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24 130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 255 Rev. 02/13/26

130 CMR 515.000: MASSHEALTH: GENERAL POLICIES

(B) Limitations (1) Reimbursement is limited to bills incurred on or after the coverage start date for the applicable coverage type as described in 130 CMR 519.000: MassHealth: Coverage Types and paid between the date of the erroneous eligibility decision and the date on which the member is notified of MassHealth eligibility. The bill must have been paid by the member, the member's spouse, the parent of a member, or a legal guardian. (2) Reimbursement is also limited to amounts actually paid for care or services that would have been covered under MassHealth had eligibility been determined correctly, even if these amounts exceed the MassHealth rate. Before reimbursing a member for care or services that would have required prior authorization, MassHealth may require submission of medical evidence for consideration under the prior-authorization standards. Reimbursement is available even if the medical care or services were furnished by a provider who does not participate in MassHealth.

(C) Verification (1) Applicants or members seeking reimbursement must provide MassHealth with (a) a bill for medical services that includes 1. the provider's name; 2. a description of the services provided; and 3. the date the service was provided; and (b) proof of payment of the bill presented, such as a canceled check or receipt. (2) Recipients of SSI must also provide documents from the SSA establishing the date of application and the date of application denial.

515.016: Severability

The provisions of 130 CMR 515.000 are severable. If any provision of 130 CMR 515.000 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 130 CMR 515.000 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

130 CMR 515.000: M.G.L. c. 118E.