Fillable Gen 16 (Commonwealth of Massachusetts)

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Gen 16 (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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1
GEN-16 (Rev. 11/15)
c o m m o n w e a lt 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
Provider Contract for Entities
Provider Contract between the Commonwealth of Massachusetts, acting by and through the Executive Oce of
Health and Human Services (hereinaer MassHealth), and
(Legal Name of Provider, hereinaer the “Provider”)
doing business as
(Doing Business As (DBA) Name of Entity)
e Executive Oce of Health and Human Services operates a program of Medical Assistance under 42 U.S.C.
§1396 et seq., and M.G.L. c. 118E, §1 et seq. (hereinaer MassHealth) and desires to purchase services and goods
for eligible members in said program from participating providers, and desires to operate said program in a
scally responsible manner; and
e Provider desires to furnish services and/or goods to eligible members in accordance with the legal
requirements of MassHealth and the terms of this Provider Contract and to receive reimbursement therefore;
In consideration of the mutual promises contained herein, the parties agree as follows.
I. The Provider and MassHealth mutually agree:
A. that this Provider Contract shall take eect upon notication of acceptance by MassHealth and shall
continue in eect until terminated by either party upon written notice to the other party; and that
MassHealth may not terminate this Provider Contract without aording to the Provider any applicable
right to contest such termination available under federal and state law and regulation that has been
properly requested by the Provider.
B. that, if MassHealth determines that the continued participation of the Provider may endanger the
health, safety, or welfare of MassHealth members, MassHealth, without prior notice or hearing, may
immediately suspend the Provider from participation in MassHealth, and/or take other appropriate
administrative action against the Provider; that in such event MassHealth shall notify the Provider in
writing of the reasons for the immediate suspension and of the appeal rights available to the Provider as
soon as possible thereaer; and that in such event MassHealth shall aord the Provider a preliminary
hearing on the propriety of the immediate suspension within 30 days of the date on which MassHealth
receives a written request for such a preliminary hearing, so long as the Provider makes such written
request for a preliminary hearing within 21 days of the date on which the Provider received written
notication of the reasons for the immediate suspension.
C. that this Provider Contract shall be governed by and construed in accordance with the laws of the
Commonwealth of Massachusetts; that the terms of this Provider Contract shall be construed, to the
extent possible, so as to be consistent with applicable federal and state laws and regulations; and that,
if a court nds any provision of this Provider Contract to be illegal or ineective, the remainder of this
Provider Contract shall not be aected thereby.
2
GEN-16 (Rev. 11/15)
D. that failure by the Provider or MassHealth, in any instance or series of instances, either to exercise
any of its rights or to insist on the performance of any of the other party’s duties under this Provider
Contract, shall not be construed as a waiver by the Provider or MassHealth of its rights or of the other
party’s duties under this Provider Contract.
II. The Provider agrees:
A. to furnish services and/or goods that conform to the requirements for such services and/or goods as
set forth in MassHealth regulations; to furnish only those services and goods that qualify as medically
necessary under MassHealth regulations; and to furnish services and/or goods that conform to the
professionally recognized standards of health care within the Commonwealth for the applicable
provider type and/or specialty type, or, if appropriate, that conform to the generally accepted standards
within the Commonwealth for the trade.
B. to comply with all federal and state laws, regulations, and rules applicable to the Provider’s participation
in MassHealth, now existing or adopted during the term of this Provider Contract.
C. that all information submitted to MassHealth on or with the Provider Application that has been
incorporated by reference into this Provider Contract is true, accurate, and complete; and that any
information submitted to MassHealth about future changes in, or amendments to, the information
submitted on or with the Provider Application shall be true, accurate, and complete.
D. to notify MassHealth, in writing, of any change in the information submitted on or with the Provider
Application, within 14 days of the date on which the Provider becomes aware of such change; to notify
MassHealth within three days of receiving any written communication that indicates an intention,
conditionally or otherwise, to revoke, void, suspend, delay, or deny the issuance, renewal, or extension
of any license, certicate, or other statement of qualication that constitutes a MassHealth eligibility
criterion for its particular provider type or any specialty type therein; and to notify MassHealth, in
writing, within three days of expressing to an issuing agency any intention or desire to surrender,
terminate, or substan tially modify any such license, certicate, or other statement of qualication.
E. to keep such records as are necessary to disclose fully to MassHealth, to MassHealth’s designees, or to
any other federal or state agency that has a legal right of access to such records, the extent and medical
nessesity of the services and/or goods provided to, or prescribed for, eligible members for each claim
submitted to MassHealth; to maintain in these records all information required both by MassHealth
regulations and by generally accepted standards for recordkeeping within the applicable provider type;
to keep such records for a period of six years from the date the service was furnished or the goods
delivered, or longer if so dictated by the generally accepted standards for recordkeeping within the
applicable provider type; and that MassHealth’s prior authorization form and claim form shall not be
con sidered to be records for the purposes of this paragraph.
F. to furnish on request all information maintained pursuant to the pre ceding paragraph to MassHealth
or its designees, or to any other federal and state ocials and agencies authorized by law to inspect such
information or their designees, including the United States Secretary of Health and Human Services,
the Comptroller General of the United States, the Governor of Massachusetts, the Massachusetts
Secretary of Administration and Finance, the Massachusetts State Auditor, and the Massachusetts
Medicaid Fraud Control Unit; and to allow these ocials, agencies, or their designees to examine and
photocopy all information maintained pursuant to the preceding paragraph, including medical records,
at reasonable times and upon reasonable notice, at the location where these records are normally stored
if such location is within the Commonwealth of Massachusetts, or at a designated MassHealth oce if
the normal storage location is outside the Commonwealth.
3
GEN-16 (Rev. 11/15)
G. to furnish payable services and/or goods of the types furnished by the Provider to any eligible member
who requests such services, without regard to race, color, religion, national origin, handicap, age, or
status as a recipient of public assistance, including MassHealth, except as required or permitted by
governing program regu lations, 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; Section 504 of the Rehabilitation
Act of 1973 as amended (29 U.S.C. § 794) and its implementing regulations at 45 CFR Part 84; M.G.L.
c. 151B, § 4(10); and other applicable federal and state laws or regulations.
H. to comply with 42 CFR § 455.105 by submitting, within 35 days aer 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 signicant 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.
I. to furnish to MassHealth its national provider identier (NPI) if eligible for an NPI; and include its NPI
on all claims.
III. MassHealth agrees:
A. to pay the Provider at rates set by the Massachusetts Executive Oce of Health and Human Services
and/or contained in the applicable MassHealth fee schedules for all payable services and goods actually
and properly delivered to eligible members and properly billed to MassHealth both in accordance
with the terms of this Provider Contract and in accordance with all applicable federal and state laws,
regulations, rules, and fee schedules.
B. that, if MassHealth determines that the Provider has violated the laws, regulations, or rules that govern
MassHealth, and MassHealth decides to take administrative action, MassHealth shall give notice to
the Provider specifying all such violations and informing the Provider of all applicable appeal rights
contained in MassHealth regulations; and that MassHealth shall make all such appeal rights available to
the Provider so long as the Provider makes a proper and timely request for each appeal right.
C. to maintain, in accordance with applicable MassHealth regulations con cerning privacy of member
records, all records furnished to MassHealth pursuant to the requirements of Section II, Paragraph F,
above.
(continued on back)
4
GEN-16 (Rev. 11/15)
P
(Legal Name of Provider)
By:
(Signature)
Name:
(Printed Name)
Title:
Date:
E O  H  H S
By:
(Signature)
Name:
(Printed Name)
Title:
Date:
IV. In conclusion, the Provider and MassHealth mutually agree:
that the entire agreement of the parties is contained in this Provider Contract, taken together with the laws,
regulations, and rules that govern MassHealth; that this Provider Contract supersedes all previous provider
agreements, contracts, negotiations, and verbal agreements between the parties; and that the following
attachments will be deemed to be part of this Provider Contract:
A. any Special Conditions that indicate they are to be incorporated into this Provider Contract and that
are signed by both parties to this Provider Contract; and
B. the Provider Application of the above-named Provider, dated ___________________ (insert date from
Provider Application), and any changes or amendments thereto accepted or agreed to by MassHealth.
If the Provider is a legal entity other than a person, the person signing this Provider Contract on behalf of the
Provider warrants that he/she has actual authority to bind the Provider.
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Gen 16 (Commonwealth of Massachusetts)

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Completed 26 July 2020

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