reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 129 CMR - HEALTH CARE QUALITY AND COST COUNCIL › Title 129 CMR 3.00 - Disclosure Of Health Care Claims Data › Section 3.05 - Other Provisions

Current through Register 1525, July 5, 2024
(1) Nothing in 129 CMR 3.00 shall be construed to limit the Council from releasing information through the website as contemplated in M.G.L. c. 6A, § 16k.
(2) Nothing in 129 CMR 3.00 shall be construed to limit the Council from disclosing health care claims data to a Provider as permitted by M.G.L. 6A, § 16k and 129 CMR 4.00.
(3) The Council shall not release data sets that are materially incomplete or that failed to meet data quality standards delineated in the Statistical Plan established pursuant to 129 CMR 2.08.
(4) The Council shall charge a non-refundable fee, as approved by the Executive Office for Administration and Finance, to all applicants for data released by the Council that is not otherwise posted on the Council's website for public use. The chairperson of the Councilor designated Council staff may waive the fee only if the applicant can demonstrate that imposition of a fee would constitute a hardship.
(5) Sanctions. The Councilor the Board may impose the following sanctions if an approved applicant fails to comply with any of the data restrictions, prohibitions, protections and conditions specified in the Data Use Agreement:
(a) deny access to any and all data in the future;
(b) terminate current access to data; and
(c) demand and secure the return of all data.
Such applicants may also be subject to applicable statutory sanctions.
Code of Massachusetts Regulations › 129 CMR - HEALTH CARE QUALITY AND COST COUNCIL › Title 129 CMR 3.00 - Disclosure Of Health Care Claims Data › Section 3.06 - Severability

Current through Register 1525, July 5, 2024
The provisions of 129 CMR 3.00 are severable and if any such provisions or the application of such provisions to any applicant or circumstances are held invalid or unconstitutional, such invalidity or unconstitutionality shall not be construed to affect the validity or unconstitutionality of any of the remaining provisions of 129 CMR 3.00 or of such provisions to an applicant or circumstances other than those as to which it is held invalid.
Code of Massachusetts Regulations › 129 CMR - HEALTH CARE QUALITY AND COST COUNCIL › Title 129 CMR 4.00 - Disclosure Of Health Care Claims Data To A Provider › Section 4.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Authority
. 129 CMR 4.00 is promulgated under the authority of and in conformity with M.G.L. c. 6A, §§ 16J, 16K and 16L.
(2)
Scope and Purpose
. 129 CMR 4.00 governs the disclosure to providers of Health Care Claims Data submitted by Carriers to the Health Care Quality and Cost Council. The purpose of 129 CMR 4.00 is to provide for disclosure of a particular provider's claims data to that provider for the purpose of verifying the accuracy of the provider's data.
(3)
Effective Date
. 129 CMR 4.00 is effective on May 23, 2008.
Code of Massachusetts Regulations › 129 CMR - HEALTH CARE QUALITY AND COST COUNCIL › Title 129 CMR 4.00 - Disclosure Of Health Care Claims Data To A Provider › Section 4.02 - Definitions

Current through Register 1525, July 5, 2024
The following words shall have the following meanings:
Carrier
. Any entity subject to the insurance laws and rules of Massachusetts, or subject to the jurisdiction of the commissioner of insurance, that contracts or offers to provide, deliver, arrange for, pay for, or reimburse any of the costs of health services, including an insurance company, a health maintenance organization, a nonprofit hospital services corporation, a medical service corporation, third-party administrator or any other entity arranging for or providing insured health coverage.
Council
. The Health Care Quality and Cost Council established under M.G.L. c. 6A, § 16K.
Disclosure
. The release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information.
Health Care Claims Data
. Information consisting of, or derived directly from, member eligibility information, medical claims, pharmacy claims, and all other data submitted by health care claims processors pursuant to 129 CMR 2.00.
Provider
. A health care practitioner, health care facility, health care group, medical product vendor or pharmacy.
Code of Massachusetts Regulations › 129 CMR - HEALTH CARE QUALITY AND COST COUNCIL › Title 129 CMR 4.00 - Disclosure Of Health Care Claims Data To A Provider › Section 4.03 - Data Disclosure Procedures

Current through Register 1525, July 5, 2024
(1) The Council may disclose to a Provider some or all of a Carrier's Health Care Claims Data that the Carrier received from that particular provider and submitted to the Council pursuant to M.G.L. c. 6A, § 16L(d) and 129 CMR 2.00. The Provider may submit, in writing and within a time period specified by the Council, comments to the Council regarding the Health Care Claims Data. The Council shall consider any such timely submitted comments prior to publication of data on the Council's website.
(2) The Provider shall maintain the confidentiality of the Health Care Claims Data it receives from the Council. The provider shall not disclose the Health Care Claims Data except to the Council or as otherwise provided by applicable state or federal law.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 401.000 contains
				regulations governing independent clinical laboratory services under Mass
				Health. All independent clinical laboratories participating in Mass Health must
				comply with the regulations governing Mass Health, including, but not limited
				to,
				130 CMR 401.000 and
				450.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
Mass Health
			 Members
. The Mass Health agency covers independent clinical
			 laboratory services only when provided to eligible Mass Health members, subject
			 to the restrictions and limitations described in Mass Health regulations. Mass
			 Health regulations at
			 130 CMR 450.105
			 specifically state, for each Mass Health 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.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
An independent clinical laboratory must be enrolled in Mass
				Health on the date of service in order to be eligible for payment.
(A)
In-state
			 Providers
. To be eligible to enroll as a Mass Health provider, an
			 independent clinical laboratory must be
(1)
			 located and doing business in the Commonwealth of Massachusetts;
(2) certified as an independent clinical
			 laboratory by the Centers for Medicare & Medicaid (CMS), based on the
			 criteria set forth in the Clinical Laboratory Improvement Amendments (CLIA) of
			 1988; and
(3) licensed as a
			 clinical laboratory by the Massachusetts Department of Public Health.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.405 - Laboratory Services Provided Outside of Massachusetts

Current through Register 1525, July 5, 2024
When provided out of state, independent clinical laboratory
				services are reimbursable only if
(A)
			 the member is temporarily out of state and requires clinical laboratory
			 services under the circumstances described in
			 130 CMR
			 450.109;
(B) the MassHealth agency determines that the
			 independent clinical laboratory services required by the member are not
			 available from any laboratory in Massachusetts; or
(C) the out-of-state independent clinical
			 laboratory is a subsidiary-related entity of an in-state independent clinical
			 laboratory that is enrolled in MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.410 - Covered Services

Current through Register 1525, July 5, 2024
MassHealth covers independent clinical laboratory services that
				are medically necessary for the diagnosis, treatment, and prevention of
				disease, and for the maintenance of the health of MassHealth members, subject
				to all restrictions and limitations described in
				130 CMR 401.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.411 - Noncovered Services and Payment Limitations

Current through Register 1525, July 5, 2024
(A) The MassHealth agency does not pay
			 separately for routine specimen collection and preparation for the purpose of
			 clinical laboratory analysis (for example, venipunctures; urine, fecal, and
			 sputum samples; Pap smears; cultures; and swabbing and scraping for removal of
			 tissue). The cost for such services is included in the payment for conducting
			 the test and analysis.
(B) The
			 MassHealth agency does not pay for the following services:
(1) laboratory tests associated with male or
			 female infertility, unless those tests are for diagnostic purposes;
(2) calculations (for example, red cell
			 indices, A/G ratio, creatinine clearance), and ratios calculated as part of a
			 profile;
(3) tests performed for
			 experimental or clinical investigational purposes (
e.g
., to
			 establish safety and effectiveness), or that are themselves experimental or
			 clinically investigational;
(4)
			 tests performed only for purposes of civil, criminal, administrative, or social
			 service agency investigations, proceedings, or monitoring activities;
(5) tests performed for residential
			 monitoring purposes;
(6) tests
			 performed to establish paternity;
(7) post-mortem examinations;
(8) tests where the request is not in
			 accordance with
			 130 CMR
			 401.416;
(9) tests that are not medically necessary as
			 defined in
			 130 CMR
			 450.204:
Medical Necessity
;
			 and
(10) any other tests or
			 activities performed for any purpose other than those described in
			 130 CMR
			 401.410.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.412 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				laboratory 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 401.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.415 - Specimen Referral

Current through Register 1525, July 5, 2024
(A) If an
			 independent clinical laboratory cannot perform a requested test, it may refer
			 the specimen to another laboratory that can perform the test. The testing
			 laboratory must be an independent clinical laboratory or a hospital laboratory
			 participating in MassHealth.
(B)
			 When providing the test results, the referring laboratory must inform the
			 authorized prescriber of the name and address of the testing
			 laboratory.
(C) The testing
			 laboratory must inform the referring laboratory of each test result within one
			 business day of completing each test.
(D) The referring laboratory may not bill the
			 MassHealth agency for tests performed by the testing laboratory.
(E) Under no circumstances may both the
			 referring and testing laboratories bill for the same procedure performed on the
			 same specimen.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.416 - Request for Laboratory Services

Current through Register 1525, July 5, 2024
(A)
Request Requirements
. The independent clinical
			 laboratory may not bill for a service unless it has received a written request
			 to perform that specific service from an authorized prescriber who is treating
			 the member and will use the test for the purpose of diagnosis, treatment, or an
			 otherwise medically necessary reason as defined in
			 130 CMR
			 450.204. Any independent clinical laboratory
			 billing for a service must maintain such request in its records, and make such
			 records available to the MassHealth agency and the Attorney General's Medicaid
			 Fraud Division upon request. If the laboratory that billed for the service
			 cannot produce the original request, the MassHealth agency may deny or recover
			 payment for all services the laboratory provided based on that
			 request.
(B)
Standing
			 Orders
. An authorized prescriber may request an independent
			 clinical laboratory to perform one or more tests on a single date, or issue a
			 standing order for such tests. Standing order requests may not exceed 180 days
			 in length with the exception of standing order requests for substance abuse
			 testing, which may not exceed 30 days in length. Standing order requests are
			 not permissible unless such repeated tests are medically necessary and required
			 as part of the member's medical or drug treatment plan.
(C)
Required
			 Information
. Requests for laboratory services must be written and
			 include the following information:
(1) the
			 date of the request;
(2) the name
			 or any other means of identifying the member to be tested;
(3) the name and address of the authorized
			 prescriber (if the authorized prescriber is a Massachusetts Department of
			 Public Health licensed substance abuse treatment program for the sole purpose
			 allowed pursuant to
			 130 CMR 401.402, the
			 request must include the names and addresses of both the substance abuse
			 treatment program and the physician initiating the request);
(4) the name of the specific laboratory tests
			 to be performed;
(5) the frequency
			 for performing each laboratory test (applicable to standing orders
			 only);
(6) the duration and maximum
			 number of times each laboratory test or tests are to be performed (applicable
			 to standing orders only); and
(7) a
			 statement by the authorized prescriber that such testing is required as part of
			 the member's medical or drug treatment plan (applicable to standing orders
			 only).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.417 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
Both referring and testing laboratories must keep a record of
				each written request for laboratory services, each specimen, and each test
				result for at least six years from the date on which the results were reported
				to the authorized prescriber. If the testing laboratory is a subsidiary-related
				entity of the referring laboratory, such records may be maintained at one
				location, but must be made available to the MassHealth agency and the Attorney
				General's Medicaid Fraud Division upon request, in accordance with
				130 CMR
				450.205. If an independent clinical
				laboratory cannot produce the record to substantiate a MassHealth claim, the
				MassHealth agency may deny or recover payment for that claim. The laboratory
				record must contain the following information:
(A) The written request for laboratory
			 services with all information required by
			 130 CMR
			 401.416;
(B) the identification number of the
			 specimen;
(C) the name or any other
			 means of identifying the person from whom the specimen was taken;
(D) the name of the authorized prescriber
			 and, if applicable, the referring laboratory that submitted the
			 specimen;
(E) the date on which the
			 specimen was collected by the authorized prescriber or laboratory, the location
			 of the collection, and the name of the collector;
(F) the date on which the specimen was
			 received in the laboratory;
(G) the
			 condition of unsatisfactory specimens when received (for example, broken,
			 leaked, hemolyzed, or turbid);
(H)
			 the specific tests performed;
(I)
			 the date or dates on which each test was performed;
(J) the results of each test, the name and
			 address of all persons to whom each test result is reported, and the date of
			 reporting; and
(K) the name and
			 address of the laboratory to which the specimen was referred, if
			 applicable.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.418 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
(A) The Division
			 of Health Care Finance and Policy (DHCFP) determines the maximum allowable fees
			 for independent clinical laboratory services. The maximum allowable payment for
			 a service is the lowest of the following:
(1)
			 the amount listed in the applicable DHCFP fee schedule;
(2) the independent clinical laboratory's
			 usual and customary fee; or
(3) the
			 amount that would be recognized under 42 U.S.C. § 13951(h) for tests
			 performed for a person with Medicare Part B benefits.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.419 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) Some tests
			 listed in Subchapter 6 of the
Independent Clinical Laboratory
			 Manual
are designated "I.C.," an abbreviation for individual
			 consideration. A fee has not been established for these services. Payment for
			 an individual-consideration service is determined by the MassHealth agency's
			 professional advisers, based on the laboratory's description of the test, which
			 must be included with the claim.
(B) If a test is not listed in Subchapter 6
			 of the
Independent Clinical Laboratory Manual
, an independent
			 clinical laboratory may submit a claim by using the appropriate "unlisted test"
			 service code. Payment for an unlisted test is determined by individual
			 consideration, based on the laboratory's description of the test, which must be
			 included with the claim.
(C) The
			 MassHealth agency considers the following factors when determining the
			 appropriate payment for an individual-consideration service:
(1) the amount of time required to perform
			 the service;
(2) the degree of
			 skill required to perform the service;
(3) policies, procedures, and practices of
			 other third-party payers;
(4)
			 prevailing medical-laboratory ethics and accepted custom of the
			 medical-laboratory community; and
(5) other standards and criteria as may be
			 adopted by DHCFP.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.420 - Panel Tests

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay an independent clinical
				laboratory separately for a test included in a panel test when a panel test has
				been performed by that laboratory or requested by an authorized
				prescriber.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 401.000 - Independent Clinical Laboratory Services › Section 401.421 - Quality Assurance and Provider Review

Current through Register 1525, July 5, 2024
The MassHealth agency conducts reviews of providers and
				administers quality-control programs to ensure that MassHealth members are
				receiving high-quality medical services. An independent clinical laboratory
				must maintain its own quality-control program and successfully participate in
				one or more proficiency testing programs that cover all Medicare-certified
				specialties and subspecialties of the laboratory. The laboratory must make the
				results of the proficiency testing programs available to the MassHealth agency
				and the Attorney General's Medical Fraud Division upon request or during an
				on-site visit.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.401 - Introduction

Current through Register 1525, July 5, 2024
(A)
								130 CMR
			 402.000 states the requirements and procedures for
			 vision care services under MassHealth. Professional and technical services must
			 be provided in accordance with the established standards of quality and
			 health-care necessity recognized by the vision care industry and licensing
			 agencies in Massachusetts.
(B) All
			 vision care providers participating in MassHealth must comply with MassHealth
			 regulations, including but not limited to
			 130 CMR
			 402.000 and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				402.000 have the meanings given in
				130
				CMR 402.402 unless the context clearly
				requires a different meaning. The reimbursability of services defined in
				130
				CMR 402.402 is not determined by these
				definitions, but by the application of regulations elsewhere in
				130 CMR
				402.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Date of Service
- the date of service
				for dispensing vision care materials is the date on which the vision care
				materials are delivered to the member. The date of service for fitting vision
				care materials is the date that the order for materials was placed. The date of
				service for all other vision care services is the date on which the service is
				provided to the member.
Dispensing Practitioner
- any licensed
				optician, licensed optometrist, licensed ophthalmologist, or other licensed
				participating provider authorized by the MassHealth agency to dispense eyeglass
				frames, lenses, and other ophthalmic materials to members.
Optical Supplier
- the optical
				laboratory contracted by the MassHealth agency to supply the following
				ophthalmic materials and services:
(1)
			 eyeglass frames;
(2) eyeglass
			 lenses;
(3) frame cases;
(4) tints, coatings, ground-on prisms, and
			 prisms by decentration; and
(5)
			 repair or replacement parts.
Order
- the process by which a
				dispensing practitioner requests ophthalmic materials (completed eyeglasses,
				repair parts, and other services) from the optical supplier.
Prescriber
- any optometrist,
				ophthalmologist, or other practitioner licensed and authorized to write
				prescriptions for eyeglass frames, lenses, and other vision care
				services.
Vision Care Provider
- a health care
				practitioner or facility licensed to perform and provide appropriate vision
				care services in compliance with
				130 CMR
				402.000 and
				450.000:
Administrative and Billing Regulations
.
Vision Care Services
- the
				professional care of the eyes to examine, diagnose, treat, and manage diseases
				and disorders of the visual system, the eye, and associated structures. These
				services include eye examinations, vision training, managing and treating
				complex eye and vision problems, and the prescription and dispensing of
				ophthalmic materials.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for vision care 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 MassHealth 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 402.000 - Vision Care Services › Section 402.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for services described in
				130 CMR
				402.000 will be made only to providers of vision care
				services who are participating in MassHealth on the date of service. The
				eligibility requirements for providers of vision care services are as
				follows.
(A)
In
			 State
.
(1)
Optometrists
. A Massachusetts optometrist is eligible
			 to participate in MassHealth only if licensed to practice by the Massachusetts
			 Board of Registration in Optometry.
(a) A
			 Level I optometrist is one who is not qualified to apply topical
			 agents.
(b) A Level II optometrist
			 is one who has obtained a Certificate of Qualification for the Use of
			 Diagnostic Pharmaceutical Agents (DPAs) from the Board of Registration in
			 Optometry.
(c) A Level III
			 optometrist is one who has obtained a Certificate of Qualification for the Use
			 of Therapeutic Pharmaceutical Agents (TPAs) from the Board of Registration in
			 Optometry.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.405 - Nonreimbursable Circumstances

Current through Register 1525, July 5, 2024
With the exception of the dispensing of ophthalmic materials,
				vision care services are not reimbursable to a vision care provider under
				130 CMR
				402.000 when the services are furnished in a state
				institution, in an acute inpatient hospital setting, or when the services are
				among those for which the provider is otherwise compensated by the state or
				institution.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.406 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The Executive Office of Health and Human Services (EOHHS)
				determines the maximum allowable fees for all vision care services and
				ophthalmic materials, except for those ophthalmic materials purchased through
				the optical supplier where the basis for the rates is set by the terms of the
				contract. Payment is always subject to the conditions, exclusions, and
				limitations set forth in
				130 CMR
				402.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
. Payment for vision care services and ophthalmic materials
				will be made pursuant to
				101 CMR
				315.00:
Rates for Vision Care Services and
				Ophthalmic Materials
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.407 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) MassHealth has
			 designated certain services in Subchapter 6 of the
Vision Care
			 Manual
as requiring individual consideration. This means that the
			 MassHealth agency will establish the appropriate rate for these services based
			 on the standards and criteria set forth in
			 130
			 CMR 402.407(B). Providers
			 claiming payment for any service requiring individual consideration must submit
			 with such claim a report that includes a detailed description of the service,
			 and is accompanied by supporting documentation that may include, but is not
			 limited to, a descriptive report, or in the case of a purchase, a copy of the
			 supplier's invoice. The MassHealth agency does not pay claims for services
			 requiring individual consideration unless it is satisfied that the report and
			 documentation submitted by the provider are adequate to support the
			 claim.
(B) The MassHealth agency
			 determines the appropriate payment for a service requiring individual
			 consideration in accordance with the following standards and criteria:
(1) the amount of time required to perform
			 the service;
(2) the degree of
			 skill required to perform the service;
(3) the severity and complexity of the
			 member's disease, disorder, or disability;
(4) any applicable relative-value
			 studies;
(5) any complications or
			 other circumstances that the MassHealth agency deems relevant;
(6) the policies, procedures, and practices
			 of other third-party insurers; and
(7) for ophthalmic materials or supplies, a
			 copy of the invoice from the supplier showing the actual acquisition
			 cost.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.408 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) For certain
			 services specified in
			 130
			 CMR 402.426 through
			 402.434, the MassHealth
			 agency requires that the provider of the service obtain prior authorization as
			 a prerequisite to payment. In addition, services that are designated in
			 Subchapter 6 of the
Vision Care Manual
with the abbreviation
			 "P.A." require prior authorization. These services include but are not limited
			 to the following:
(1) certain contact
			 lenses;
(2) low-vision
			 aids;
(3) unlisted
			 services;
(4) high-index
			 lenses;
(5) special-needs
			 glasses;
(6) polycarbonate lenses
			 for members 21 years of age or older, except for members who are amblyopic or
			 monocular; and
(7) vision
			 training.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.409 - Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary vision
				care services for EPSDT eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnostic and Treatment (EPSDT) Services: Introduction
,
				without regard to service limitations described in
				130 CMR
				402.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.417 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) A vision care
			 provider must maintain a suitable medical record for each member for a period
			 of as long as the minimum period required by
			 130
			 CMR 450.205(G). The record
			 must fully disclose all pertinent information about the services furnished,
			 including the date of service, the dates on which materials were ordered and
			 dispensed, and a description of materials ordered and dispensed (including the
			 frame style and the manufacturer's name). All findings resulting from vision
			 care services, whether they are normal or abnormal, must be recorded. When
			 extenuating circumstances prevent the use of one or more procedures normally
			 performed in vision care services, the record must contain the reasons that the
			 tests were not performed.
(B) For
			 comprehensive vision care examinations and diagnoses performed in the office, a
			 nursing facility, a hospital, or the member's home, the record must contain the
			 following information or test results:
(1)
			 case history;
(2) visual acuity
			 testing;
(3) ophthalmoscopy and
			 external eye health examination;
(4) ocular mobility testing, heterophoria
			 testing, and fusion testing;
(5)
			 pupillary reflex testing;
(6)
			 refraction (objective, subjective refraction, and keratometry);
(7) confrontation fields or other screening
			 tests;
(8) tonometry;
(9) case analysis and disposition;
			 and
(10)
			 biomicroscopy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.418 - Services Provided outside the Office

Current through Register 1525, July 5, 2024
(A)
Member's Home
. The MassHealth agency pays for vision
			 care services provided to a member in the member's home. A health-care record
			 must be kept on file at the provider's office.
(B)
Nursing
			 Facility
. The MassHealth agency pays for vision care services for
			 a member residing in a nursing facility only when the service is specifically
			 requested by the medical director, the nursing director, or responsible staff
			 member at the facility, or by the member's personal physician. The request must
			 be documented in the member's record at the facility. If eyeglasses or other
			 visual aids are to be dispensed to a member in the facility, the facility must
			 document in the member's record that a consultation has occurred between the
			 facility's staff member and the vision care provider, and that they have
			 determined that the member is able to benefit from eyeglasses or other visual
			 aids. A copy of the eye-examination results, including the prescription, must
			 be filed in the member's record at the facility and at the vision care
			 provider's primary office location.
(C)
Other
			 Facilities
. The MassHealth agency pays for vision care services
			 provided to a member residing in a public or private facility, if payment for
			 these services is not included in the facility's rate. A medical record must be
			 kept on file at the provider's office.
(D)
Other Locations of
			 Service
. The MassHealth agency pays for vision-care services
			 provided to eligible members at other places of service as approved by the
			 MassHealth agency.
(E)
Claims for Payment
.
(1) A vision care examination performed for a
			 member outside of the office must be claimed using the appropriate service
			 codes. (
See
Subchapter 6 of the
Vision Care
			 Manual
.)
(2) The
			 MassHealth agency pays separately for transportation once per member per date
			 of service for each member for whom the provider delivered or picked up
			 eyeglasses, or to whom vision care services were provided out of the office in
			 accordance with
			 130
			 CMR 402.418(A) through
			 (D).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.426 - Service Limitations: Eye Examinations

Current through Register 1525, July 5, 2024
(A)
(1) The MassHealth agency does not pay for a
			 comprehensive eye examination in an optometrist's office or a visual analysis
			 in a home or nursing facility if a comprehensive eye examination or a visual
			 analysis has been furnished:
(a) within the
			 preceding 12 months, for a member younger than 21 years old; or
(b) within the preceding 24 months, for a
			 member 21 years of age or older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.427 - Service Limitations: Dispensing Eyeglasses

Current through Register 1525, July 5, 2024
(A) The MassHealth agency pays for only one
			 initial pair of eyeglasses and only if there is a corrective power of at least
			 ± .75D sphere or ±.50D cylinder. (
See
130
			 CMR 402.431 for an exception which permits
			 two pairs of eyeglasses instead of bifocals and
			 130
			 CMR 402.434 regarding spare
			 eyeglasses.)
(B) The MassHealth
			 agency pays for new eyeglasses for a member younger than 21 years old every 12
			 months and for a member 21 years of age or older every 24 months with a
			 prescription that meets the standards set at
			 130
			 CMR 402.427(A).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.428 - Service Limitations: Replacement Eyeglasses

Current through Register 1525, July 5, 2024
(A)
Broken
			 Eyeglasses
. The MassHealth agency pays for the repair of broken
			 eyeglasses, including the replacement of broken parts, subject to the following
			 limitations.
(1) If a broken frame can be
			 repaired and replacement parts are available from the optical supplier, the
			 MassHealth agency pays for repair rather than replacement. If replacement parts
			 are not available from the optical supplier, the MassHealth agency pays for an
			 entire replacement frame.
(2)
			 Except for members younger than 21 years old, the MassHealth agency does not
			 pay without prior authorization for the replacement of broken frames and lenses
			 if a repair of either broken frames or lenses was furnished within the
			 preceding 24 months.
(3) Dispensing
			 practitioners must order replacement eyeglass frames, lenses, and repair parts
			 from the optical supplier. Dispensing practitioners must use the order form to
			 obtain replacement parts.
(4)
			 Payment for dispensing replacement lenses may be claimed under the appropriate
			 service code (
see
Subchapter 6 of the
Vision Care
			 Manual
) where applicable for the lens being dispensed, but only if
			 each broken lens meets the minimum power criteria for an initial pair of
			 eyeglasses as described in
			 130
			 CMR
			 402.427(A).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.429 - Service Limitations: Tinted Lenses

Current through Register 1525, July 5, 2024
(A)
			 The MassHealth agency pays for "pink l" and "pink 2" colored lenses, up to 25%
			 absorption or equal-density tint, if at least one of the following conditions
			 applies:
(1) the member has a pathological or
			 other abnormal condition such as aphakia; or
(2) the member has habitually worn tinted
			 lenses of this nature, and the prescriber concludes that the member should
			 continue to wear them. The MassHealth agency does not pay for tinted lenses
			 prescribed only because the member complains of photophobia.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.431 - Service Limitations: Two Pairs of Eyeglasses Instead of Bifocals

Current through Register 1525, July 5, 2024
The MassHealth agency pays for two pairs of eyeglasses instead
				of bifocals if one or more of the following conditions exists. Any condition
				listed below that warrants the use of two pairs of eyeglasses instead of
				bifocals must be fully documented in the member's medical record.
(A) The member's prescription cannot
			 satisfactorily be made into bifocal lenses.
(B) The member has shown an inability to
			 adjust to bifocals.
(C) The member
			 has a physical disability or medical condition (for example, severe arthritis)
			 that would preclude or impede adjustment to bifocals.
(D) The member's advanced age would make
			 adjustment to bifocals unduly difficult.
(E) The member's occupation would make
			 bifocals hazardous.
(F) The member
			 has a marked facial asymmetry.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.433 - Service Limitations: Contact Lenses

Current through Register 1525, July 5, 2024
(A)
			 The MassHealth agency pays for hard, soft, or gas-permeable contact lenses if
			 one or more of the following conditions exists:
(1) postoperative cataract
			 extraction;
(2)
			 keratoconus;
(3) anisometropia of
			 more than 3.00D; or
(4) more than
			 7.00D of myopia or hyperopia.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.434 - Service Limitations: Extra or Spare Eyeglasses

Current through Register 1525, July 5, 2024
The MassHealth agency pays for an extra or spare pair of
				eyeglasses on a prior-authorization basis only. Any condition that warrants the
				use of an extra or spare pair of eyeglasses must be fully documented in the
				member's medical record. The MassHealth agency grants a prior authorization
				request for extra or spare eyeglasses only if one or more of the following
				conditions exists:
(A)
			 aphakia;
(B) more than 7.00D of
			 myopia or hyperopia; or
(C) more
			 than 3.00D of astigma.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 402.000 - Vision Care Services › Section 402.435 - Service Exclusions

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency does not pay for any of the following services or materials:
(1) absorptive lenses of greater than 25%
			 absorption;
(2) prisms obtained by
			 decentration;
(3) non-medical
			 interventions;
(4) routine
			 adjustments or follow-up visits to check visual acuity and ocular comfort
			 (payment for such visits is included in the dispensing fee for six months after
			 the date on which the eyeglasses were dispensed);
(5) contact lenses for extended-wear
			 use;
(6) invisible bifocals/no line
			 progressive lenses; and
(7)
			 substitutions.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.401 - Introduction

Current through Register 1525, July 5, 2024
All home health agencies participating in MassHealth must
				comply with MassHealth regulations including, but not limited to,
				130 CMR
				403.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
. Home health agencies
				that provide Continuous Skilled Nursing (CSN) services must also comply with
				130 CMR 438.000:
Continuous Skilled Nursing
				Agency
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.404 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. MassHealth pays for home health
			 services for eligible members, subject to the restrictions and limitations
			 described in
			 130
			 CMR 450.105:
Coverage Types
which specifically states, for each MassHealth 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 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 403.000 - Home Health Agency › Section 403.405 - Provider Eligibility: In-state

Current through Register 1525, July 5, 2024
To participate in MassHealth, a Massachusetts home health
				agency must
(A) be certified as a
			 provider of home health services under the Medicare program by the
			 Massachusetts Department of Public Health and meet all requirements within the
			 Medicare Conditions of Participation for home health agency services;
(B) obtain a MassHealth provider number
			 before providing home health services;
(C) agree to periodic inspections, by the
			 MassHealth agency or its designee, that assess the quality of member care and
			 ensure compliance with
			 130 CMR
			 403.000;
(D) participate in any Home Health Agency
			 provider orientation required by the Executive Office of Health and Human
			 Services (EOHHS);
(E) submit to the
			 MassHealth agency or its designee a statement of fiscal soundness attesting to
			 the financial viability of the home health agency provider supported by
			 documentation to demonstrate that the provider has adequate resources to
			 finance the provision of services in accordance with
			 130 CMR
			 403.000 and as specified in
			 130 CMR
			 403.419(D)(1);
(F) notify the MassHealth agency in writing
			 within 14 days of any change in any of the information submitted in the
			 provider application in accordance with
			 130 CMR
			 450.223(B):
Provider
			 Contract: Execution of Contract
including, but not limited to, change
			 of ownership, change of address, change in status of Medicare Certification
			 and/or reaccreditation, and additional home health agency branch
			 office;
(G) accept MassHealth
			 payments as payment in full for all home health services;
(H) agree to comply with all the provisions
			 of
			 130 CMR
			 403.000 and
			 450.000:
Administrative and Billing Regulations
, and all other
			 applicable MassHealth rules and regulations; and
(I) meet all provider participation
			 requirements described in
			 130 CMR
			 403.000 and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.406 - Provider Eligibility: Out of State

Current through Register 1525, July 5, 2024
(A)
			 To participate in MassHealth, an out-of-state home health agency located within
			 50 miles of the Massachusetts border must
(1)
			 ensure that the agency and each participating branch is certified as a provider
			 of home health services under the Medicare program;
(2) participate in the Medicaid program in
			 its state and meet all requirements within the Medicare Conditions of
			 Participation for home health agency services;
(3) provide home health services to a member
			 who resides in a Massachusetts community near the border of the home health
			 agency's state;
(4) obtain a
			 MassHealth provider number before providing home health services; and
(5) notify the MassHealth agency in writing
			 within 14 days of any change in any of the information submitted in the
			 provider application in accordance with
			 130 CMR
			 450.223(B):
Provider
			 Contract: Execution of Contract
including, but not limited to, change
			 of ownership, change of address, change in status of Medicare Certification
			 and/or reaccreditation, and additional home health agency branch
			 office.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.407 - Services Provided under Contract

Current through Register 1525, July 5, 2024
(A)
Introduction
. A home health agency may provide home
			 health services directly or through contractual arrangements made by the home
			 health agency. Whether the services are provided directly or through contracts,
			 the home health agency is responsible for submitting claims for services and
			 for meeting the requirements in
			 130 CMR
			 403.000 and all other applicable state and federal
			 requirements. A home health agency may provide services through contracts in
			 the following situations:
(1) when a home
			 health agency, in order to be approved to participate in MassHealth, makes
			 arrangements with another agency or organization to provide the nursing, home
			 health aide, or other therapeutic services that it does not provide directly;
			 or
(2) when a home health agency
			 that is already approved for participation in MassHealth makes arrangements
			 with others to provide services it does not provide.