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1.) It is important that your applications processing staff know exactly under what program (i.e., MassHealth, C-CHIP or UCP) each applicant will fall as this will ultimately determine the processes and procedures they must use in order to expedite and secure eligibility. Equally important, they must understand and anticipate under what category or type of coverage the applicant will be covered (MassHealth Standard, Limited, etc.; Commonwealth Cares (subsidized plan) or Commonwealth Choice (Connector commercial insurance product) or Full/Partial UCP. These factors dictate by whom and how you will be paid and the rules you must follow to be paid after eligibility is achieved as the provider of services. Similarly, as the provider, you need to know and be proactive in protecting the date when such coverage will begin. Without knowing this information at the time of application and monitoring it throughout the process, there is no way to know whether the denial or approval received on the application is correct or not and there is no guarantee that all the work you are doing on the front-end to assist with eligibility will result in payment on the back-end when claims for the services provided are submitted to the payer. Achieving eligibility for your patients is indeed a good thing, but being paid for the services provided is equally important.


2.) Start dates are very important, particularly when inpatient admission services are at issue. Even if your staff does everything else properly, if they do not know what start date should result on any given application (often referred to as the Retroactive Eligibility Start Date or “RESD”) and what to do to preserve the earliest possible date, you may be doing a lot of work for nothing. By regulation the applicant is entitled to ten (10) days retroactive eligibility on most MassHealth applications and up to ninety (90) days on others. The importance of these regulations cannot be understated in terms of the likelihood of securing payment for services rendered prior to application. Along the same lines, this can be valuable to your patients as often other outstanding medical bills can be captured by the retroactive eligibility period. If you are not appealing denials and approvals (yes, I did say appealing approvals) then you are missing out on potential reimbursement opportunities. In our experience, the retroactive eligibility start date as issued by MassHealth is often incorrect. This can sometimes be remedied informally but often requires a Fair Hearing to be corrected. While this point pertains to only certain categories of MassHealth eligibility and not to C-CHIP products or the UCP generally, this point is not trivial as it could very well mean the difference (on the reimbursement side) between getting paid your SPAD and getting paid nothing! If you would like a further explanation of this point, please do not hesitate to call and ask to speak to one of our attorneys.  


3.) There is more to successfully navigating the MassHealth applications process than merely submitting an application. With the advent of the Virtual Gateway we often hear things like “I don’t have issues with MassHealth Applications because the Virtual Gateway has resolved the same”. You may do well to take a closer look at your approvals and denials. There are a myriad of reasons for MassHealth to deny an application. Failure to cooperate, lack of verifications, timeline issues, etc., to name only a few. What you may be viewing as legitimate denials and proper approvals may not, upon closer inspection, in fact be the same. Whether you are using the Virtual Gateway or filing a hardcopy application (also known as a “Medical Benefits Request” or MBR), if you are relying on your patients to perform all of the necessary follow-up and to keep you apprised of all activity (and inactivity!) on their application, you are missing opportunities. You need to have systems in place that track and monitor the progress of each application as it goes through MassHealth process. You also need the documents in place to ensure that if something goes wrong, more time is needed, decisions are not being made timely or the ultimate decision is incorrect, that you can do something about it. Without these protections in place you are essentially at the mercy of your patients and the MassHealth agency. One can debate whether this should be the case, but experience has demonstrated to us that if you want applications to process through the system timely, efficiently, and accurately you, the provider, need to be proactive and handle as much of the follow-up and documentation requirements as possible. Patients and family members are often distracted by other more pressing concerns like the health issues that prompted them to come to your facility in the first instance.   


4.) MassHealth has strict regulatory timelines. The timelines under MassHealth’s Fair Hearing rules are even more stringent and significantly less forgiving. This is not to say many cases cannot be successfully resolved informally with the agency, either before the need for a hearing or even at hearing. Quite the contrary, the vast majority of appeals are resolved informally. But this is a time consuming and labor intensive process. If you are not proactively tracking verification deadlines, regulatory requirements and inaction limitations imposed by the agency, by the time you learn of a problem, it may well be too late to do anything about it. You have to have a system in place to effectively track and aggressively pursue available procedures, rights and remedies under the program regulations. If you do, you can minimize erroneous denials and approvals (yes, once again, I said we appeal approvals, because they can be and often are incorrect and this impacts your patients’ eligibility and the likelihood you will be paid for services provided). Failure to monitor applications in this fashion can result in compromised retroactive eligibility start dates, incorrect eligibility determinations, administrative denials that could have been avoided and approvals for less that the richest category of benefits for which your patient qualifies.


5.) Most providers who assist applicants with the MassHealth applications process realize that a “Permission to Share Information” or “PSI” form is necessary in order for MassHealth to share information as to the status of any pending application with the provider. What very few realize is that additional documentation is needed to allow the provider to intervene or act on behalf of the applicant in the event that the application does not process timely and correctly. There are additional documentary requirements to allow the provider to assist at the appeal stages before the Office of Medicaid, Board of Hearings and beyond. While formal appeals are certainly not necessary in the vast majority of applications, if you do not have these forms in place and eligibility is improperly or erroneously denied, there is very little you can do to assist your patients and even less that you can do to ensure that the services you provided are ultimately paid for. We secure this documentation up front to minimize issues and to allow us to intervene immediately upon discovery of an issue that might compromise eligibility or impact the effective retroactive eligibility start date. In short, we handle all applications and appeals related issues so that your staff and your patient can focus on more important priorities. If you do not have the appropriate documentation at the time of application, securing the same if and when needed is risky and is likely to not be obtained within the tight appeal timeframes set by MassHealth regulations. If you have it and don’t need it, it is no big deal. If you need it and don’t have, that’s when both the provider and patient risk losing out on benefits that might otherwise be available.  


6.) Our experience shows that virtually no providers that handle their own applications appeals. In fact, most don’t even understand that such procedures exist or that they can be used to meet the needs of both the provider and the patient. While many issues can be corrected informally with the MassHealth Enrollment Center (MEC) personnel, many cannot. Providers that are not taking advantage of these processes and procedures are doing a disservice to their patients and are negatively impacting the likelihood of being paid for the services they provide. We aggressively pursue all avenues of eligibility, ensuring that the richest benefit level available is secured for your patients and that the providers’ chances of being reimbursed are maximized.


7.) If terminology like “post-eligibility date” and the entity known as the “Final Deadline Appeals Board” or “FDAB” are foreign concepts to the staff handling your applications, then even if they are achieving high rates of MassHealth applications approvals, you may still be missing out in the end. The post-eligibility date refers to the time from the date the MassHealth approval is issued and the date a claim based on the same is billed. If this date is compromised, while you may have achieved eligibility for your patient, you may still not be paid. Likewise, the need to resort to the FDAB for waivers based on post-eligibility date and related issues can be avoided in many instances through effective and efficient use of available appeals and related informal resolution procedures. So, even if you are seeing a high rate of approvals on the front end, if you are not aware of these issues all of your good work will be for naught on the back end. We leverage of knowledge of billing and claims issues to maximize the return on all MassHealth approvals.    


8.) In the area of Long-term Care Applications processing the retroactive eligibility start date becomes imminently more important. This is true because the consequences of not achieving the earliest possible start date impacts the ability to secure placement and very often involves significant dollars. The same is true of community disability based applications. The verification requirements are more onerous and the chances that an application falls by the wayside are increased because the applications by their very nature take longer to process through the MassHealth system. One misstep and weeks and sometimes months of work is wasted. Finally, the retroactive eligibility date can, in certain cases, go back up to 90 days.    


9.) The easy part is submitting an application. The real work is in the verification, follow-up and appeals process. Disability applications demonstrate the importance of such efforts because, while MassHealth will issue requests for medical records from listed medical providers and issue consultative exam notices, they are not equipped to go secure the records and rely on other providers to actually send the requested documents. If nothing is returned then there is nothing for the agency to review. Similarly, while they will issue consultative exam notices, they do not send reminders and will not do follow-up calls to ensure attendance. Failure to attend by the patient is tantamount to failure to cooperate and will result in a denial. Often there are legitimate reasons for failing to attend (i.e., patient is institutionalized on date of appointment). These denials need to be appealed and the potential retroactive eligibility date tied thereto preserved.   


10.) Nothing is more important in the area of MassHealth Applications Processing and Appeals than a complete and thorough understanding of the applicable rules and regulations. Unfortunately, because healthcare is in an almost constant state of change, MassHealth must likewise frequently update, amend and change its regulations to remain compliant with federal and state requirements. Our applications department does nothing but MassHealth applications and appeals related work. They are supported by attorneys with over 60 years of combined healthcare related legal experience.




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