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GEN-15 (Rev. 11/15)
C O M M O N W E A L T H O F M A S S A C H U S E T T S
E X E C U T I V E O F F I C E O F H E A L T H A N D H U M A N S E R V I C E S
MassHealth Provider Contract for Individuals
Provider Contract between the Commonwealth of Massachusetts, acting by and through the Executive Oce of
Health and Human Services (hereinaer MassHealth), and
(Legal Name of Provider, hereinaer the “Provider”)
doing business as
(Doing Business As (DBA) Name of Provider)
In consideration of the mutual promises contained herein, the parties agree as follows.
I. The Provider agrees:
A. to comply with all state and federal statutes, rules, and regulations applicable to the Provider’s
participation in MassHealth.
B. to provide services to eligible members without regard to religion, race, color, or national origin
in compliance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et seq. and its
implementing regulations at 45 CFR Part 80), and without regard to handicap in compliance with
Section 504 of the Rehabilitation Act of 1973 as amended (29 U.S.C. § 794 and its implementing
regulations at 45 CFR Part 84).
C. to keep such records as are necessary to disclose fully the extent and medical necessity of the
services provided to, or prescribed for, members and to preserve these records for at least six
years, or for such a length of time as may be dictated by the generally accepted standards for
recordkeeping within the applicable provider type, whichever period is longer.
D. to furnish MassHealth and any other state and federal ocials and agencies or their designees,
upon request, with such information, including copies of medical records, about any services for
which payment was claimed from MassHealth, to the extent permitted or authorized by law.
E. to comply with 42 CFR § 455.105 by submitting, within 35 days aer the date of a request by the
federal Secretary of Health and Human Services or MassHealth, full and complete information
about
1. the ownership of any subcontractor with whom the provider has had business transactions
totaling more than $25,000 during the 12-month period ending on the date of the request;
and
2. any signicant business transactions between the provider and any wholly owned supplier, or
between the provider and any subcontractor, during the ve-year period ending on the date of
the request.
F. to furnish to MassHealth its national provider identier (NPI) if eligible for an NPI; and include
its NPI on all claims.
