COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

Office of Medicaid
One Ashburton Place
Boston, MA 02108


								


FOURTH AMENDED AND RESTATED
PRIMARY CARE CLINICIAN (PCC) PLAN
PROVIDER CONTRACT


								




TABLE OF CONTENTS


Section 1. DEFINITIONS	1
Section 2. PCC ELIGIBILITY	5
Section 3. PCC RESPONSIBILITIES	5
Section 3.1 Administration and Contract Management	5
Section 3.2 Provision of Medical Services	7
Section 3.3 Member Enrollment, Disenrollment, Reenrollment, and 
Orientation	11
Section 3.4 Privacy, Confidentiality, Security of Personal Data and 
HIPAA Compliance	14
Section 3.5 Enrollee Grievances	15
Section 3.6 Enrollee Rights	15
Section 3.7 Performance Improvement Management Services (PIMS)	16
Section 4. EOHHS RESPONSIBILITIES	16
Section 4.1 Provider Application	16
Section 4.2 Administration and Contract Management	16
Section 4.3 Member Enrollment and Disenrollment Activities	17
Section 5. PAYMENT	18
Section 5.1 PCC Enhanced Rate	18
Section 5.2 EPSDT Enhanced Rate	18
Section 5.3 Prospective Interim Payment (PIP)	19
Section 5.4 Claims Submission	20
Section 6. ADDITIONAL TERMS AND CONDITIONS	20
Section 6.1 Compliance with Law	20
Section 6.2 Subcontracts	20
Section 6.3 Prohibited Affiliations	21
Section 6.4 Intermediate Sanctions	21
Section 6.5 Contract Termination	21
Section 6.6 Amendment	22


ATTACHMENT A:  PCC Enhanced Fee Codes (As of 4/29/03)









WHEREAS, the Executive Office of Health and Human Services 
(“EOHHS”) is a governmental agency responsible for the administration of 
the Title XIX and Title XXI (“MassHealth”) Program; and

WHEREAS, the Primary Care Clinician (“PCC”) has met the criteria for 
participation in EOHHS’ Primary Care Clinician Plan; and

WHEREAS, the parties wish to amend the Contract as set forth here;

NOW, THEREFORE, in consideration of the mutual covenants and 
agreements contained herein, the PCC and EOHHS agree as follows:



SECTION 1. DEFINITIONS
As used in this Contract, each of the following terms has the indicated meaning unless the 
context clearly requires otherwise.
Behavioral Health Program -- a managed care program administered by EOHHS 
through the Behavioral Health Program Contractor, for the provision of mental health and 
substance abuse services to Members enrolled in the PCC Plan.  

Behavioral Health Program Contractor -- EOHHS’ contractor responsible for 
providing mental health and substance abuse services to Members enrolled in the PCC 
Plan, for implementing quality management activities to support PCCs in delivering 
health care services to Enrollees, and for implementing administrative services to support 
EOHHS in managing its network of PCCs.  

Behavioral Health Services -- MassHealth covered mental health and substance abuse 
treatment services. 

Cold-Call Marketing -- any unsolicited personal contact by a PCC, its employees, 
agents, or subcontractors with a Member who is not enrolled with the PCC Plan that 
reasonably can be interpreted as intended to influence the Member to enroll in the PCC 
Plan, or to disenroll from, a MassHealth Managed Care Organization or the PCC Plan.  

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) -- the delivery of 
health care services to Members under the age of 21, in accordance with 42 U.S.C. § 
1396d(a)(4), 42 CFR Part 441 Subpart B, and 130 CMR 450.140 et seq. 

EPSDT Periodicity Schedule -- The EPSDT Medical Protocol and Periodicity Schedule 
that appears in Appendix W of all MassHealth provider manuals and is developed and 
periodically updated by MassHealth in consultation with the Massachusetts Chapter of 
the American Academy of Pediatrics, Massachusetts Department of Public Health, dental 
professionals, the Massachusetts Health Quality Partners, and other organizations 
concerned with children's health.  The Schedule consists of screening procedures 
arranged according to the intervals or age levels at which each procedure is to be 
provided.

Easily Understood Format – the provision of information in a manner, format, and 
language that is easily understood, including written at no higher than a sixth-grade 
reading level.

Emergency Medical Condition -- a medical condition, whether physical or mental, 
manifesting itself by symptoms of sufficient severity, including severe pain, that the 
absence of prompt medical attention could reasonably be expected by a prudent layperson 
who possesses an average knowledge of health and medicine, to result in placing the 
health of the Member or another person, or in the case of a pregnant woman, the health of 
the woman or her unborn child, in serious jeopardy, serious impairment to body function, 
or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, 
as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. § 
1395dd(e)(1)(B). 

Emergency Services -- medical services that are furnished by a qualified provider and 
are needed to evaluate or stabilize an Emergency Medical Condition. 

Enrollee -- a person determined eligible for MassHealth who is enrolled in the PCC Plan, 
either by choice or by assignment by EOHHS. 
Executive Office of Health and Human Services (EOHHS) -- the Executive Office of 
Health and Human Services is the single state agency responsible for the administration 
of the MassHealth Program, pursuant to M.G.L. c. 118E and Title XIX and XXI of the 
Social Security Act and other applicable laws and waivers.

Grievance -- a complaint made by an Enrollee, which may be made either in writing or 
verbally, based on an issue of concern with any aspect of MassHealth or its participating 
provider network.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) -- federal law 
enacted as Pub. L. No. 104-191, and the regulations promulgated at 45 CFR Parts 160, 
162 and 164, to ensure health care insurance portability, to streamline the administration 
of health care, and to protect the security and privacy of patient information. 

Health Plan and Employer Data Information Set (HEDIS) -- a data set developed by 
the National Committee for Quality Assurance (NCQA), that is part of a national effort to 
standardize the measurement and reporting of health plan performance.  EOHHS collects 
a subset of HEDIS measures each year to assess the performance of the PCC Plan and 
MassHealth-contracted Managed Care Organizations. 

Individual Care Plan (ICP) – the plan of care developed by an Intensive Clinical 
Management clinician in conjunction with an individual’s Behavioral Health Program 
Provider.

Individual Care Plan Report (ICPR) – a written version of the ICP that is mailed to 
PCCs.

Managed Care Contact -- an individual, designated by the PCC, to serve as the primary 
liaison between the PCC practice and EOHHS. 

Marketing -- any communication from a PCC, its employees, agents or subcontractors to 
a Member who is not enrolled in the PCC Plan that reasonably can be interpreted as 
intended to influence the Member to enroll in the PCC Plan, or either to not enroll in, or 
to disenroll from, a MassHealth Managed Care Organization or the PCC Plan.  This 
includes the production and dissemination by or on behalf of the PCC of any Marketing 
Materials.  Marketing shall not include:  (1) any one-to-one contact between a Provider 
and a Member who is a prospective, current, or former patient of that Provider regarding 
the provisions, terms, or requirements of MassHealth as they relate to the treatment needs 
of that particular Member; (2) any one-to-one contact between a Provider and a Member 
who was a patient of that Provider at the time the Member was enrolled in a MassHealth 
Managed Care Organization or the PCC Plan to inform the Member how to select the 
Provider going forward, if the Member so chooses, provided that the Provider informs the 
Member of all the MassHealth managed care plans with which the Provider is 
participating, including the PCC Plan and any Managed Care Organization.

Marketing Materials -- materials that are produced in any medium, by or on behalf of 
the PCC and can reasonably be interpreted as intended for Marketing to Members.  This 
includes the production and dissemination by or on behalf of the PCC of any promotional 
material or activities by any medium including, but not limited to, oral presentations and 
statements, community events, print media, audio visual tapes, radio, television, 
billboards, Yellow Pages, and advertisements that explicitly or implicitly refer to 
MassHealth managed care or Title XIX of the Social Security Act, and are targeted in any 
way toward Members.

MassHealth -- the medical assistance or benefit programs administered by EOHHS to 
provide and pay for medical services to eligible Members pursuant to Title XIX of the 
Social Security Act (42 U.S.C. 1396), Title XXI of the Social Security Act (42 U.S.C. § 
1397), M.G.L. c.118E, and other applicable laws and waivers. 

MassHealth Card -- the identification card issued to persons who have been determined 
eligible for MassHealth.

MassHealth Coverage Type -- a scope of medical services and other benefits that is 
available to Members who meet specific MassHealth eligibility criteria.  See 130 CMR 
450.105 for a list of services covered under each coverage type. 

Medically Necessary -- those MassHealth covered services that have been determined to 
meet the Commonwealth’s definition of “medically necessary services” at 130 CMR 
450.204.

Member -- a person determined by the Executive Office of Health and Human Services 
to be eligible for MassHealth.

Non-Symptomatic Care – an Enrollee encounter with a Provider, not associated with 
any presenting medical signs.  Examples include well-visits and physical examinations.

Non-Urgent Symptomatic Care – an Enrollee encounter with a Provider, associated 
with presenting medical signs and symptoms, but not requiring immediate medical 
attention.  Examples include recurrent headaches or fatigue.

Panel -- all MassHealth members enrolled with a particular PCC.

Performance Improvement Management Services (PIMS) -- a quality improvement 
program administered by EOHHS’ Behavioral Health Program Contractor to help PCCs 
improve the rate at which certain preventive care services are provided to PCC Plan 
Enrollees and improve the PCC’s ability to manage the care of PCC Plan Enrollees with 
chronic diseases.

Poststabilization Care Services -- MassHealth covered services, related to an 
Emergency Medical Condition, that are provided after an Enrollee is stabilized in order to 
maintain the stabilized condition, or when covered pursuant to 42 CFR 438.114(e) to 
improve or resolve the Enrollee’s condition.

Primary Care -- health care services customarily furnished by or through a general 
practitioner, family physician, internal medicine physician, obstetrician/gynecologist, 
pediatrician, independent nurse practitioner or independent nurse midwife, to the extent 
the furnishing of those services is legally authorized in the Commonwealth.  Primary 
Care does not include emergency or poststabilization services provided in a Hospital or 
other setting.

Primary Care Case Management -- a system under which the PCC contracts with the 
State to furnish case management services (which include the location, coordination, and 
monitoring of Primary Care health services) to Enrollees.

Primary Care Clinician (PCC) -- a physician, independent nurse practitioner, group 
practice organization, community health center, hospital-licensed health center, or acute 
hospital outpatient department, with a signed PCC Plan Provider application that is 
approved by EOHHS.

Primary Care Clinician (PCC) Plan -- the Primary Care Case Management program 
administered by EOHHS through which Enrollees receive coordinated Primary Care and 
certain other medical services.

Provider -- a MassHealth-participating individual, group, facility, agency, institution, 
organization, or other entity that directly provides medical or Behavioral Health Services 
to Members.

Recipient Eligibility Verification System (REVS) -- EOHHS’ on-line Member 
eligibility and enrollment verification system for use by MassHealth Providers.

Recipient Identification (RID) Number -- the 10-digit identification number assigned 
to each Member and printed next to or below the Member's name on the Member’s 
MassHealth Card.

Referral -- authorization for those services that a PCC does not provide directly that 
require the PCC’s referral or authorization in accordance with the provisions of this PCC 
Contract and applicable MassHealth regulations at 130 CMR 450.118.

Regional Network Manager (RNM) -- an individual who is assigned to a particular 
region of the state to conduct Performance Improvement Management Services (PIMS) 
with the PCCs that have a substantial number of Enrollees on their Panel. 

Urgent Care -- medical services that are not primary care and are needed to treat a 
medical condition that is not an emergency medical condition.
SECTION 2. PCC ELIGIBILITY
The PCC shall, at the time of executing the Contract and at all times during the Contract 
term, meet the PCC Provider eligibility and participation requirements established in 130 
CMR 450.118.
The PCC shall notify EOHHS and withdraw as a PCC if, at any time during the Contract 
term, the PCC no longer meets the PCC Provider eligibility and participation 
requirements at 130 CMR 450.118. 
SECTION 3. PCC RESPONSIBILITIES
Section 3.1 Administration and Contract Management
A.	Managed Care Contact
The PCC shall identify a Managed Care Contact to represent the PCC on 
all matters related to the fulfillment of the PCC Contract.
B.	Notification of PCC Changes 
1.	Notice to EOHHS

The PCC shall notify EOHHS, in writing, at least 14 days prior to 
any changes affecting delivery of care, the administration of its 
PCC practice, or its performance of PCC Contract requirements.  
Such changes include, but are not limited to the following:
a.	Voluntarily withdrawing from the PCC Plan or the 
MassHealth program for any reason;
b.	A change in any information contained in the PCC Plan 
Provider application or other application submitted by the 
PCC to EOHHS;
c.	A change of address;
d.	A change in the Managed Care Contact required in Section 
3.1.A.; and
e.	A change in the PCC’s hours of operation or designation of 
PCC specialty. 
2.	Notice to PCC Plan Enrollees

The PCC shall provide notice to its PCC Plan Enrollees in advance 
of any changes listed in Section 3.1.B.1.a. and c. above. 
C.	Medical Records
The PCC shall maintain an individual medical record for each PCC Plan 
Enrollee based on the following guidelines:
1.	The medical record shall be consistent with MassHealth 
regulations and generally accepted medical practice and 
professional standards.
2.	The medical record shall fully disclose the nature and extent of the 
services provided to PCC Plan Enrollees. 
3.	The PCC shall, upon request, furnish EOHHS and any other state 
and federal officials and agencies that have a legal right of access, 
or their designees, with such information, including copies of 
medical records of any Enrollee for whom payment was claimed 
from EOHHS, in accordance with 42 U.S.C. § 1396a(a)(30)(A) 
and 42 U.S.C. § 1396u-2(c)(1).
4.	Upon an Enrollee’s request, the PCC shall provide to the Enrollee 
a copy of the portion of his or her medical record created or 
maintained by the PCC at no cost to EOHHS or the Enrollee.
D.	PCC Plan Panel Capacity 
Upon approval of the PCC’s Provider application, EOHHS will assign an 
Enrollee Panel capacity at the level requested by the PCC, except that 
EOHHS will not approve a Panel capacity in excess of 1500 Enrollees per 
individual PCC provider within the PCC practice.  If the PCC Provider 
Application did not specify a Panel capacity, EOHHS will assign an 
Enrollee capacity of 1500 Enrollees per PCC site.


E.	Marketing
The PCC shall not, in the performance of its services under this Contract:
1.	Engage in any Cold-call Marketing; or
2.	Engage in any Marketing unless EOHHS approves the Marketing 
Materials in advance and such Marketing Materials satisfy all 
applicable requirements in 42 CFR 438.104(b).
F.	Informational and Instructional Materials
The PCC shall provide informational materials and instructional materials 
relating to Enrollees in an Easily Understood Format.
Section 3.2 Provision of Medical Services
A.	Provision of Care
The PCC shall:
1.	Comply with generally accepted medical practice and professional 
standards in the delivery of medical care to Enrollees;
2.	Provide or refer for all Primary Care services covered under the 
Enrollee’s MassHealth Coverage Type, as specified in 130 CMR 
450.105; 
3.	Inform all MassHealth Standard and CommonHealth Enrollees 
under age 21 about the EPSDT program, including the benefits of 
preventative health care, the range of services available under the 
EPSDT program, including behavioral health services, and where 
and how to obtain those services;
4.	Inform all MassHealth Standard and CommonHealth Enrollees 
under age 21 that medically necessary services in accordance with 
42 U.S.C. § 1396d(a)(4), 42 CFR Part 441 Subpart B, and 130 
CMR 450.140 et seq. are available without cost, except as may be 
provided under federal law, and that necessary transportation and 
scheduling assistance is available upon request;
5.	Offer to screen all MassHealth Enrollees under age 21 in 
accordance with the EPSDT Periodicity Schedule and 130 CMR 
450.140 through 150; 
6.	Provide or refer all MassHealth Standard and CommonHealth 
Enrollees under age 21 for all medically necessary treatment 
services, whether or not included in their coverage type, in 
accordance with the EPSDT Periodicity Schedule, 130 CMR 
450.140 through 149, and applicable prior authorization 
procedures;   
7.	Provide or refer all MassHealth Basic, Essential, and Family 
Assistance Enrollees under age 21 for medically necessary 
treatment services that are covered by their coverage type, as 
described in 130 CMR 450.105;
8.	Offer to screen using the standardized behavioral health screening 
tools described in the EPSDT Periodicity Schedule when 
conducting behavioral health screens according to the EPSDT 
Periodicity Schedule and 130 CMR 450.140 through 150;
9.	Take any other actions with respect to providing and documenting 
EPSDT screens, referrals, and treatment services that are required 
by EOHHS, as directed and notified by EOHHS;
10.	Inform all Enrollees that family planning services are available to 
the Enrollee through any MassHealth family planning provider, 
and that Enrollees do not need a referral in order to receive such 
services;
11.	Not deny any Enrollee MassHealth covered services for which the 
Enrollee is eligible on account of the Enrollee’s inability to pay the 
cost sharing; and 
12.	Acknowledge the rights of Enrollees (see Section 3.6) and take 
these rights into account when furnishing services to Enrollees.

B.	Access
The PCC shall provide reasonable and adequate hours of operation and 
shall ensure that the following access standards are met:
1.	Non-urgent, Symptomatic Primary Care Appointments.  The PCC 
shall ensure that Enrollees are offered a date for non-urgent, 
symptomatic Primary Care appointments within 10 days of the 
Enrollee’s request.
2.	Non-symptomatic Primary Care Appointments.  The PCC shall 
ensure that Enrollees are offered a date for non-symptomatic 
Primary Care appointments within 45 days of the Enrollee’s 
request unless otherwise mandated by the EPSDT Periodicity 
Schedule in Appendix W of all MassHealth provider manuals, per 
130 CMR 450.141.
3.	Urgent Care Appointments.  The PCC shall ensure that Enrollees 
are offered a date for urgent care within 48 hours of the Enrollee’s 
request.
4.	Special Rules for Appointments for Enrollees Placed in the Care of 
Custody of the Department of Social Services (DSS).  For 
Enrollees newly placed in the care or custody of the Department of 
Social Services (DSS), make best efforts to provide a DSS Health-
care Screening within seven calendar days of receiving a request 
from a DSS case worker for such DSS Health-care Screening, and 
provide a Comprehensive Medical Examination within 30 calendar 
days of receiving a request from a DSS case worker for such a 
Comprehensive Medical Examination unless otherwise mandated 
by the EPSDT Periodicity Schedule in Appendix W of all 
MassHealth provider manuals, per 130 CMR 450.141.  A DSS 
Comprehensive Medical Examination shall be conducted, if 
applicable, in accordance with the EPSDT Periodicity Schedule.
5.	Emergency Services.  The PCC shall provide Emergency Services 
immediately upon request, or instruct the Enrollee to go to the 
nearest emergency room or to call 911, as appropriate. 
6.	Poststabilization Care Services.  The PCC must provide any 
necessary referrals for Poststabilization Care Services.
7.	24 hours/7 days per week.  The PCC shall provide Enrollees with a 
telephone number to contact the PCC during the hours when the 
office is not open.  The PCC shall respond to all such calls within 
one hour.
8.	Arrangement for Care in the PCC’s Absence.  The PCC may 
arrange with another Provider to deliver health care services to 
Enrollees in his or her absence.  If the PCC has such arrangement, 
the PCC shall ensure that the Provider is a MassHealth 
participating Provider.
C.	Referral for Service 
The PCC shall:
1.	Inform Enrollees of those services which do not require a PCC 
referral (see 130 CMR 450.118);
2.	Refer the Enrollee when unable to provide a MassHealth-covered 
service that requires a referral to an appropriate MassHealth 
Provider who is able to provide the service, taking into account 
Enrollee preferences to the extent possible;
3.	Provide for arrangements with, or referrals to, sufficient numbers 
of physicians and other practitioners enrolled with MassHealth to 
ensure that MassHealth covered services can be furnished to 
Enrollees promptly and without compromise to quality of care;


4.	Initiate a PCC referral either by: 
a.	Telephone; 
b.	Using the MassHealth referral form; or
c.	Using the PCC’s own referral form as long as it includes 
the same information contained in the MassHealth referral 
form.
5.	Make best efforts to make all PCC referrals before the Enrollee 
receives services that require a referral; 
6.	Provide the referred-to Provider with the PCC’s MassHealth 
Provider number for use on their claim form; 
7.	At its discretion, provide referrals for Enrollees the PCC has not 
yet seen; and
8.	Document each referral in the Enrollee’s medical record.  
Documentation shall include a copy of any medical report the 
referred to Provider submits to the PCC.
D.	Coordination of Care
The PCC shall:
1.	Monitor all MassHealth-covered services, whether provided 
directly or through a referral to other MassHealth providers.  
Monitoring of services that do not require a referral is at the 
discretion of the PCC in keeping with generally accepted medical 
practice and professional standards;
2.	Communicate and coordinate, to the extent permissible by law, 
with any provider delivering any medical or Behavioral Health 
Services to the PCC’s Enrollees, including all specialists, home 
health agencies, behavioral health professionals and providers, 
state agency case managers, care or disease managers, school-
based health centers, local education authorities (schools), and 
discharge planners, as appropriate and applicable. Coordination 
shall include, upon receipt of an Individual Care Plan (ICP) Report 
from the Behavioral Health Program Contractor, reviewing and 
acknowledging receipt of the ICP Report.
3.	Enroll in the Massachusetts Department of Public Health’s 
Immunization Program.


E.	Pharmacy Management
The PCC shall participate as directed in EOHHS’ pharmacy management 
initiatives, and shall refer to the MassHealth Drug List when prescribing 
Medically Necessary medications.
F.	Verification of Enrollee Eligibility
The PCC shall verify each Enrollee’s health care coverage and PCC Plan 
enrollment before providing services.
Section 3.3 Member Enrollment, Disenrollment, Reenrollment, and Orientation
A.	Member Enrollment to PCC Panel
The PCC shall accept for enrollment or reenrollment all Members 
assigned to the PCC’s panel in the order in which they are assigned 
without restriction unless:
1.	The PCC is operating at full Panel capacity. 
2.	The PCC shall not accept for enrollment or reenrollment any 
particular Member if the PCC is not medically qualified to provide 
Primary Care to that Member, provided that the PCC shall not 
discriminate and will not use any policy or practice that has the 
effect of discriminating against an Enrollee with respect to 
enrollment, disenrollment, or reenrollment on the basis of race, 
color, national origin, age, physical or mental disability, marital 
status, sexual orientation, health care status, or need for health care 
services.  
B.	Enrollee Disenrollment
1.	The PCC may not disenroll an Enrollee from its Panel.  The PCC 
may request that EOHHS disenroll an Enrollee from its Panel, 
provided that the PCC may not request disenrollment because of an 
adverse change in the Enrollee’s health status, or because of the 
Enrollee’s utilization of medical services, diminished mental 
capacity, or uncooperative or disruptive behavior resulting from 
his or her special needs (except where his or her continued 
enrollment seriously impairs the PCC’s ability to furnish services 
to either the particular Enrollee or other Enrollees).  EOHHS may 
in its sole discretion grant this request if the PCC demonstrates, in 
writing, to the satisfaction of EOHHS that:
a.	The Enrollee has a pattern of noncompliant or disruptive 
behavior which is not the result of the Enrollee’s special 
needs;
b.	The continued enrollment of the Enrollee with the PCC 
seriously impairs the PCC’s ability to furnish services to 
either this particular Enrollee or other Enrollees; or
c.	The PCC is unable to meet the medical needs of an 
Enrollee.  
C.	Enrollee’s Initial Visit and Orientation
1.	PCC Plan Orientation

The PCC shall orient all Enrollees to the PCC Plan.  The PCC Plan 
orientation shall include, at a minimum, the following information:
a.	The Importance of Primary Care.  The PCC shall explain 
the importance of Primary Care and the role of the PCC in 
managing and providing that care.
b.	Updating Enrollee Information.  The PCC shall explain the 
importance of keeping the PCC and EOHHS updated about 
any change in address or telephone number.
c.	Services That Do Not Require a Referral.  The PCC shall 
tell Enrollees about those services that do not require a 
PCC referral.  See 130 CMR 450.118. 
d.	Carrying the MassHealth Card.  The PCC shall emphasize 
that Enrollees should carry the MassHealth Card to enable 
Providers to check MassHealth eligibility and identify the 
Enrollee’s PCC.


e.	Helpful Telephone Numbers for Enrollees.  The PCC shall 
provide Enrollees with the telephone numbers, in addition 
to the PCC’s, for the following PCC Plan services:
1)	MassHealth customer service; and
2)	Behavioral Health Program Contractor’s customer 
service line.
f.	PCC Practice Specifics.  The PCC shall tell Enrollees 
about:
1)	The days and hours that the PCC’s practice is open;
2)	How long the Enrollee should expect to wait for an 
appointment for Primary and Urgent Care, 
consistent with access requirements specified in 
Section 3.2.B.;
3)	Appointment cancellation procedures;
4)	Alternate phone numbers; and
5)	Procedures for contacting the PCC’s office after 
normal business hours, including who to contact, 
who will call the Enrollee back, and how long the 
Enrollee should expect to wait for a return call, 
consistent with access requirements specified in 
Section 3.2.B.  
2.	Initial Visit
a.	Timing of Initial Visit
1)	For New Enrollees
The PCC shall attempt to contact a new Enrollee 
within three weeks of enrollment in order to 
schedule an initial visit unless the Enrollee has 
previously been known to the PCC and is already in 
the care of the PCC.  The PCC shall make best 
efforts to schedule the initial visit, when required, 
within four months of enrollment with the PCC.



2)	For New PCC Plan Enrollees Previously Known to 
and Currently in the Care of the PCC
No initial visit is required if the PCC has performed 
a physical examination within the last 12 months or, 
in the case of an Enrollee under age 21, within the 
period described in the EPDST Schedule.

3)	Outreach to Pregnant Enrollees
The PCC shall attempt to contact an Enrollee who is 
pregnant within seven days of the PCC learning of 
the Enrollee’s pregnancy to ensure that the Enrollee 
is accessing prenatal care services.
b.	Purpose of Initial Visit
The initial visit shall include, at a minimum: 

1)	A medical history intake;
2)	A physical examination; 
3)	For Enrollees under age 21, provision of services 
according to the EPSDT Schedule; and
4)	Medically Necessary treatment.
Section 3.4 Privacy, Confidentiality, Security of Personal Data and HIPAA 
Compliance
A.	Covered Entities
The parties acknowledge that they are covered entities, as defined in 
HIPAA regulations at 45 CFR 160.103.
B.	Requirements Regarding Personal Data
The PCC shall comply with all applicable requirements regarding the 
privacy, confidentiality, security, use and disclosure of personal data 
(including protected health information), including but not limited to the 
requirements set forth in M.G.L. c.66A, 42 CFR 431, Subpart F, and 45 
CFR Parts 160, 162 and 164. 


C.	PCC’s Compliance with HIPAA
The PCC shall:
1.	Conform to all applicable HIPAA requirements and regulations no 
later than the compliance date of each of those requirements or 
regulations.
2.	At all times subsequent to the applicable compliance dates be in 
compliance with such requirements and regulations.
3.	Work cooperatively with EOHHS on all activities related to 
implementation of and ongoing compliance with HIPAA 
requirements, as directed by EOHHS; and
4.	Execute, at EOHHS’ direction, a Trading Partner Agreement and 
any other agreements EOHHS determines are necessary to comply 
with HIPAA requirements.

Section 3.5 Enrollee Grievances
The PCC shall assist in Grievance resolution procedures as follows:
A.	If an Enrollee has a Grievance related to the PCC, the PCC shall work 
cooperatively with the Enrollee and EOHHS to resolve the Grievance.
B.	If the Enrollee wishes to file a Grievance, the PCC shall instruct the 
Enrollee to contact the MassHealth Customer Service Center. 
Section 3.6 Enrollee Rights
A.	The PCC must comply with all applicable Federal and State laws that 
pertain to Enrollee rights, including but not limited to, the Americans with 
Disabilities Act and the Civil Rights Act of 1964.
B.	The PCC must ensure that its staff and any affiliated providers take those 
rights into account when furnishing services to Enrollees.
C.	Enrollee rights shall include:
1.	The right to receive the information required pursuant to this 
Contract;
2.	The right to be treated with respect and with due consideration of 
his or her dignity and privacy;
3.	The right to receive information on available treatment options and 
alternatives, presented in a manner appropriate to the Enrollee’s 
condition and ability to understand;
4.	The right to participate in decisions regarding his or her health 
care, including the right to refuse treatment;
5.	The right to be free from any form of restraint or seclusion used as 
a means of coercion, discipline, convenience, or retaliation;
6.	The right to request and receive a copy of his or her medical 
records, and request that they be amended or corrected, as 
specified in 45 CFR 164.524 and 164.526 (HIPAA); 
7.	The right to freely exercise his or her rights without adversely 
affecting the way the PCC treats the Enrollee; and
8.	The right to choose his or her health professional to the extent 
possible and appropriate.

Section 3.7 Performance Improvement Management Services (PIMS)
The PCC shall participate in PIMS and other quality improvement activities specified 
by EOHHS.  Participation by PCCs for whom a PCC Profile Report is produced shall 
include, without limitation:
A.	Site visits by a Regional Network Manager with a PCC clinician, or a PCC 
clinician and an administrative staff member to review PCC Profile Report 
and any other reports and materials; and
B.	The development and implementation of written action plans around 
specific quality improvement activities.
SECTION 4. EOHHS RESPONSIBILITIES
Section 4.1 Provider Application
EOHHS will act upon each received PCC Plan Provider Application, and either 
approve the application, withhold a decision pending the receipt of additional 
information, or deny the application and provide the reason or reasons for the denial 
within 30 days of the receipt of the application.
Section 4.2 Administration and Contract Management
EOHHS shall:
A.	Provide the PCC with information on how to contact relevant EOHHS 
units and vendors for assistance with issues such as billing, prior 
authorization, covered services and other PCC responsibilities;
B.	Conduct ongoing data and record reviews to help ensure the delivery of 
services in the most appropriate setting in accordance with medical 
standards and protocols; 
C.	Conduct quality management activities such as HEDIS measurement and 
Member satisfaction surveys to assess the effectiveness of the PCC Plan 
performance and make the results available to PCCs;
D.	Pay the PCC an enhanced rate for certain Primary Care services provided 
to the PCC’s Enrollees (see Sections 5.1 and 5.2);
E.	Notify the PCC of all programmatic and policy changes that may affect 
the PCC's participation in MassHealth; and
F.	Reserve the right to change the current MassHealth program, including but 
not limited to covered services, Member eligibility, cost-sharing, or PCC 
Plan programmatic features upon written notice to the PCC of any such 
changes.
Section 4.3 Member Enrollment and Disenrollment Activities
EOHHS shall:
A.	Ensure an equitable Member enrollment process, which considers PCC 
Panel size and restrictions and existing Member and Provider relationships 
as guidelines;
B.	Provide the PCC with a monthly report of Member enrollment;
C.	Include on the Recipient Eligibility Verification System (REVS) the name 
and telephone number of the PCC with whom the Member is enrolled;
D.	Provide Members with enrollment materials that describe the PCC Plan; 
E.	Transfer Members, through the MassHealth Customer Service Center, 
when a PCC leaves the PCC Plan;
F.	Respond within three business days of receipt to a written non-urgent 
request made by a PCC to disenroll an Enrollee from the PCC’s Panel, and 
within one business day of receipt to a written, urgent request made by a 
PCC to disenroll an Enrollee from the PCC’s Panel;
G.	Assist in the outreach to PCC Enrollees that the PCC is unable to locate; 
and
H.	Inform the PCC of any new EOHHS-sponsored contract that affects PCC 
Plan Enrollees.
SECTION 5. PAYMENT
Section 5.1 PCC Enhanced Rate
A.	EOHHS shall pay the PCC for services delivered to PCC Plan Enrollees in 
accordance with the terms and conditions contained in the EOHHS 
regulations that govern the PCC’s MassHealth provider type.  (See 130 
CMR 433.000 and 410.000.)
B.	EOHHS shall pay the PCC an enhanced rate for providing certain Primary 
Care services designated by EOHHS to PCC Plan Enrollees.  See 
Attachment A for codes eligible for an enhanced rate.   
C.	EOHHS reserves the right to add or delete service codes to which such 
enhanced rate applies without a Contract amendment.  EOHHS will 
provide PCCs with written advance notice of any changes to the codes to 
which the enhanced rate applies.  EOHHS will provide such notice 
through written notification to PCCs.
D.	The enhanced rate will only be paid for services provided by the PCC to 
Enrollees enrolled in the PCC’s Panel on the date that the service was 
delivered.
E.	EOHHS shall not pay PCCs for any claims submitted for an appointment 
missed by an Enrollee.  PCCs are prohibited from charging EOHHS or 
Enrollees for a missed appointment.
Section 5.2 EPSDT Enhanced Rate
A.	PCCs will receive an EPSDT enhanced rate for providing well-child care 
screens  to Enrollees under age 21, when delivered in accordance with the 
EPSDT Periodicity Schedule and 130 CMR 450.140 through 150, and 
billed in accordance with all applicable billing instructions.
B.	PCCs will receive a separate rate for providing the following services 
when delivered in accordance with the EPSDT Periodicity Schedule and 
130 CMR 450.140 through 150, and billed in accordance with all 
applicable billing instructions:
1.	The laboratory services that are listed in Appendix Z of all 
MassHealth provider manuals and included in the EPSDT 
Periodicity Schedule are payable (see 130 CMR 450.146(A));
2.	The audiometric hearing test and the bilateral quantitative 
screening of visual acuity that are listed in Appendix Z of all 
MassHealth provider manuals and included in the EPSDT 
Periodicity Schedule (see 130 CMR 450.146(B)); and
3.	The standardized behavioral health screening tools that is listed in 
Appendix Z of all MassHealth provider manuals and set forth in 
the EPSDT Periodicity Schedule (see 130 CMR 450.146(C)).

Section 5.3 Prospective Interim Payment (PIP)
A.	Upon written request to EOHHS, EOHHS will make a monthly advance in 
the form of a prospective interim payment (PIP) to physician, independent 
nurse practitioner, group practice, and community health center PCCs.  
Outpatient department (OPD) and hospital-licensed health center (HLHC) 
PCCs are not eligible for a PIP.
B.	The PIP is a monthly amount equal to 25% of the average monthly 
payments, including enhancements, made the previous quarter for all 
services provided to Enrollees.
C.	EOHHS will conduct an ongoing reconciliation between the PIP and 
actual paid claims, and will adjust the PIP accordingly.
D.	Upon notice of termination or planned termination of this Contract by 
either party, EOHHS will, at its discretion, close the PIP account.  


Section 5.4 Claims Submission
A.	PCC Claims
All statutes, regulations, rules, billing instructions, bulletins, and other 
written policy statements governing claims submissions for physicians, 
independent nurse practitioners, group practices, community health 
centers, and outpatient departments apply to the PCC Plan. 
B.	Other Provider Claims
The PCC shall provide the PCC referral number to all referred Providers.  
If a Provider submits a claim for a service that requires a referral and the 
PCC’s referral number is not on the claim, the claim will be denied.
SECTION 6. ADDITIONAL TERMS AND CONDITIONS
Section 6.1 Compliance with Law
The PCC shall comply with all state and federal statutes, rules, regulations, billing 
instructions, provider bulletins, and other written policy guidance applicable to the 
PCC Plan.  All statutory and regulatory citations contained in this Contract refer to 
those statutes and regulations, as they may be amended.  Without limiting the 
generality of the foregoing, the PCC shall comply with Title VI of the Civil Rights 
Act of 1964, as implemented by regulations at 45 CFR Part 80; Title IX of the 
Education Amendments of 1972; the Age Discrimination Act of 1975, as 
implemented by regulations at 45 CFR Part 91; the Rehabilitation Act of 1973; the 
Americans with Disabilities Act; Titles XIX and XXI of the Social Security Act and 
waivers thereof; and 42 CFR Part 438, to the extent such provisions apply.
Section 6.2 Subcontracts
The PCC shall:
A.	Maintain all subcontracts relating to this Contract in writing.  All such 
subcontracts shall fulfill all applicable requirements of 42 CFR Part 438, 
and shall contain all relevant provisions of this Contract appropriate to the 
subcontracted service or activity.
B.	Remain fully responsible for meeting all of the terms and requirements of 
this Contract regardless of whether the PCC subcontracts for performance 
of any Contract responsibility.  No subcontract will operate to relieve the 
PCC of its legal responsibilities under this Contract.
C.	Prior to any delegation, evaluate the prospective subcontractor’s ability to 
perform the activities to be delegated.
D.	Monitor the subcontractor’s performance on an ongoing basis.
Section 6.3 Prohibited Affiliations
In accordance with 42 U.S.C. § 1936u-2(d)(1) and 42 CFR 438.610, the PCC shall 
not knowingly have an employment, consulting, or other agreement for the provision 
of items and services that are significant and material to the PCC’s obligations under 
this Contract with any person, or affiliate of such person who is debarred, suspended, 
or otherwise excluded, under federal law, regulation, executive order, or guidelines, 
from certain procurement and non-procurement activities.  Further, no such person 
may have beneficial ownership of more than five percent of the PCC’s equity nor be 
permitted to serve as a director, officer, or partner of the PCC.
Section 6.4 Intermediate Sanctions
A.	EOHHS shall provide the PCC with timely written notice prior to 
imposing any intermediate sanctions, which explain the basis and nature 
of the sanction, including any other due process protections that EOHHS 
elects to provide.
B.	At any point during the Contract term, if EOHHS identifies any deficiency 
in the PCC’s performance of this Contract, EOHHS may impose sanctions 
that it deems necessary, including termination in accordance with Section 
6.5, notifying Enrollees of the violation, intermediate sanction, and their 
right to disenroll, restricting Member enrollment, reassigning Enrollees 
within the PCC’s Panel, and disenrolling Enrollees from the PCC’s Panel 
and such other measures as EOHHS determines appropriate to address the 
deficiency.
C.	The intermediate sanction provisions in this Contract are pursuant to state 
authority.
Section 6.5 Contract Termination
A.	Either party may terminate this Contract without cause by giving written 
notice to the other at least 30 calendar days prior to the effective date of 
termination as stated in the notice, or such other period as is mutually 
agreed upon by the parties.
B.	Either party may terminate this Contract if the other party fails to fulfill 
the obligations of this Contract or laws governing this Contract by giving 
written notice to the other at least 14 days before the effective date of 
termination stated in the notice.  The notice shall state the circumstances 
of the alleged breach and may state a reasonable period, not less than 
seven calendar days, during which the alleged breach may be cured.  
EOHHS may terminate this Contract immediately and without prior notice 
in the event of fraud or program abuse or if the health or safety of 
Enrollees is in jeopardy.
C.	EOHHS will provide the PCC with a hearing before termination when 
required by law.  Any such hearing will be held in substantial conformity 
with the procedures set forth in EOHHS’ Provider sanction regulations
D.	The termination provisions in this Contract are pursuant to state authority.
Section 6.6 Amendment
A.	By mutual agreement, the parties may amend this Contract where such 
amendment does not violate state or federal statutory, regulatory, or 
waiver provisions, provided that such amendment is in writing.  Further, 
the PCC agrees to take such actions as is necessary to amend this Contract 
in order for EOHHS to comply with all applicable state and federal laws 
and waivers, including, but not limited to HIPAA and the Balanced 
Budget Amendments of 1997 (BBA) and any regulations promulgated 
thereunder.
B.	The PCC shall submit to EOHHS an executed original of any amendment 
to this Contract within 60 days of receipt.  If the PCC does not execute the 
amendment, the PCC’s participation in the PCC Plan shall continue under 
the terms and conditions of this Contract as amended by EOHHS, unless 
EOHHS opts to terminate this Contract in accordance with Section 6.5 
above.




ii
Fourth Amended and Restated
PCC Plan Provider Contract
December 2007