgical provider or for a new facility affiliated with a Plan-contracted facility)
  • Submit forms in one of the following ways:
    • Fax the documents to 1-617-897-0818.
    • E-mail the documents to BMCHP.providerprocessingcenter@bmchp.org.
    • Postal-mail the documents to:
      Boston Medical Center HealthNet Plan
      Provider Processing Center
      Two Copley Place, Suite 600
      Boston, MA 02116
  • After receiving the appropriate forms, Plan staff will notify the new provider of his/her credentialing status and assist with the credentialing process, as needed. See section 15 for a sample of the BMC HealthNet Plan Provider Data Form , and the HCAS Enrollment Form, go to hcasma.org/attach/HCAS_Provider_Enrollment_Form.doc.

8.5.2.5 If a Contracted Provider Requests Participation of Additional Provider Site

To request Plan participation of an additional provider site:

  • Complete the BMC HealthNet Plan Provider Data From and the HCAS Enrollment Form (for a new medical/surgical provider site for an individual professional provider contracted with the Plan or for a new provider site for a Plan-contracted facility).

    Submit forms to the Provider Processing Center in one of the ways listed above. After receiving the forms, our staff will notify you when we have credentialed the additional location and members may be treated at this location. Section 15 contains provider forms.

8.5.2.6 Provider Requirements for Locum Tenens Physician Services

All contracted providers using locum tenens physician services must comply with the following guidelines:

  • A locum tenens physician must comply with our credentialing guidelines specified in section 11.3.1.
  • You can use locum tenens physician services for up to six months. If a locum tenens physician needs to be in place beyond six months, a physician needs to be fully credentialed. The physician may extend these services past the initial six months when required by the practice. To facilitate an extension beyond six months, notify us 30 calendar days prior to the end of the locum tenens physician’s term so we can conduct the full credentialing process. Failure to notify us will result in claims denial.
  • A locum tenens physician must adhere to the clinical standards established for all Plan network providers.
  • We reimburse for locum tenens physician services in accordance with the reimbursement guidelines specified in section 2.

8.5.2.7 Hours of Operation

Providers must offer hours of operation to MassHealth and Commonwealth Care members that are no less than the hours of operation offered to commercial enrollees (or MassHealth fee-for-service enrollees if the provider serves only Plan members and other individuals enrolled in any MassHealth program).

8.5.2.8 Consent of Treatment

Providers should be aware that in certain situations under the law, minors may consent to medical procedures without parental consent.

8.5.2.9 Provider Obligation to Screen Employees and Contractors

The U.S. Department of Health and Human Services, Office of Inspector General (OIG) may exclude individuals and entities from participation in federal health care programs, such as MassHealth, if such individuals and entities have engaged in certain program-related misconduct or have been convicted of certain crimes, including patient abuse or fraudulent submission of claims. Federal regulations at 42 CFR 1001.1901(b), prohibit MassHealth from paying for any items or services furnished, ordered, or prescribed by the excluded individual or entity. Consistent with MassHealth All Provider Bulletin #196, http://www.mass.gov/eohhs/docs/masshealth/bull-2009/all-196.pdf, all BMC HealthNet Plan providers participating in MassHealth have an obligation to screen their employees and contractors to determine if they have been excluded from participation in federal health care programs. Situations where payment is barred include but are not limited to:

·         Services performed by excluded physicians, nurses, technicians, pharmacists, or other excluded individuals who work for a hospital, nursing home, home health agency, pharmacy or physician practice, even if the services are of an administrative nature or individuals do not furnish direct care/services/prescription drugs to BMC HealthNet Plan MassHealth members;

·         Services performed by an excluded administrator, billing agent, accountant, claims processor or utilization reviewer that are related to and reimbursed, directly or indirectly, by BMC HealthNet Plan;

·          Items or equipment sold by an excluded manufacturer or supplier, used in the care or treatment of recipients and reimbursed, directly or indirectly, by BMC HealthNet Plan.

To protect against payments for items or services furnished, ordered, or prescribed by excluded individuals or entities, you must:

·         Use OIG’s List of Excluded Individuals/Entities (LEIE) to screen all employees and contractors to determine if OIG has excluded them from participation in federal health care programs, both upon initial hiring or contracting and on an ongoing monthly basis. The LEIE website is located at: www.oig.hhs.gov/fraud/exclusions.asp

·         Immediately report any discovered exclusion of an employee or contractor to the BMC HealthNet Plan Compliance Officer or the Compliance hotline 1-888-411-4959

8.6 Responsibilities of Contracted PCPs

A primary care provider/practitioner (PCP) is a physician or nurse practitioner whom the member selects or whom we assign to provide and coordinate all of the member’s healthcare needs and to facilitate referrals for specialty services when required. See section 11.9.1 for our definition of a PCP. Most primary care services must be delivered by the member’s PCP or a covering contracted PCP. We only reimburse for primary care services rendered to a member by his/her PCP or a contracted provider listed in the PCP’s covering group (as documented by the Plan).

8.6.1 PCP Requirements

In addition to the responsibilities of all Plan providers specified in Section 8.5, the PCP is also responsible for the following:

  • Deliver all primary care services to the member. Primary care services do not require a referral if a member seeks primary care services from his/her assigned PCP or a covering physician who is contracted and listed with us as one of the PCP’s covering physicians. You may deliver services in your office, a healthcare facility or the member’s home. To accurately identify whether a member has selected you or a physician in your group as his/her PCP, go to bmchp.org. Click on ‘Provider Login’ and enter your username and password. Once logged in, click on ‘Provider e-services’ in the left column. Click on member eligibility to check the member’s PCP assignment. (See section 14.3.2.1 for information on our website.) You may also check the member’s PCP assignment by calling our provider line at 888-566-0008 and selecting the member eligibility option.
  • If a member presents for services and is not on your panel or on that of your covering group, and if that member wishes to have you serve as his/her PCP, the member should do either of the following:
    • Call our Member Services department to change his/her PCP assignment at 888-566-0010 (MassHealth), 877-957-5300 (Commonwealth Care) or 877-492-6967 (Commercial plans).
    • Complete and fax the Primary Care Provider Selection Form to our Enrollment department. See section 15 for a sample form (Form 15.5.2 ‘PCP Selection Form) (which includes the fax number for our Enrollment department).
  • Schedule a baseline physical examination for each new member according to the access to care guidelines outlined in section 8.3 (unless you determine that the exam has been performed and documented within our approved timeframes for the member’s age/gender category).
  • Be available to respond to urgent healthcare needs of Plan members 24 hours a day, seven days a week, with a telephone answered by a live voice, or have arrangements for such coverage by another Plan-participating PCP. A Plan medical director must approve coverage arrangements that are not in compliance with this requirement.
  • Meet our applicable appointment availability and office waiting time standards (listed in sections 8.3 and 8.4).
  • For medical/surgical admissions, admit or arrange to admit Plan members to a network hospital (if clinically appropriate) and coordinate the medical care of the member while hospitalized.
  • Follow the latest Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) schedule for MassHealth members under the age of 21 (see section 8.9.5 for more information). To ensure that the schedule is the most current, we recommend that you visit the MHQP website at mhqp.org.
  • Review our enrollment report that lists all eligible members in your panel as of the time the report was printed. We generate reports to identify new members, disenrolled members, and those who have historically been seeking care at the health site. These reports include member name, address, Plan member ID number and gender. Your panel report does not guarantee current member eligibility or PCP assignment. Please follow the step-by-step instructions in section 8.2.6 to determine member eligibility.
  • PCPs must coordinate all Plan members’ behavioral health and medical care needs by communicating with members’ behavioral health providers. PCPs must request written consent from the member to release information for these purposes. The consent form must conform to the requirements set forth in 42 CFR 2.00 et. seq., when applicable. See section 15 (Form 15.2.1 ‘Combined MCE BH Provider PCC Form) for a copy of the form. PCPs also must document all instances in which consent was not given and, if possible, the reason why.

8.6.2 Requesting a Change in a Member’s PCP Assignment

We allow a member to change his/her PCP assignment with or without cause. There are no restrictions on the number of times a MassHealth member changes his/her PCP. Commonwealth Care and Commercial plans members may request a PCP change only three times per year. See section 12.7 for information about member selection and assignment of PCPs.

You may request that we remove a member from your panel. You must make your best efforts to communicate with the member and address any healthcare or interpersonal issues. If you cannot achieve a reasonable working relationship with the member, you may request a transfer. After addressing your concerns with the member, document interventions taken to:

  • Establish a satisfactory patient/physician relationship
  • Develop and maintain an effective individual care plan
  • Ensure the member does not experience in interruption in care or services

You must give us 60 calendar days' notice before the effective date of the member termination from your member panel. Complete a Member PCP Transfer Request Form with the appropriate documentation and fax it to the Enrollment department (using the fax number listed on the form). A sample form is in section 15 (Form 15.5.1). If you don't have a copy of the form, contact your Provider Relations representative and request assistance re-assigning the member with 60 calendar days' notice. We will initiate the outreach and re-assignment of the member, and we will arrange a transition plan, when necessary, to ensure that the member does not experience an interruption in care or services.

We will also:

  • Track PCP requests for member disenrollment
  • Monitor the occurrence of such situations on a quarterly basis as part of our Quality Management program
  • Follow up with providers where trends are identified

8.7 Responsibilities of Contracted Specialists and Ancillary Providers

Participating specialists and ancillary providers must comply with all applicable requirements in their Plan contract and this manual. You are expected to coordinate all care with the member’s PCP. You must:

  • Provide the member’s PCP with copies of all medical information, reports and discharge summaries resulting from the specialist’s provision of care.
  • Meet the applicable appointment availability and office/service waiting time standards (included in sections 8.3 and 8.4).
  • Obtain prior authorization, when required, for visits (See section 3 of this manual for additional information regarding this requirement.) Also, please refer to our Prior Authorization Matrix located at bmchp.org. Click on ‘Provider’ on the task bar located just below our logo, click on ‘Clinical Resources’ in the left-hand column and on the ‘Prior Authorization Requirements Matrix’ option.

8.8 Responsibilities of Contracted Hospitals

Contracted hospitals must comply with all applicable requirements in their Plan contract and this manual. You are responsible for obtaining Plan authorization for medical/surgical hospital services and providing Plan notification of emergency care and observation services rendered to members. You must update us on maternity/newborn services used by Plan members according to our notification guidelines. In addition, your staff must:

  • Work collaboratively with our hospital care coordinators on concurrent review and discharge planning activities for medical/surgical services
  • Coordinate a member’s behavioral healthcare services with our Behavioral Health care managers
  • Immediately contact an Emergency Services Program (ESP) when a member presents in a behavioral health crisis.

8.8.1 Hospital Responsibilities Related to Medical/Surgical Services

8.8.1.1 Plan Prior Authorization for Medical/Surgical Hospital Services

See section 3.2 for our guidelines on the medical/surgical prior authorization and notification process and for a list of medical/surgical services that require Plan authorization. All elective, inpatient admissions require Plan prior authorization five calendar days in advance. Ancillary services are authorized if the inpatient admission is approved and do not need to be reviewed separately. Please refer to our Prior Authorization Matrix located on our website: bmchp.org. Click on ‘Provider’ on the task bar located just below our logo, click on ‘Clinical Resources’ in the left-hand column and on the ‘Prior Authorization Requirements Matrix’ option.

8.8.1.2 Plan Notification for Emergency Medical/Surgical Admissions

You must notify us of an emergency admission within one business day. You are not required to notify us if a member receives care in an emergency department unless the member is admitted as an inpatient or is in observation status.

When an emergency condition arises, a member should seek care in the nearest emergency department. We reimburse for emergency care services delivered in both contracted and non-contracted facilities. It is the responsibility of the emergency department to provide an appropriate medical screening examination within its capability, including routinely available ancillary services, to determine whether an emergency medical condition exists and what treatment is needed.

After the emergency department has stabilized the member for discharge or transfer, it is the emergency department’s responsibility to immediately notify the member’s PCP or physician–on-call for coordination of post-stabilization services and follow-up care. The emergency department must also give the member instructions regarding care and the need to contact his/her physician for follow-up services.

If the attending physician and the on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician will prevail and such treatment will be considered appropriate treatment for an emergency medical condition if the treatment is:

  • Consistent with generally accepted principles of professional medical practice, and
  • A covered benefit

8.8.1.3 Plan Notification for Observation Status

We require notification within one business day if a member receives care in an observation setting. An inpatient admission for the same episode of care requires a separate Plan authorization. Please refer to section 3.5.1 for a description of observation services. Also, please refer to our Prior Authorization Matrix located at bmchp.org. Click on ‘Provider’ on the task bar below our logo, then click on ‘Clinical Resources’ in the left-hand column and on the ‘Prior Authorization Requirements Matrix’ option.

8.8.1.4 Plan Notification of Newborn Delivery

You must call in or fax to our Prior Authorization department notification of every newborn delivery to a Plan member – within one business day of delivery – in order to be reimbursed for hospital services, including any associated ancillary services rendered. See section 3.2.2 for provider requirements related to our Maternity Program. See section 8.2.5 for instructions on how to verify eligibility and obtain a Plan-assigned “T” number for the newborn. See section 3.7.1 for a description of our newborn delivery notification requirements for MassHealth and Commonwealth Care members. Also, please refer to our Prior Authorization Matrix located at bmchp.org. Click on ‘Provider’ on the task bar below our logo, then click on ‘Clinical Resources’ in the left-hand column and on the ‘Prior Authorization Requirements Matrix’ option.

8.8.1.5 MassHealth and Commonwealth Care Notification of Newborn Delivery

You must notify MassHealth of all newborn deliveries for mothers who receive MassHealth or Commonwealth Care. Complete a MassHealth NOB-1 form and submit the form directly to the MassHealth Enrollment Center Notification of Birth Unit in a timely manner, no later than 30 calendar days after the delivery. Questions about this process should be directed to MassHealth. See section 8.2.5 for additional information on eligibility verification and the notification process for newborns. Please refer to section 3.7 for a description of our newborn delivery notification requirements for MassHealth and Commonwealth Care members. Also, please refer to our Prior Authorization Matrix located at bmchp.org. Click on ‘Provider’ on the task bar below our logo, then click on ‘Clinical Resources’ in the left-hand column and on the ‘Prior Authorization Requirements Matrix’ option.

8.8.1.6 Plan Notification of Newborn Hospitalization Following Mother’s Discharge

You must notify our Prior Authorization department if a newborn stays in the hospital after the mother is discharged. Notification must occur prior to or at the time of the mother’s discharge.

See section 3.2.2.7 for guidelines on how to submit a Plan authorization request for a newborn hospitalization following the mother’s discharge. Also, please refer to our Prior Authorization Matrix located at bmchp.org. Click on ‘Provider’ on the task bar below our logo, then click on ‘Clinical Resources’ in the left-hand column and on the ‘Prior Authorization Requirements Matrix’ option.

If a home care visit is needed upon discharge of the infant (when the mother was discharged on an earlier date), Plan prior authorization is required for the initial and all subsequent home care visits.

8.8.1.7 Plan Continued Stay Review for Medical/Surgical Services

Your case managers must work collaboratively with our hospital care coordinators to conduct continued-stay review, coordinate discharge planning, and facilitate transfers to alternative levels of care. Section 4 describes the role of our hospital care coordinator in detail.

8.8.1.8 Plan Investigation of Non-Behavioral Health Adverse Incidents and Serious Reportable Events 

Please see section 9.6 for information about and directions for Serious Reportable Events (SRE), Adverse Incidents and Provider Preventable Conditions.

8.9 EPSDT Services for MassHealth Members

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and Preventive Pediatric Health-care Screening and Diagnosis (PPHSD) services are available to the Plan’s MassHealth members under age 21. This important screening requirement applies to:

  • EPSDT: MassHealth Standard and Common/Health
  • PPHSD: MassHealth Family Assistance, Basic and Essential

We pay for these members to see their primary care providers on a periodic schedule. At all well-child visits, primary care providers (PCPs) perform a series of health screens, including approved, standardized behavioral health screens (see below for more information). If the member’s screen indicates the need for behavioral health follow-up, we pay for further assessment, diagnosis and treatment services. We also pay for visits to primary care doctors or nurses between periodic visits when there might be something wrong.

To ensure the health of young members and to comply with contractual and state requirements, all Plan PCPs must:

  • Screen all MassHealth Standard and CommonHealth members under age 21 in accordance with the Executive Office of Health and Human Services (EOHHS) EPSDT medical protocol and periodicity schedule (see section 8.9.5).
  • Provide or refer these members for all medically necessary care in accordance with EPSDT requirements.
  • Screen all MassHealth Basic, Family Assistance and Essential Enrollees under age 21 in accordance with EOHHS’s Preventive Pediatric Healthcare Screening and Diagnosis (PPHSD) medical protocol and periodicity schedule found at 130 CMR 450.140-450.150.
  • Provide or refer these members for medically necessary treatment services included in their benefit package.

In addition:

  • For Plan members entitled to EPSDT services, we pay for all medically necessary assessments, diagnoses and treatment services that are covered by federal Medicaid law, even if the services are not described in the Plan contract, MassHealth regulations, or procedure codes covered for the member’s coverage type.
  • PCPs must offer to perform a behavioral health (mental health and substance abuse) and developmental screens as part of every EPSDT or PPHSD visit.

We reimburse for behavioral health and developmental screening services (CPT 96110) performed as part of all EPSDT visits when using a standardized behavioral health screening tool to administer the behavioral health screen. Choose a clinically appropriate behavioral health screening tool from a menu of MassHealth-approved standardized tools (see the table below). These tools accommodate a range of ages while permitting some flexibility for provider preference and clinical judgment.

Below is the menu of standardized tools, approved by the EOHHS, along with a description of who should complete the tool and the appropriate age group for the tool. Please note that the table below is for your information only. The EPSDT Periodicity Schedule (section 8.9.5) controls the approved behavioral health screening tools.

Behavioral Health Screening Tools Who completes the tool Appropriate age group for the tool
ASQ:SE Ages and Stages Questionnaires: Social-Emotional
brookespublishing.com/tools/asqse/index.htm		 Parent 4 - 60 months
BITSEA Brief Infant and Toddler Social and Emotional Assessment
harcourtassessment.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8007-352&Mode=summary 		Parent 12 to 36 months
CBCL
YSR
ASR 		Achenbach System:
Child behavior checklist
Youth self-report
Adult self-report
ASEBA.org 		Parent
Youth
Young adult 		1.5 to 18 years
11 to 18 years
18 to 59 years
CRAFFT Car, Relax, Alone, Forget, Friends, Trouble
Screening for substance abuse
ceasar-boston.org/clinicians/crafft.php 		Youth 14 +
M-CHAT

Modified Checklist for Autism in Toddlers
Screening for autism
http://www.aap.org/sections/dbpeds/screening.asp

http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D._files/M-CHAT_new.pdf		 Parent 18 to 30 months
PEDS Parents’ Evaluation of Developmental Status
pedstest.com 		Parent Birth to 8 years
PHQ-9 Patient Health Questionnaire-9
Screening for depression
phqscreeners.com/ 		Young Adult 18+
PSC
Y-PSC 		Pediatric Symptom Checklist
Pediatric Symptom Checklist-Youth Report

http://brightfutures.aap.org/pdfs/Other%203/Bright%20Futures%20Kit%20contents%20&%20development.pdf

 Parent
Youth 		4 thru 16 years
11+ years

8.9.1 Eligible Providers

We pay for administering and scoring approved, standardized behavioral health tools when administered in an office or clinic, community health center or hospital outpatient department, and when services are rendered by the following types of network providers:

  • Physicians
  • OB/GYNs
  • Independent nurse practitioners
  • Nurse practitioners, nurse midwives and physician assistants under a physician’s supervision

8.9.2 Reimbursement Terms—Non-Capitated Providers

Submit your claim using the following Current Procedural Terminology (CPT) service code: 96110.
We will reimburse you for administering one standardized behavioral health screening tool per MassHealth member, per day, regardless of the number of behavioral health screening tools administered on the same day for a given member. See section 2.14.4 for details.

8.9.3 Reimbursement Terms

You must submit an encounter form every time you conduct the standardized behavioral health and developmental screening services (CPT 96110 plus appropriate modifier U1 – U8 required)). See section 2.14.4 for details.

8.9.4 Training Available On the Web

See the MassHealth website for information about children’s behavioral health and useful links for finding additional information, including training on how to administer the standardized behavioral health screening tools. Go to mass.gov/masshealth/childbehavioralhealth. Bookmark this page for future reference as MassHealth will continue adding new information periodically. You can also access this information through our website; go to bmchp.org and click the Providers tab.

If you have any questions about billing for EPSDT/PPHSD services, including billing for administering a standardized behavioral health screening tool, please contact your Provider Relations Representative, or call the provider line at 888-566-0008.

8.9.5 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Medical Protocol and Periodicity Schedule

The EPSDT Medical Protocol and Periodicity Schedule (Appendix W) applies to providers treating MassHealth and Commonwealth Care members only and consists of screening procedures arranged according to the intervals or age levels at which each procedure is to be provided. See 130 CMR 450.140 through 450.150 for more information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) services.

8.10 Legal Notice

The Plan is required under state law to provide the following notice: This notice applies to any doctor of medicine, osteopathy, or dental science, or a registered nurse, social worker, doctor of chiropractic, or licensed psychologist, or an intern, or a licensed resident, fellow, or medical officer, or a licensed hospital, clinic or nursing home and its agents and employees, or a public hospital and its agents and employees ("Statutory Reporters"). Under M.G.L. c. 112, § 5F, Statutory Reporters are required to report to the Board of Registration in Medicine ("BORM") any person they reasonably believe is in violation of M.G.L. c. 112, § 5, or any BORM regulation, except as otherwise prohibited by law. This includes, but is not limited to, any physician who they have a reasonable basis to believe has fraudulently procured a certificate of registration, has violated a law related to the practice of medicine, whose conduct places into question the physician’s ability to practice of medicine, or is guilty of being impaired due to alcohol or drug use. Certain exemptions to this reporting requirement, as to a physician who is in compliance with the requirements of a drug or alcohol program satisfactory to the BORM, are described in the BORM regulation 243 CMR 2.00.

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