reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.412 - Notice of Prior Authorization and Clinical Eligibility Determination

Current through Register 1525, July 5, 2024
(A)
Notice of
			 Approval
. For all approved prior authorization requests for CSN
			 agency services, the MassHealth agency or its designee sends written notice to
			 the member and the CSN agency, if applicable, specifying the frequency and
			 duration of care authorized, and the effective date of the
			 authorization.
(B)
Notice of Modification and Right of Appeal
.
(1) For all modified prior authorization
			 requests, the MassHealth agency or its designee notifies the member of the
			 modification, reason, member's right to appeal, and appeal procedure. The CSN
			 agency receives the information about the modification and the reason from the
			 MassHealth agency or its designee.
(2) A member may request a fair hearing from
			 the MassHealth agency if the MassHealth agency or its designee modifies a prior
			 authorization request. The member must request a fair hearing in writing within
			 30 days after the date of the modification. The Office of Medicaid Board of
			 Hearings conducts the hearing in accordance with
			 130 CMR
			 610.000:
MassHealth: Fair Hearing
			 Rules
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.413 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary CSN
				agency services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnostic and Treatment (EPSDT) Services: Introduction
,
				with prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.415 - Provider Responsibilities

Current through Register 1525, July 5, 2024
In addition to meeting all of the qualifications set forth in
				130 CMR
				438.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
, CSN agencies must meet all of the following
				requirements.
(A)
Policies
			 and Procedures
. Each CSN agency must develop comprehensive
			 policies and procedures governing the delivery of CSN agency services. The
			 agency must maintain the policies and procedures, review/update them, comply
			 with them, and make them available to members, in part or in their entirety, on
			 request. At a minimum, the policies and procedures must contain the following:
(1) administrative policies and procedures
			 including, but not limited to,
(a) human
			 resource and personnel;
(b) staff
			 and staffing requirements;
(c)
			 backup staff in the event coverage is required due to illness, vacation, or
			 other reasons;
(d) staff education
			 and training;
(e) CSN agency staff
			 evaluation and supervision;
(f)
			 emergencies including fire, safety and disasters, including notifying the fire
			 department and police in emergencies;
(g) MassHealth member rights;
(h) human rights and
			 nondiscrimination;
(i) incident and
			 accident reporting;
(j) staff and
			 member grievances;
(k) staff
			 cultural competency;
(l) quality
			 assurance and improvement;
(m)
			 emergency services and plans for members;
(n) recognizing and reporting abuse
			 (physical, sexual, emotional, psychological), neglect, self-neglect, and
			 financial exploitation;
(o) Health
			 Insurance Portability and Accountability Act (HIPAA);
(p) procedures to be followed if a member is
			 missing or lost; and
(q) member
			 complaint resolution protocol.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.416 - Plan of Care Requirements

Current through Register 1525, July 5, 2024
All CSN agency services must be provided under an
				individualized plan of care developed for the member. The physician or ordering
				non-physician practitioner must sign the plan of care before services are
				provided to the member.
(A)
Providers Qualified to Establish a Plan of Care
.
(1) The member's physician or ordering
			 non-physician practitioner in consultation with the CSN agency must establish a
			 written plan of care and the physician or ordering non-physician practitioner
			 must recertify, sign, and date the plan of care every 60 calendar
			 days.
(2) The CSN agency may
			 establish an additional nursing plan of care, when appropriate, that may be
			 incorporated into the physician or ordering non-physician practitioner's plan
			 of care, or be prepared separately. The additional plan of care does not
			 substitute for the physician or ordering non-physician practitioner's plan of
			 care.
(3) If a CSN agency is
			 co-vending a case with other CSN providers or home health agency providers,
			 each provider is responsible for establishing a separate plan of care signed by
			 the member's physician or ordering non-physician practitioner.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.417 - Quality Management, Utilization Review, and Reporting Requirements

Current through Register 1525, July 5, 2024
(A) A CSN agency must participate in any
			 quality management and program integrity processes as required by the
			 MassHealth agency and EOHHS including making any requested data available and
			 providing access to visit the CSN agency's place of business upon request by
			 MassHealth or its designee.
(B) A
			 CSN agency must submit requested documentation to the MassHealth agency or its
			 designee for purposes of utilization review and provider review and audit,
			 within the MassHealth agency's or its designee's time specifications. The CSN
			 agency must provide the MassHealth agency or its designee with any supporting
			 documentation the MassHealth agency or its designee requests, in accordance
			 with M.G.L. c. 118E, § 38 and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
(C) A CSN
			 agency must provide MassHealth or its designee any requested documentation for
			 purposes of a member's medical necessity review for CSN agency services. The
			 requested documentation must be submitted to MassHealth or its designee within
			 the MassHealth agency's or its designee's time specifications.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.418 - Transfers and Discharge Planning

Current through Register 1525, July 5, 2024
(A)
Discharge Procedures
.
(1) A member shall be discharged by the CSN
			 agency provider under the following conditions
(a) upon the member's request;
(b) if the member no longer meets the
			 clinical eligibility for CSN agency services;
(c) if the member selects another service
			 that is duplicative of CSN agency services;
(d) if the member transitions to another CSN
			 provider; or
(e) if the CSN agency
			 ceases operations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.419 - Conditions of Payment

Current through Register 1525, July 5, 2024
The following conditions for payment apply to all CSN agency
				services, in addition to conditions of payment described throughout
				130 CMR
				438.000.
(A)
Place of Service
. The MassHealth agency pays for CSN
			 agency services provided to a member who meets the clinical criteria in
			 130
			 CMR 438.410 and resides in a noninstitutional
			 setting, which may include, without limitation, a homeless shelter or other
			 temporary residence or a community setting. In accordance with
			 42 CFR
			 440.70(c), the MassHealth
			 agency does not pay for CSN agency services provided in a hospital, nursing
			 facility, intermediate care facility, or any other institutional setting
			 providing medical, nursing, rehabilitative, or related care. MassHealth will
			 pay for CSN agency services when the CSN agency must accompany the member in
			 transport to and from an institutional setting to ensure medical stability
			 during transitions in and out of the institutional setting. CSN agency services
			 provided to a member while under the care of an institutional setting will be
			 viewed as duplication of services and not covered by MassHealth.
(B)
Medical Necessity
			 Requirement
. In accordance with
			 130
			 CMR 450.204:
Medical
			 Necessity
, the MassHealth agency pays for only those CSN agency
			 services that are medically necessary.
(C)
Plan of Care
.
			 The MassHealth agency pays only for CSN agency services provided according to a
			 plan of care authorized by a physician or a non-physician practitioner and that
			 meets the plan of care requirements at
			 130
			 CMR 438.416.
(D)
Prior
			 Authorization
. The MassHealth agency pays for CSN agency services
			 only when prior authorization has been obtained from the MassHealth agency or
			 its designee, in accordance with
			 130
			 CMR 438.411.
(E)
Members for Whom Services Are
			 Approved
. The MassHealth agency does not pay for CSN agency
			 services provided to any individual other than the member who is eligible to
			 receive such services and for whom such services have been authorized by the
			 MassHealth agency or its designee.
(F)
Multiple-patient Care and CSN
			 Services
. The MassHealth agency pays for one nurse to provide CSN
			 services in the same household and during the same time period to more than one
			 member, but not more than three members, if
(1) the members have been determined by the
			 MassHealth agency or its designee to meet the criteria listed at
			 130
			 CMR 438.410(A) and
			 (B);
(2) the members receive services in the same
			 household and during the same time period;
(3) the MassHealth agency or its designee has
			 determined that it is appropriate for one nurse to provide nursing services to
			 the members simultaneously; and
(4)
			 the CSN agency has received a separate prior authorization from the MassHealth
			 agency or its designee for each member as described at
			 130
			 CMR 438.413.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.420 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
CSN agencies must accept MassHealth payment in full for CSN
				agency services in accordance with the rates and regulations established by
				EOHHS as set forth in
				101 CMR
				361.00:
Rates for Continuous Skilled Nursing
				Agency and Independent Nursing Services
. Payments are subject to the
				conditions, exclusions, and limitations set forth in
				130 CMR
				438.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.421 - Denial of Services and Administrative Review

Current through Register 1525, July 5, 2024
(A) A failure or refusal by a CSN agency to
			 furnish services that have been ordered by the member's attending physician or
			 ordering non-physician practitioner and are within the range of payable
			 services, constitutes a violation of
			 130 CMR
			 438.000 for which administrative sanctions may be
			 imposed, with the exception of instances where the CSN agency does not have
			 nursing availability to provide services.
(B) When a CSN agency believes that services
			 ordered by the attending physician or ordering non-physician practitioner are
			 not payable under
			 130 CMR
			 438.000, the CSN agency must refer the matter to the
			 MassHealth agency for a payment decision. If and to the extent the MassHealth
			 agency determines that the ordered services are payable, the CSN agency must
			 provide those services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.422 - Prohibited Marketing Activities

Current through Register 1525, July 5, 2024
A CSN agency provider must not
(A) with the knowledge that a member is
			 enrolled in a capitated program, engage in any practice that would reasonably
			 be expected to have the effect of steering or encouraging the member to
			 disenroll from the capitated program in order to obtain services on a
			 fee-for-service basis;
(B) offer to
			 a member, or his or her family or caregivers, in person or through marketing
			 any inducement to retain the CSN agency provider to provide CSN agency
			 services, such as a financial incentive, reward, gift, meal, discount, rebate,
			 giveaway, or special opportunity;
(C) pay a "finder's fee" to any third party
			 in exchange for referring a member to the CSN agency provider; or
(D) engage in any unfair or deceptive acts or
			 practices in connection with any marketing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.401 - Introduction

Current through Register 1525, July 5, 2024
All early intervention program providers participating in
				MassHealth must comply with the regulations of the Division governing
				MassHealth, including but not limited to Division regulations set forth in
				130 CMR 440.000 and CMR
				450.000. The general operation of early intervention programs is governed by
				the Massachusetts Department of Public Health, through its Early Intervention
				Operational Standards.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. The Division covers early
			 intervention program services only when provided to eligible MassHealth members
			 who meet all of the criteria in 130 CMR 440.403(A)(1) through (3 ), subject to
			 all other restrictions and limitations described in the Division's regulations.
			 The Division's regulations at
			 130 CMR 450.105
			 specifically state which services are covered and which members are eligible to
			 receive those services.
(1) The member is
			 considered to be subject to a biological, environmental, or established
			 risk.
(2) Failure to receive early
			 intervention services is expected to impede the member's development.
(3) The member is aged three years or
			 younger. An exception may be made if the member is in the process of
			 transferring from the program. The Division will continue to pay as follows for
			 services delivered to such a member:
(a) if
			 the member was born on or before April 1, for three months after the member's
			 third birthday; and
(b) if the
			 member was born after April 1, until September 1 of the year of the member's
			 third birthday or until three months after the member's third birthday,
			 whichever is longer.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
In
			 State
. To participate in MassHealth, an early intervention program
			 located in Massachusetts must fulfill the following requirements.
(1) Evidence of the program's compliance with
			 the Operational Standards must be submitted to the Division. This evidence,
			 supplied by the provider as a result of an on-site review of the program, must
			 consist of a letter on Department of Public Health stationery stating that the
			 program is in compliance with the Operational Standards and has been reviewed
			 by the Department of Public Health. The letter must include the date of the
			 review.
(2) The provider must
			 complete the MassHealth Provider Application.
(3) After completion of the application
			 process, the provider must enter into a provider agreement with the Division.
			 Payments will not be made for services provided prior to the effective date of
			 the provider agreement. Continuation of the agreement will be subject to the
			 Division's receipt each year of documentation from the Department of Public
			 Health as specified in 130 CMR 440.404(A)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.411 - Staff Qualifications

Current through Register 1525, July 5, 2024
The Division will pay for early intervention services only when
				they are furnished by those professional program staff members designated in
				130 CMR
				440.412 who possess the qualifications listed
				below.
(A) A nurse must possess a
			 bachelor's degree in nursing from an accredited program or a diploma in nursing
			 from an accredited program and a current registration by the Massachusetts
			 Board of Registration in Nursing.
(B) An occupational therapist must be a
			 graduate of an occupational therapy curriculum approved by the American
			 Occupational Therapy Association, and be licensed by the Massachusetts Board of
			 Registration in Allied Health Professions.
(C) A physical therapist must be a graduate
			 of a physical therapy curriculum approved by the American Physical Therapy
			 Association, and be licensed by the Massachusetts Board of Registration in
			 Allied Health Professions.
(D) A
			 psychologist must possess a master's degree from an accredited program in
			 psychology, educational psychology, counseling psychology, or developmental
			 psychology.
(E) A social worker
			 must at a minimum be licensed as a licensed clinical social worker (LCSW) by
			 the Massachusetts Board of Registration for Social Work.
(F) A speech and language pathologist must be
			 licensed by the Massachusetts Board of Registration in Allied Health
			 Professionals and either possess a Certificate of Clinical Competence (CCC)
			 granted by the American Speech, Language, and Hearing Association, or be in the
			 clinical fellowship the year prior to being granted a Certificate of Clinical
			 Competence.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.412 - Reimbursable Services

Current through Register 1525, July 5, 2024
(A) The Division
			 pays early intervention programs for the following services only when they are
			 furnished by a nurse, an occupational therapist, a physical therapist, a speech
			 and language pathologist, a social worker, or a psychologist:
(1) a home visit;
(2) a center-based individual
			 visit;
(3) a child-focused group
			 session; and
(4) a parent-focused
			 group session.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.413 - Non reimbursable Services

Current through Register 1525, July 5, 2024
The Division does not pay early intervention programs for the
				following:
(A) research or
			 experimental treatment;
(B)
			 educational services;
(C)
			 recreational services;
(D)
			 nutritional counseling
(E) respite
			 services;
(F) home- or center-based
			 visits not conducted by a nurse, an occupational therapist, a physical
			 therapist, a speech and language pathologist, a social worker, or a
			 psychologist; and
(G) any visits,
			 screenings, group sessions, or assessments that are missed by a member or
			 canceled.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.414 - Coordination of Services

Current through Register 1525, July 5, 2024
The Division pays for early intervention services only when the
				following conditions are met.
(A)
Case Coordinator
. The program must assign to each
			 member a service coordinator who is responsible for the following:
(1) coordinating services provided to the
			 member; and
(2) coordinating the
			 development of the member's individualized family service plan.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.415 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
Early intervention programs must maintain, for at least four
				years after the member leaves the program, records for each member that include
				at least all the information required by the Department of Public Health in its
				Operational Standards and the following:
(A) the member's name, address, and
			 MassHealth identification number;
(B) the name and address of the member's
			 caregiver;
(C) the name ofthe
			 service coordinator;
(D) the name
			 and address of the member's primary physician, clinic, or coordinated health
			 site (see Part 1 of the billing instructions in Subchapter 5 of the
Early Intervention Program Manual
);
(E) a schedule of visits, group sessions,
			 assessments, progress reviews, and other services that have been or will be
			 provided;
(F) an attendance
			 record;
(G) a report for each
			 reimbursable service provided, listing the date, duration, and type of service,
			 the program staff involved, the ratio of staff to participants, and the work
			 accomplished; and
(H) copies of any
			 correspondence and reports of any consultations about the member's treatment
			 with the member's family or friends or other individuals not employed by the
			 program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.421 - Payment Limitations: Duration and Frequency

Current through Register 1525, July 5, 2024
(A)
Home Visit
.
			 Payment for a home visit is limited to two hours per visit. Payment will be
			 made for no more than two home visits on a single day.
(B)
Center-Based Individual
			 Visit
. Payment for a center-based individual visit is limited to
			 two hours per visit.
(C)
Child-Focused Group Session
. Payment for a
			 child-focused group session is limited to 2½ hours per
			 session.
(D)
Parent-Focused Group Session
. Payment for a
			 parent-focused group session is limited to two hours per session and one
			 session per week.
(E)
Services Provided on the Same Day
. The Division does
			 not pay for more than one visit or session with the same service code provided
			 to the same member on the same day with the exception of the home visit
			 limitation as noted in 130 CMR 440.421(A).
(F)
Evaluation/Assessment
. An evaluation must be conducted
			 upon the member's enrollment in the program and then annually to determine
			 continued eligibility. An assessment may be conducted periodically to determine
			 the child's strengths and needs. Payment is limited to ten working hours per
			 12-month period for evaluation/assessment.
(G)
Intake/Screening
. Payment for a screening is limited
			 to two working hours.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 440.000 - Early Intervention Program Services › Section 440.422 - Rates of Payment

Current through Register 1525, July 5, 2024
(A) The
			 Massachusetts Division of Health Care Finance and Policy determines the maximum
			 allowable fees for reimbursable services provided by early intervention
			 programs. Payment is subject to the conditions, exclusions, and limitations set
			 forth in the regulations in
			 130 CMR 440.000. Payment
			 for a service provided by an early intervention program is the lowest of the
			 following:
(1) the provider's usual and
			 customary fee; or
(2) the maximum
			 allowable fee listed in the fee schedule in Subchapter 6 of the
Early
			 Intervention Program Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 441.000 establishes the requirements for the provision
				and payment of chiropractor services under MassHealth. All chiropractors
				participating in MassHealth must comply with MassHealth regulations including,
				but not limited to, 130 CMR 441.000, and 130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in 130 CMR 441.000 have the meanings
				given in
				130 CMR 441.402
				unless the context clearly requires a different meaning. The reimbursability of
				services defined in
				130 CMR 441.402 is
				not determined by these definitions, but by application of 130 CMR 441.000, and
				130 CMR 450.000:
Administrative and Billing
				Regulations
.
Chiropractic Manipulative Treatment
-
				the correction of misalignments, subluxations, or segmental joint dysfunction
				of the bony articulations of the vertebral column, the pelvis, and adjacent
				areas.
Chiropractor
- one who is licensed to
				practice chiropractic manipulation to correct interference with spinal nerves
				by adjusting the spinal column.
Community Health Center (CHC)
- a
				participating community health center enrolled as a MassHealth CHC provider
				under 130 CMR 405.000:
Community Health Center Manual
.
Office Visit
- a visit by a MassHealth
				member to a chiropractor's office for evaluation and management services
				performed by a MassHealth-enrolled chiropractor, or to a community health
				center (CHC) for evaluation and management services performed by a qualified
				chiropractor employed by, or under contract with, a MassHealth-enrolled CHC.
				These services do not include chiropractic manipulative treatment.
Subluxation
- a segmental joint
				dysfunction, misalignment, fixation, or abnormal spacing of the
				vertebrae.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for chiropractor services only
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each coverage type,
			 which services are covered and which members are eligible to receive those
			 services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
The MassHealth agency pays only chiropractors who are
				participating in MassHealth on the date of service. Chiropractors must meet the
				following eligibility requirements.
(A)
In-state Providers
. To be eligible to participate in
			 MassHealth, an in-state chiropractor must
(1)
			 be licensed by the Massachusetts Board of Registration of
			 Chiropractors;
(2) be an active
			 MassHealth provider; and
(3)
			 participate in the Medicare program as a chiropractor.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.405 - Out-of-state Chiropractor Services

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays out-of-state chiropractors for covered services provided
			 to an eligible MassHealth member when the chiropractor practices in a community
			 of Connecticut, Maine, New Hampshire, New York, Rhode Island, or Vermont that
			 is within 50 miles of the Massachusetts border and he or she provides covered
			 services to a member who resides in a Massachusetts community near the border
			 of the chiropractor's state. The out-of-state chiropractor's office must be
			 more accessible to the member than the office of an in-state chiropractor who
			 participates in MassHealth.
(B)
			 Prior authorization is required from the MassHealth agency before a
			 chiropractor whose office is located in a community more than 50 miles from the
			 Massachusetts border may provide covered chiropractor services to a member.
			 Prior authorization will not be granted if the MassHealth agency determines
			 that the chiropractor's office is less accessible to the member than the office
			 of any other chiropractor participating in MassHealth. All requests for prior
			 authorization must be submitted in accordance with the instructions found in
			 Subchapter 5 of the
Chiropractor Manual
. The MassHealth agency
			 does not pay for covered services provided at a site more than 50 miles from
			 the Massachusetts border unless the chiropractor obtains prior authorization
			 from the MassHealth agency before the delivery of service. The MassHealth
			 agency does not grant retroactive requests for prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.406 - Payable Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays chiropractors (or the CHC in the
				case of chiropractor services provided on-site at the CHC by a CHC-employed or
				contracted chiropractor) only for the following services as specified in
				Subchapter 6 of the
Chiropractor Manual,
subject to the
				restrictions and limitations specified in 130 CMR 441.000 for chiropractic
				manipulative treatment, office visits, and radiology
				services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.407 - Service Limitations

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for medically necessary chiropractic treatment related to a
			 neuromusculoskeletal condition only. Services must have a direct therapeutic
			 relation to the patient's condition and must be provided by the chiropractor in
			 the chiropractor's office, or in the case of a MassHealth-enrolled CHC billing
			 for chiropractor services provided on-site by a CHC-employed or contracted
			 chiropractor, at the CHC. Conditions that may be considered to provide
			 therapeutic grounds for chiropractic treatment include functional disabilities
			 of the spine, nerve pains, and documented incidents that produce sprains and
			 strains of the spinal axis.
(B) The
			 MassHealth agency does not pay for both an office visit and chiropractic
			 manipulative treatment provided to a MassHealth member on the same day. This
			 limitation does not apply to a significant, separately identifiable office
			 visit provided by the same chiropractor on the same day of the procedure or
			 other service.
(C) The MassHealth
			 agency limits payment for chiropractor services to a total of 20 office visits
			 or chiropractic manipulative treatments, or any combination of office visits
			 and chiropractic manipulative treatments, up to a total of 20, per member per
			 calendar year, without prior authorization. Office visits and chiropractic
			 manipulative treatments above these limits require prior authorization in
			 accordance with 130 CMR 441.411. (
See
130 CMR
			 441.409 for limits on radiology
			 services.)
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.408 - Reporting Requirements

Current through Register 1525, July 5, 2024
Chiropractors who furnish services to MassHealth members must
				report the results of these services to the member's primary-care provider or
				PCC in writing. The chiropractor may report the results of treatment initially
				by telephone, but he or she must then submit a written
				report.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.409 - Radiology Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for radiology services when the services are needed to confirm the
			 existence of a neuromusculoskeletal condition requiring treatment.
(B) Payment for radiology services is not
			 included in the fees for office visits or chiropractic manipulative treatment
			 and must be claimed separately.
(C)
			 All equipment used in providing radiology services must be inspected and
			 approved by the Massachusetts Department of Public Health.
(D) The MassHealth agency pays chiropractors
			 for only those radiology services provided in the chiropractor's office and
			 only when the films are developed and read in the chiropractor's office;
			 provided, however, that in the case of a MassHealth CHC provider that bills for
			 chiropractor services provided on-site by a CHC-employed or contracted
			 chiropractor, the radiology services must be provided in, and the films must be
			 developed and read in, the CHC.
(E)
			 All X-rays must be labeled with the member's name, date of the exam, and the
			 nature of the exam and must be maintained in the member's medical record in
			 accordance with
			 130 CMR
			 441.412.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.410 - Nonpayable Services

Current through Register 1525, July 5, 2024
Nonpayable services include, but are not limited to, the
				following:
(A) the chiropractic
			 treatment of diseases and pathological disorders other than those related to a
			 neuromusculoskeletal condition (including, but not limited to, rheumatoid
			 arthritis, muscular dystrophy, multiple sclerosis, pneumonia, and
			 emphysema);
(B) chiropractic
			 manipulative treatment, office visits, and radiology services not personally
			 provided by the chiropractor, in accordance with
			 130 CMR 450.301:
Claims
;
(C)
			 chiropractor services provided in settings other than the chiropractor's
			 office, or in the case of a MassHealth CHC provider billing for chiropractor
			 services provided on-site by a CHC-employed or contracted chiropractor, at a
			 CHC. Nonpayable settings include, but are not limited to, inpatient or
			 outpatient hospitals, nursing facilities, rest homes, and the member's
			 home;
(D) laboratory
			 services;
(E) orthotic devices,
			 corrective devices, and orthopedic appliances;
(F) research, or experimental, unproven, or
			 medically unnecessary procedures or treatment;
(G) maintenance therapy, that is,
			 chiropractic manipulative treatment to maintain health or prevent regression
			 when the member is no longer suffering or presenting symptoms;
(H) supportive services such as, but not
			 limited to, nutritional counseling, educational services, and printed
			 materials;
(I) physiotherapy,
			 physical therapy, muscular stimulation, heat packs, or massage; and
(J) vitamins, minerals, food supplements, or
			 other such supplies.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.411 - Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Services that Require Prior Authorization
. The
			 MassHealth agency requires that the chiropractor obtain prior authorization as
			 a prerequisite to payment for more than 20 office visits or chiropractic
			 manipulative treatments, or any combination of office visits and chiropractic
			 manipulative treatments, above a total of 20, per member per calendar
			 year.
(B)
Submission
			 Requirement
. The chiropractor must submit all prior-authorization
			 requests in accordance with the billing instructions in Subchapter 5 of the
Chiropractor Manual
. Prior authorization determines only the
			 medical necessity of the authorized service, and does not establish or waive
			 any other prerequisites for payment such as member eligibility or resort to
			 health insurance payment.
See
130 CMR
			 450.303:
Prior Authorization
for additional information about prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.412 - Record-keeping Requirements

Current through Register 1525, July 5, 2024
(A) Federal and
			 state regulations require that all MassHealth providers maintain complete
			 written medical records of all patients who are MassHealth members. Medical
			 records must comply with the provisions of
			 233
			 CMR 4.04:
Insurance Requirements for
			 Limited Liability Companies and Limited Liability Partnerships
. All
			 records must be kept for a minimum of six years after the date of service.
			 Payment for maintaining the member's medical record is included in the fee for
			 chiropractic services. Each medical record must contain sufficient information
			 to document fully the nature, extent, quality, and necessity of the care
			 furnished to the member for each date of service claimed for payment. If the
			 documentation is not sufficient to justify the service for which payment is
			 claimed by the provider, the MassHealth agency will not pay for the service or,
			 if payment has been made, may consider such payment to be an overpayment
			 subject to recovery in accordance with 130 CMR 450.000:
Administrative
			 and Billing Regulations.
(B) The medical records must contain the
			 following:
(1) MassHealth member
			 identification, including name, address, telephone number, date of birth, and
			 the MassHealth member's identification number;
(2) a complete medical history;
(3) examination results, including a
			 description of the chief complaint and diagnosis;
(4) a written referral from the member's
			 primary-care provider or PCC;
(5)
			 copies of X-rays, with interpretations;
(6) copies of all prior-authorization
			 requests for out-of-state services;
(7) the date and nature of each visit,
			 including a complete description of services furnished, written and signed by
			 the chiropractor;
(8) when more
			 than one visit is indicated, a treatment plan for future visits written and
			 signed by the chiropractor, which is updated on an ongoing basis to reflect
			 changes in the member's presenting symptoms;
(9) upon completion of treatment, a summary
			 of the treatment and the member's current condition;
(10) recommendations for additional
			 treatment, signed and dated by the chiropractor; and
(11) if the medical record or any component
			 included therein is released for use by another party, the medical record must
			 also contain a release form signed by the member. Release of the medical record
			 to MassHealth for authorized use does not require the member's
			 consent.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.413 - Rates of Payment

Current through Register 1525, July 5, 2024
(A) The Executive
			 Office of Health and Human Services (EOHHS) determines the payment rates for
			 chiropractor services. Payment is subject to the conditions, exclusions, and
			 limitations set forth in 130 CMR 441.000. Payment for a service will be in
			 accordance with 101 CMR 317.00:
Medicine
, or 101 CMR 318.00:
Radiology
.
(B) The
			 payment rates established for chiropractor services include payment for all
			 aspects of service delivery including administrative costs. Providers may not
			 bill separately for services such as, but not limited to the following:
(1) telephone contacts;
(2) information and referral services;
			 and
(3) recordkeeping.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 441.000 - Chiropractor Services › Section 441.420 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				chiropractor services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnosis and Treatment (EPSDT) Services: Introduction
,
				without regard to service limitations described in 130 CMR 441.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				442.000 states the requirements and procedures for the
				purchase and repair of orthotics covered under MassHealth. All providers of
				orthotics participating in MassHealth must comply with MassHealth regulations
				including, but not limited to, regulations set forth in
				130 CMR
				442.000, and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
and
				101 CMR
				334.00:
Prostheses, Prosthetic Devices and
				Orthotic Devices
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. The MassHealth agency covers
			 orthotics provided to eligible MassHealth members, subject to the restrictions
			 and limitations described in
			 130 CMR
			 442.000 and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
			 130
			 CMR 450.105:
Coverage Types
,
			 specifically states, for each coverage type, which services are covered and
			 which members are eligible to receive those services.
(B)
Recipients of the Emergency
			 Aid to the Elderly, Disabled and Children Program
. For information
			 on covered services for recipients of the Emergency Aid to the Elderly,
			 Disabled and Children Program,
see
130
			 CMR 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
(C) For information on verifying MassHealth
			 member eligibility and coverage type,
see
130
			 CMR 450.107:
Eligible Members and the
			 MassHealth Card
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
Provider Participation Requirements
. Payment for
			 services described in
			 130 CMR
			 442.000 is made to orthotics providers who, as of the
			 date of service, are participating in MassHealth as an orthotics provider; to
			 providers also enrolled as MassHealth participating DME providers; OXY
			 providers, or prosthetic services providers and who meet all program-specific
			 requirements. Applicants must meet the requirements in
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
as well as the requirements in
			 130 CMR
			 442.000. Participating orthotics providers must
			 continue to meet provider eligibility participation requirements throughout the
			 period of their provider contract with the MassHealth agency.
(B)
General
			 Qualifications
. To qualify as a MassHealth orthotics provider, all
			 applicants and providers must enter into a provider contract or agreement with
			 MassHealth and
(1) have a service facility
			 that:
(a) is open a minimum of 30 hours per
			 week;
(b) is staffed with an
			 employee during posted business hours;
(c) is available to members during regular,
			 posted business hours;
(d) is
			 physically accessible to members with disabilities, and complies with all ADA
			 guidelines;
(e) has clear access
			 and space for individualized ordering, returns, repair, and storing of business
			 records;
(f) has the space and
			 capability for evaluating/assessing, repairing, modifying, adjusting and
			 customizing products to meet members' needs;
(g) the provider must demonstrate that they
			 can fill orders, fabricate, or fit items from its own inventory or by direct
			 purchase of items necessary to fill the order.
(h) has a sign visible from outside the
			 service facility identifying the business name and hours that the service
			 facility is open. If the provider's place of business is located within a
			 building complex, the sign must be visible with the business name both at the
			 main entrance of the building and the location where the service facility is
			 located. The hours must be posted within the business complex where the service
			 facility is located;
(i) has a
			 primary business telephone number listed in the name of the business with a
			 local toll-free telephone number that is answered by customer service staff
			 during business hours, and that has TTY transmission and reception capability.
			 During business hours, this number cannot be a pager, answering service, voice
			 message system, or cell phone; and
(j) maintains a 24-hour voice message system
			 and/or answering service.