Pursuant to M.G.L. c. 118E, ยง 38, the MassHealth agency
has established the following procedures for appealing claims that the provider
believes were denied in error or underpaid. The MassHealth agency's Final
Deadline Appeals Board has exclusive jurisdiction to review appeals submitted
by providers of claims for payment that were, as a result of MassHealth agency
error, denied or underpaid, and that cannot otherwise be timely
resubmitted.
(A)
Criteria
for Filing an Appeal. All requests for appeals submitted to the
MassHealth agency for review must be submitted electronically in a format
designated by the MassHealth agency, unless the provider has been approved for
an electronic claim submission waiver as specified in
130 CMR
450.302(A)(3). To file an
appeal with the MassHealth agency's Final Deadline Appeals Board, the provider
must meet all of the following criteria.
(1)
The provider must have submitted the original claim in a timely manner,
pursuant to
130
CMR
450.309 through
450.314.
(2) The provider must have exhausted all
available corrective actions outlined in the billing instructions provided by
the MassHealth agency.
(3) The date
of service for which the appeal is submitted must exceed the filing time limit
of 12 months, unless third-party insurance is involved, in which case the
filing time limit is 18 months (the final billing deadline).
(4) Claims for dates of service more than 36
months after the date of service are not eligible for an appeal.
(5) The provider must file the appeal within
30 days after the date on the remittance advice that first denied the claim for
exceeding the final billing deadline.
(6) The provider must demonstrate that the
claim was, as a result of MassHealth agency error, denied or
underpaid.
(B)
Accompanying Documentation. Along with each appeal of
a claim, the provider must submit the following information to substantiate the
contention that the claim was, because of MassHealth agency error, denied or
underpaid:
(1) a standard appeal form
prescribed by the MassHealth agency or cover letter describing the nature of
the MassHealth agency error that resulted in the denial or underpayment of the
claim. The statement must include the provider name, provider ID/service
location number, member name, member number, and date of service.
(2) evidence of the claim's original, timely
submission and resubmission, if applicable;
(3) a copy of the applicable page from each
remittance advice on which the claim was previously processed;
(4) a copy of the remittance advice or
electronic response that indicates that the final submission deadline has
passed;
(5) an accurately completed
electronic claim or a legible and accurately completed paper claim if the
provider has received a waiver of the electronic submission requirement;
and
(6) any other documentation
supporting the appeal.
(C)
Procedure for Deciding
Appeals. All appeals are decided by the MassHealth agency's Final
Deadline Appeals Board based upon written evidence submitted by the provider.
The provider has the burden of establishing by a preponderance of the evidence
that the claims appealed were denied or underpaid because of MassHealth agency
error.
(D)
Request for
an Adjudicatory Hearing. A provider may submit a request for an
adjudicatory hearing with a final deadline appeal if there is a dispute about a
genuine issue of material fact. The request must include a statement indicating
the specific reasons why a hearing should be conducted. The request must
include the following information:
(1) a
statement identifying the material facts in dispute;
(2) a summary of the evidence that the
provider would offer at the hearing to support his or her contentions;
and
(3) a statement explaining why
the evidence could only be presented at a hearing.
(E)
Notification of Approval or
Denial of Request for an Adjudicatory Hearing.
(1) If the Final Deadline Appeals Board
determines that a hearing is justified, the MassHealth agency notifies the
provider of:
(a) the issues of fact for which
a hearing has been justified; and
(b) the identity of the person or entity
designated by the MassHealth agency to conduct the hearing.
(2) Any hearing
hereunder, whether conducted by the Final Deadline Appeals Board or its
designee, is conducted in accordance with the provisions of
130 CMR
450.244 through
450.248.
(3) If the Final Deadline Appeals Board
determines that a hearing is not justified, the MassHealth agency notifies the
provider of the reasons why it decided not to hold a hearing.
(F)
Decisions of the Final Deadline Appeals Board. The
Final Deadline Appeals Board reviews each appeal that is properly submitted and
notifies the provider in writing of its decision. The notification includes a
brief statement of the reasons for its decision. The decision is a final agency
action, reviewable pursuant to M.G.L. c. 30A.