The Massachusetts ACA 1202 form is a crucial document for physicians seeking to qualify for enhanced payment rates for primary care services under the Affordable Care Act. This form allows eligible physicians to self-attest their qualifications, ensuring they receive the appropriate compensation for their services. If you are a physician interested in these rates, please complete the form by clicking the button below.
The Massachusetts ACA 1202 form serves as a vital instrument for physicians seeking to qualify for enhanced payment rates under the Affordable Care Act, specifically for primary care services. This form is designed for physicians practicing in family medicine, general internal medicine, or pediatric medicine, and it outlines the eligibility requirements necessary to receive Section 1202 rates. To qualify, physicians must self-attest to their specialty and board certification status, or demonstrate that a significant portion of their Medicaid claims is for eligible services. The form requires detailed information, including the physician's name, contact details, and MassHealth provider ID, along with a declaration of their practice area and board certification. It is essential for physicians to complete and submit the form accurately, as only fully completed submissions will be accepted. Furthermore, the form emphasizes the importance of compliance, as all information provided is subject to audit. For those who may have questions or need assistance, the Massachusetts Executive Office of Health and Human Services offers resources to ensure that physicians can navigate the process effectively. Understanding the nuances of this form is crucial for healthcare providers aiming to enhance their reimbursement for essential services rendered to Medicaid patients.
Commonwealth of Massachusetts
Executive Oice of Health and Human Services www.mass.gov/masshealth
SECTION I: Instructions
Physician Certification and Attestation Form
for ACA Section 1202 Rates for Physicians Who Provide Primary Care Services
For calendar years 2013 and 2014, Section 1202 of the federal Affordable Care Act requires Medicaid agencies to provide payment for certain primary care services delivered by eligible physicians consistent with rules set forth in 42 CFR Part 447, Subpart G (Section 1202 rates) and 101 CMS 317.
If you are a physician and would like to be eligible for Section 1202 Rates, please complete the information in Sections II and IV, sign and return completed forms by fax to 617-988-8974 or mail it to MassHealth Customer Service (CST) by mail at: MassHealth Customer Service, Attn: Provider Enrollment, PO Box 9118, Hingham, MA 02043.
Only completed forms will be accepted. Questions about this form can be addressed to CST. All information is subject to audit. Note: You may view your Section 1202 eligibility in your physician profile online at the MassHealth Provider Online Service Center
(POSC) at https://newmmis-portal.ehs.state.ma.us/EHSProviderPortal/appmanager/provider/desktop.
SECTION II: Physician Information
NAME
BUSINESS NAME (If applicable)
STREET ADDRESS
CITY
STATE
ZIP CODE
BUSINESS TELEPHONE NO.
BUSINESS FAX NO.
BUSINESS E-MAIL ADDRESS
CONTACT NAME
CONTACT PHONE NUMBER
CONTACT E-MAIL ADDRESS
MASSHEALTH PROVIDER ID
INDIVIDUAL PROVIDER NPI
INDIVIDUAL SSN
Are you enrolled in the MassHealth Primary Care Clinician Program? . . . . . . . . . . . . . . . . . . . .
Yes
No
Are you currently enrolled with a MassHealth-contracted managed care entity?
If yes, please provide the name of each managed care entity with which you contract and your health plan provider number under that managed care entity.
SECTION III: Information
In order to be eligible for the Section 1202 Rates, a physician must satisfy both of the following requirements:
(1)A physician must self-attest that he or she practices in family medicine, general internal medicine, or pediatric medicine or a related subspecialty recognized by the American Board of Medical Specialties (ABMS)*, the American Board of Physician Specialties (ABPS), or the American Osteopathic Association (AOA); and
(2)such physician must also self-attest that:
(a)he or she is board certified in a qualified specialty or subspecialty; or
(b) for the most recently completed calendar year, at least 60% of the Medicaid codes for which the physician had been paid were for the services eligible for the Section 1202 Rates. (Newly eligible physicians must self-attest based on the Medicaid codes paid during the prior month.)
*Note that ABMS recognizes certification in Allergy & Immunology with the American Board of Allergy & Immunology (ABAI) as an eligible subspecialty.
ACA-1202 (REV. 08/13)
The following billing codes are eligible for the Section 1202 Rates.
•E&M codes 99201-99499.
•Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473, 90474, or their successor codes
For more guidance about the 1202 rates for codes covered by MassHealth, see Administrative Bulletin 13-06 and Subchapter 6 of your Physician Manual.
Please also see 101 CMR 317.00 and All Provider Bulletins 230 and 235 for additional guidance on Section 1202.
SECTION IV: Attestation
By completing this Section IV, you are providing the self-attestation referenced in Section III of this form.
Part 1
Complete this Section IV, Part 1 if you are practicing in family medicine, general internal medicine, or pediatric medicine, and are attesting that you are certified by the ABMS, ABPS, or AOA in one of the following specialties/subspecialties.
A. Practice Area
Check the box of your practice area(s):
B. Board Certification
family medicine
general internal medicine
pediatric medicine
Check the box for specialties in which you have board certification:
family medicine general internal medicine pediatric medicine
or list any subspecialties under family medicine, general internal medicine, or pediatric medicine in which you have board certification:
Check the box for the certifying board:
ABMS*
ABPS
Provide the date of such certifications: ___ / ___ /
______
AOA
*ABMS recognizes certification in the Allergy & Immunology with ABAI as an eligible subspecialty. If you have this subspecialty, please indicate that on the subspecialty line above.
Part 2
Complete this Section IV, Part 2 only if you are attesting that you are practicing in family medicine, general internal medicine, or pediatric medicine; you do not have a certification from the ABMS, AOA, or ABPS; and at least 60% of your total Medicaid claims paid are for evaluation and management (E&M) services and vaccine-administration codes (see Section III).
B. 60% Paid Claims
Physicians (those that have a full previous calendar year of paid Medicaid claims)
I attest that at least 60% of my total Medicaid claims paid for the previous calendar year were for the E&M and vaccine-administration codes as published in the final federal regulation implementing Section 1202 of the Affordable Care Act and meet the requirements to receive the Section 1202 Rates.
New Physicians only (those that do not have a full previous calendar year of paid Medicaid claims)
I attest that at least 60% of my total Medicaid claims paid during the previous month are for qualified E&M and vaccine-administration codes as published in the final federal regulation implementing Section 1202 of the Affordable Care Act, and meet the requirements to receive the Section 1202 Rates.
I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Printed legal name of physician
Physician’s signature (Signature and date stamps, or the signature of anyone other than the provider, is not acceptable)
Date
Completing the Massachusetts ACA 1202 form is an important step for physicians seeking eligibility for specific Medicaid payment rates. Ensure that all sections are filled out accurately and completely to avoid delays in processing. Once you have completed the form, you can submit it via fax or mail to the appropriate MassHealth Customer Service address.
The Massachusetts ACA 1202 form is a Physician Certification and Attestation Form used to determine eligibility for Section 1202 rates for primary care services under the Affordable Care Act. It is designed for physicians who provide family medicine, general internal medicine, or pediatric medicine services.
Physicians who wish to be eligible for Section 1202 rates must complete the ACA 1202 form. This includes those practicing in family medicine, general internal medicine, or pediatric medicine, as well as those who meet specific certification criteria.
To qualify for Section 1202 rates, a physician must:
Once completed, the form can be submitted by fax to 617-988-8974 or mailed to the MassHealth Customer Service at the specified address. Ensure that all sections are filled out completely, as incomplete forms will not be accepted.
The services covered include specific evaluation and management (E&M) codes ranging from 99201 to 99499 and certain vaccine administration codes. Refer to the form for a complete list of eligible billing codes.
Yes, you can view your Section 1202 eligibility through your physician profile on the MassHealth Provider Online Service Center. Access the portal at the provided website link.
Providing false information can lead to civil penalties or criminal prosecution. It is crucial to ensure that all information is accurate and complete before submission.
The form should be submitted as soon as possible to ensure eligibility for the Section 1202 rates. Specific deadlines may apply depending on the billing cycle and changes in Medicaid regulations.
For any questions regarding the ACA 1202 form, you can contact the MassHealth Customer Service. They can provide assistance and clarify any uncertainties you may have.
New physicians can still qualify by attesting that at least 60% of their Medicaid claims paid during the previous month were for eligible E&M and vaccine administration codes.
Incomplete Information: One of the most common mistakes is failing to fill out all required sections of the form. Each section must be completed fully, including contact information and practice details. Leaving any part blank can lead to delays or rejection of the application.
Incorrect Certification Attestation: Physicians often mistakenly attest to being board certified without verifying their status. It's crucial to ensure that the certification is valid and recognized by the appropriate boards (ABMS, ABPS, or AOA) before submitting the form.
Misunderstanding Eligibility Requirements: Many applicants do not fully grasp the eligibility criteria for Section 1202 Rates. Physicians must either be board certified or demonstrate that at least 60% of their Medicaid claims are for eligible services. Misinterpreting these requirements can result in disqualification.
Failure to Submit on Time: Timeliness is critical. Submitting the form late can lead to missed opportunities for reimbursement under the Section 1202 Rates. Be sure to send the completed form by the specified deadline, whether by fax or mail.
The Massachusetts ACA 1202 form is an important document for physicians seeking to receive specific Medicaid payments for primary care services. Along with this form, there are several other documents that are often used in conjunction with it. Understanding these additional forms can help ensure a smoother application process and compliance with state regulations.
By familiarizing yourself with these documents, you can better navigate the requirements for the Massachusetts ACA 1202 form. This knowledge can empower you to provide quality care while ensuring you receive the appropriate compensation for your services.
The Massachusetts ACA 1202 form is similar to the Medicaid Provider Enrollment Application. Both documents require healthcare providers to submit information to confirm their eligibility for Medicaid reimbursement. The Medicaid Provider Enrollment Application collects essential details about the provider's practice, including their specialties, contact information, and any affiliations with managed care entities. Like the ACA 1202 form, it also necessitates self-attestation regarding the provider's qualifications and practice areas, ensuring that only eligible providers receive Medicaid payments for their services.
Another document akin to the Massachusetts ACA 1202 form is the CMS-855I form, which is used for individual healthcare providers to enroll in Medicare. This form, like the ACA 1202, requires detailed information about the provider's identity, practice location, and specialties. Both forms serve to verify the qualifications of healthcare professionals, ensuring compliance with federal regulations. They also require attestation to the accuracy of the information provided, emphasizing the importance of honesty in the enrollment process.
The Physician's Attestation for EHR Incentive Program is another similar document. This attestation is part of the process for physicians to qualify for incentive payments under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. Similar to the ACA 1202 form, it requires physicians to confirm their participation in specific programs and their adherence to certain criteria. Both forms focus on ensuring that healthcare providers meet established standards, thereby enhancing the quality of care provided to patients.
The National Provider Identifier (NPI) application is also comparable to the Massachusetts ACA 1202 form. This application is essential for healthcare providers to obtain a unique identification number that is necessary for billing purposes. Both documents require providers to submit personal and professional information, including their specialties and practice locations. The NPI application, like the ACA 1202, emphasizes the importance of accurate information, as it directly affects the provider's ability to receive payments for services rendered.
The Medicare Enrollment Application for Group Practices is another document that shares similarities with the ACA 1202 form. This application is intended for group practices to enroll in Medicare and requires detailed information about the group, including its members and practice locations. Both forms focus on ensuring that the entities providing care are legitimate and qualified, requiring thorough documentation and self-attestation to confirm compliance with relevant regulations.
The Credentialing Application used by hospitals and healthcare organizations also resembles the Massachusetts ACA 1202 form. This application is utilized to verify the qualifications of healthcare providers seeking privileges to practice within a facility. Both documents require detailed information regarding the provider's education, training, and certifications. The credentialing process, much like the ACA 1202, ensures that only qualified professionals are granted the authority to provide care, thereby safeguarding patient safety and quality of care.
Lastly, the Provider Enrollment Application for Health Insurance Marketplace is similar to the Massachusetts ACA 1202 form. This application is used by healthcare providers who wish to participate in health insurance plans offered through the Marketplace. Both documents require comprehensive information about the provider's qualifications, specialties, and practice locations. They share a common goal of ensuring that providers meet specific criteria before being allowed to offer services to patients, thereby promoting accountability and quality in healthcare delivery.
Filling out the Massachusetts ACA 1202 form can be straightforward if you keep a few key points in mind. Here’s a list of things you should and shouldn’t do to ensure your application is processed smoothly.
By following these guidelines, you can navigate the process more easily and increase your chances of a successful application. Good luck!
Here are five common misconceptions about the Massachusetts ACA 1202 form, along with explanations for each:
Filling out the Massachusetts ACA 1202 form is an important step for physicians seeking eligibility for specific Medicaid payment rates. Here are some key takeaways to keep in mind:
By keeping these points in mind, physicians can navigate the process more effectively and ensure they meet the necessary requirements for Section 1202 rates.