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The Massachusetts ACA 1202 form serves as a critical tool designed for physicians who provide primary care services and wish to qualify for specific payment rates under the Affordable Care Act. This form is integral in facilitating compliance with federal regulations set forth in Section 1202, which mandates that Medicaid agencies reimburse eligible primary care services at enhanced rates for the years 2013 and 2014. To be eligible, physicians must self-attest their practice in family medicine, general internal medicine, or pediatric medicine, along with board certification or a substantial portion of Medicaid claims in qualifying services. The form requires detailed information about the physician's practice, including contact details and Medicaid enrollment status, and it emphasizes the importance of accurate completions as all submissions are subject to audit. Additionally, it specifies the billing codes that qualify for enhanced reimbursement and outlines the process for submitting the completed form—either via fax or mail to MassHealth Customer Service. For those navigating this process, understanding the implications of the ACA 1202 form can significantly enhance the financial viability of their primary care practice while ensuring compliance with state and federal requirements.

Massachusetts Aca 1202 Example

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?

 

Yes

 

No

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).

A. Practice Area

Check the box of your practice area(s):

family medicine

 

general internal medicine

B. 60% Paid Claims

pediatric medicine

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
Get Massachusetts Aca 1202 PDF Form

Form Characteristics

Fact Name Detail
Governing Law The Massachusetts ACA 1202 form is governed by Section 1202 of the federal Affordable Care Act and relevant regulations under 42 CFR Part 447, Subpart G.
Purpose This form certifies and attests physicians’ eligibility for higher Medicaid payment rates for primary care services.
Eligibility Requirements Physicians must attest to practicing in family medicine, general internal medicine, or pediatric medicine and meet specific criteria.
Submission Methods Completed forms can be submitted via fax or mail to MassHealth Customer Service.
Form Sections The form consists of four sections: instructions, physician information, information regarding eligibility, and attestation.
Audit Information All submitted information is subject to audit by state authorities.
Billing Codes Eligible billing codes include E&M codes (99201-99499) and specific vaccine administration codes.
Eligibility Verification Physicians can verify their eligibility for Section 1202 rates through the MassHealth Provider Online Service Center.
Penalties for Misrepresentation Falsification or omission of information may lead to civil penalties or criminal prosecution.

Guidelines on Utilizing Massachusetts Aca 1202

The Massachusetts ACA 1202 form is an essential document for physicians who provide primary care services and want to qualify for specific payment rates set by the Affordable Care Act. Completing this form requires accurate information regarding your practice, managerial contracts, and self-attestation of your professional certifications. Make sure to fill it out completely, as only completed forms will be accepted for processing.

  1. Begin with Section II: Physician Information. Fill in your name, business name (if applicable), street address, city, state, zip code, business telephone number, business fax number, and business email address.
  2. Add your contact name, contact phone number, and contact email address.
  3. Provide your MassHealth provider ID, individual provider NPI, and individual SSN.
  4. Indicate if you are enrolled in the MassHealth Primary Care Clinician Program by checking "Yes" or "No".
  5. State your enrollment status with any MassHealth-contracted managed care entity by answering "Yes" or "No". If "Yes," list the names of these entities and your respective health plan provider number.
  6. Move to Section III, where you will self-attest that you practice in a qualifying specialty. Confirm if you practice in family medicine, general internal medicine, or pediatric medicine.
  7. Indicate if you are board certified in the relevant specialty or if 60% of your Medicaid codes are for services eligible for Section 1202 Rates.
  8. In Section IV, Part 1, check your practice area(s) and confirm your board certification status by selecting the appropriate boxes.
  9. Record the date of your certification.
  10. If applicable, in Section IV, Part 2, attest that you practice in a qualifying specialty without board certification and confirm that at least 60% of your paid claims meet requirements.
  11. Complete the certification statement under Section IV, ensuring you understand the penalties for inaccuracies.
  12. Sign and date the form using your printed legal name—remember, a stamp or third-party signature is not acceptable.

After you've completed the form, save a copy for your records. Then, submit the form by faxing it to 617-988-8974 or mailing it to the address provided. Ensure that all details are clear and legible to prevent delays in processing your application.

What You Should Know About This Form

What is the Massachusetts ACA 1202 form used for?

The Massachusetts ACA 1202 form is used by physicians to certify their eligibility for specific payment rates under Section 1202 of the Affordable Care Act. This section requires Medicaid agencies to provide payment at higher rates for certain primary care services delivered by qualified physicians. It ensures that the eligible providers can receive adequate compensation for their services, specifically in family medicine, general internal medicine, and pediatric medicine.

What criteria must a physician meet to be eligible for Section 1202 rates?

To qualify for the Section 1202 rates, physicians must meet two primary requirements. First, they need to self-attest to practicing in family medicine, general internal medicine, or pediatric medicine, or a related subspecialty recognized by relevant medical boards. Second, they must be either board-certified in a qualified specialty or demonstrate that at least 60% of their Medicaid claims in the previous year were for eligible services. Newly eligible physicians should base their self-attestation on the Medicaid codes for the prior month.

How should the completed ACA 1202 form be submitted?

Physicians should complete the ACA 1202 form and submit it by either faxing it to the provided number (617-988-8974) or mailing it to the MassHealth Customer Service. The mailing address is MassHealth Customer Service, Attn: Provider Enrollment, PO Box 9118, Hingham, MA 02043. It is important to ensure that all sections of the form are completed, as only fully completed submissions will be accepted.

Where can I find more information regarding the billing codes eligible for Section 1202 rates?

More information about the billing codes eligible for Section 1202 rates can be found in Administrative Bulletin 13-06 and Subchapter 6 of the Physician Manual. Eligible billing codes include certain evaluation and management (E&M) codes as well as specific vaccine administration codes. For further guidance, providers are encouraged to review the applicable All Provider Bulletins and the regulations set forth in 101 CMR 317.00.

Common mistakes

Completing the Massachusetts ACA 1202 form requires attention to detail. A common mistake is failing to provide complete contact information. This includes missing or incorrect entries for fields like business name, telephone numbers, and email addresses. If details are inaccurate, it can lead to delays in processing and potential denial of eligibility.

Another frequent error involves not signing the form properly. The signature must be that of the physician completing the form. Using a signature stamp or allowing someone else to sign can result in significant complications. Ensure that the form is signed by the physician themselves and includes the date.

Not indicating board certification correctly is a third mistake. Physicians must check the appropriate box for their specialty and provide the correct certifying board. Neglecting to do so may cause the application to be deemed incomplete. Additionally, if the physician has subspecialty certifications, this should also be explicitly stated.

Physicians often overlook the eligibility criteria for the Section 1202 rates. It is crucial to self-attest the correct percentage of Medicaid claims that qualify. Misrepresentation here, even unintentionally, can lead to civil penalties. Familiarity with the billing codes and requirements for prior claims is essential.

Finally, many individuals fail to review the entire form before submission. Inadvertent omissions or errors in any section can lead to rejection of the application. Always take the time to carefully check each entry for accuracy. This will smooth out the process and support timely eligibility confirmation.

Documents used along the form

The Massachusetts ACA 1202 form is essential for physicians seeking to qualify for Section 1202 rates under the Affordable Care Act. It is often accompanied by several other forms and documents that assist in the provider enrollment and certification process. Understanding these additional documents can streamline the application and ensure compliance with relevant regulations.

  • MassHealth Application for Health Care Coverage: This application is required for healthcare providers to enroll in the MassHealth program. It collects essential information about the provider's practice and the services they offer.
  • Provider Information Change Form: Use this form to update any changes to the provider's practice details, such as new addresses, contact numbers, or changes in practice type. Accurate information helps maintain compliance with MassHealth requirements.
  • Medicaid Managed Care Entity (MCE) Enrollment Form: Physicians who contract with managed care organizations must complete this form. It provides details on the physician’s participation in managed care programs and eligibility for various plans.
  • Self-Attestation Forms: These forms are used by providers to confirm their qualifications for certain services and reimbursement rates. They typically require details about specialties and board certifications.
  • CPT Billing Codes Documentation: This document outlines the current Procedural Terminology codes eligible for reimbursement under MassHealth, which is crucial for correct billing and reimbursement practices.

Having these forms ready and understanding their functions can significantly improve the efficiency of processing ACA-related claims and ensure that providers meet all necessary requirements. Proper documentation is key to successful participation in the MassHealth program.

Similar forms

  • CMS 855I Form: This document is the Medicare enrollment application for individual practitioners. Similar to the ACA 1202 form, it collects detailed information about the provider, including personal and practice details, to determine eligibility for reimbursement under federal programs.
  • MassHealth Provider Enrollment Application: This application allows healthcare providers to enroll in the MassHealth program. Like the ACA 1202 form, it requires specific information regarding the practitioner’s qualifications, practice setting, and service delivery to establish eligibility for payment under MassHealth policies.
  • Medicaid Provider Application: This document facilitates the enrollment process for providers wishing to participate in the Medicaid program. It is comparable to the ACA 1202 form as it also verifies the provider's services, qualifications, and compliance with state and federal regulations.
  • Board Certification Verification Forms: These forms are used to verify a physician’s board certification status. Similar to the ACA 1202 form, these documents require the physician to attest to their specialties and board certifications, ensuring that they meet the criteria for certain reimbursement rates.

Dos and Don'ts

Filling out the Massachusetts ACA 1202 form requires attention to detail and adherence to specific instructions. Here is a list of things you should and shouldn't do:

  • Do: Ensure that all sections of the form are completed accurately to avoid delays.
  • Do: Check your eligibility before submitting by reviewing the requirements outlined in Section III.
  • Do: Provide a valid signature and date to confirm the accuracy of the information.
  • Do: Keep a copy of the completed form for your records after you submit it.
  • Don't: Leave any required fields blank; incomplete submissions will not be accepted.
  • Don't: Use stamps for your signature, as this is not acceptable for the form.
  • Don't: Delay your submission; forms should be sent in promptly to meet any deadlines.
  • Don't: Provide false information; this can lead to civil penalties or criminal prosecution.

Misconceptions

Misconceptions can lead to confusion and unintended mistakes when filling out important forms like the Massachusetts ACA 1202 form. Here are four common misconceptions addressed to provide clarity:

  1. It’s only for existing MassHealth providers. Many believe that only those already enrolled in MassHealth can apply for Section 1202 rates. However, new physicians can also be eligible if they meet the necessary criteria related to Medicaid claims.
  2. Certification from any board is acceptable. Some physicians think that any form of medical board certification will qualify them for the Section 1202 rates. In reality, only specific boards recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS), or the American Osteopathic Association (AOA) are acceptable.
  3. Completeness of the form doesn't matter as long as it's submitted on time. A common oversight is underestimating the importance of a fully completed form. Forms that are not completely filled out will not be accepted, which may delay eligibility for payment.
  4. Submitting the form once is sufficient. Some might think that submitting the form just once guarantees ongoing eligibility. It’s essential to understand that eligibility needs to be re-evaluated, and physicians may need to submit this form annually to confirm their qualifications for the rates.

Key takeaways

Filling out the Massachusetts ACA 1202 form is essential for physicians who wish to access enhanced payment rates for primary care services. Here are key takeaways to help navigate the process effectively:

  • Eligibility Requirements: To qualify for Section 1202 rates, physicians must affirm their practice in eligible specialties, such as family medicine or pediatrics. They can do this through self-attestation in the form.
  • Focus on Board Certification: Physicians should indicate their board certification status. This can significantly impact eligibility, as it is one of the key criteria evaluated.
  • Provide Accurate Information: Ensure that all personal and practice details, including names and contact numbers, are accurately filled out. Incomplete forms will not be accepted.
  • Submission Options: Completed forms can be submitted either via fax or traditional mail. Use the designated fax number or address to ensure timely processing.
  • 60% Claims Threshold: For those without board certification, it’s crucial to demonstrate that at least 60% of Medicaid claims were for eligible services in the prior calendar year or the previous month for new physicians.
  • Online Verification: After submitting the form, physicians can check their eligibility status through the MassHealth Provider Online Service Center. This can provide peace of mind and clarity post-submission.

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