Frequently asked questions: Federally Required Disclosures

Who must provide this information?

The Federal/State requirement applies to any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, any Medicare intermediary or carrier, and an entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health related services for which it claims payment under any plan or program established under Title V or Title XX of the Social Security Act. It also applies to subcontractors which means (a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or  (b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement. Definitions are provided on the Federally Required Disclosure Form.

Why must providers submit this information to Fallon Health?

Fallon Health is contracted with the State of Massachusetts as a MassHealth Managed Care Organization (MCO) providing health insurance to Medicaid recipients. Under that contract, MCO’s are required to obtain this information from its providers. Fallon is required to obtain this information prior to the execution and renewal of the provider contract and when ownership of the provider’s business changes. Federal regulation requires termination of the contract if the provider fails to comply with Federal disclosure mandates. The following information from the MassHealth Provider Billing and Services Updates & Upcoming Initiatives Massachusetts Health Care Training Forum July 2011, page 3 states:

Provider Disclosure Statement

  • All provider organizations are required to comply with Federal, State and local laws and regulations (42 CFR sections 431.107, 447.10 and 455.100 through 455.106; and section 1902(a)(9) of the Social Security Act).

Subsequently, entities must disclose to EOHHS the identity of any person who:

  • Has ownership or control interest in the provider organization, or is an agent or managing employee of the provider, and of those people; and
  • Those who have been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs (42 CFR 455.106 paragraph (a))

I am a health system employed practitioner. Should I provide this information to Fallon?

As a health system employed practitioner, there is no need for you to provide this information directly to Fallon. Fallon is requesting information for health system employed practitioners from the hospital system and/or PHO.

As a MassHealth contracted provider, I am required to provide and update this information to the State. Why must I also disclose the same information to Fallon?

As directed by the Centers of Medicare & Medicaid Services, the State of Massachusetts is required to direct its MCOs to obtain this information from their providers.

How will Fallon use this information?

Fallon is required to conduct criminal and other background checks on its providers, its providers' managing employees, and other related entities. Fallon cannot pay claims to providers if they or their managing employees/related entities have been convicted of a crime involving Medicare or Medicaid or if they have been suspended, debarred, or excluded from participating in a federal program.

Why are the full name, address, and social security number being requested?

MassHealth requires Fallon to obtain from providers their tax identification number (TIN), social security number (SSN), or employer identification number (EIN) for purposes necessary to properly administer this federal requirement. This is the same information providers are required to submit with their Medicaid provider contracts. This information is the minimum data required in order to perform an accurate background check.

How will Fallon maintain the confidentiality and security of this information?

Fallon will comply with all federal and state privacy and security rules and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). All information obtained shall be kept confidential and used only for the purposes of conducting criminal and other background checks. Data will be maintained only for a period of time as either required by the State of Massachusetts, or until Fallon receives notification from the provider that the information is obsolete.

How do we submit the data?

For your convenience, you can submit your data using our secure electronic form. It is strongly suggested to gather all information prior to entering your data. The form cannot be saved prior to submitting the information.

Quick links: MassHealth Federally Required Disclosures