reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.427 - Medicare Coverage

Current through Register 1525, July 5, 2024
(A) When
			 Medicare-covered oxygen and respiratory therapy equipment or services are
			 furnished to a recipient who receives Medicare Part B benefits, the rate of
			 payment is always based on the Medicare amount approved. The Division's payment
			 for such services is limited to the coinsurance and deductible amounts. The
			 provider must submit claims for services furnished to recipients receiving
			 Medicare benefits in accordance with the instructions in Subchapter 5 of the
Oxygen and Respiratory Therapy Equipment Manual
.
(B) Prior authorization from the Division is
			 not required for Medicare-covered services that are furnished to recipients who
			 receive Medicare Part B benefits.
(C) When Medicare Part B, or any other
			 primary insurer, denies services or considers services not covered, the
			 provider must obtain prior authorization in accordance with
			 130 CMR
			 427.409 through
			 427.411.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.428 - Oxygen and Respiratory Therapy Equipment for Institutionalized Recipients

Current through Register 1525, July 5, 2024
(A)
Nursing
			 Facilities
. The Division pays for the purchase, rental, and repair
			 of oxygen and respiratory therapy equipment provided to a recipient residing in
			 a nursing facility, subject to the limitations set forth in
			 130 CMR 427.000, with the
			 following exception: the Division does not pay for oxygen or respiratory
			 therapy equipment prescribed for standby emergency or
pro
			 renata
(PRN) use, which is covered under the nursing facility's
per diem
rate.
(B)
Acute Inpatient Hospitals,
			 Chronic Disease Hospitals, and Rehabilitation Hospitals
. The
			 Division does not pay for the purchase, rental, or repair of oxygen or
			 respiratory therapy equipment furnished to a hospitalized recipient, except for
			 oxygen and respiratory therapy equipment prescribed primarily for the home use
			 of the recipient after discharge.
(C)
Intermediate Care Facilities
			 for the Mentally Retarded (ICFs/MR) with 16 Beds or More (State
			 Schools)
. The Division does not pay for the purchase, rental, or
			 repair of oxygen or respiratory therapy equipment furnished to a recipient
			 residing in a state school.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.429 - Provider Responsibility

Current through Register 1525, July 5, 2024
(A) The provider
			 must make reasonably certain that the oxygen and respiratory therapy equipment
			 and supplies furnished are the most cost effective available, given the medical
			 need for which they are prescribed and the recipient's physical
			 limitations.
(B) Before purchasing
			 oxygen or respiratory therapy equipment and supplies, the provider must make a
			 reasonable effort to purchase from the least costly reliable source by
			 comparing prices charged by different suppliers for comparable items.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.430 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
Payment for any service listed in
				130 CMR 427.000 is
				conditioned upon its full and complete documentation in the recipient's medical
				record. In addition to fulfilling all the recordkeeping requirements of
				130 CMR
				450.205, the provider must keep a record of
				all oxygen and respiratory therapy equipment and repair services furnished to a
				recipient for at least four years following the date of service. This record
				must include the following:
(A) a
			 prescription for all rentals and purchases that fulfills the requirements of
			 130 CMR
			 427.408;
(B) a copy of the approved
			 prior-authorization request for all equipment, supplies, or services requiring
			 prior authorization;
(C) an
			 acknowledgment of receipt, including:
(1) the
			 date the equipment was delivered or the service was furnished;
(2) a description of the equipment or
			 service, including the manufacturer's brand name, model number, and serial
			 number; and
(3) the signature of
			 the recipient or the recipient's legal representative, acknowledging receipt of
			 the equipment, supplies, or services on that date; and
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.440 - Clinical Requirements: Introduction

Current through Register 1525, July 5, 2024
Any deviation from the following clinical requirements must be
				justified through the submission of clear and objective data supporting
				therapeutic intervention. This data must originate from recognized medical
				journals and demonstrate statistically significant and generally accepted
				results. Documentation of medical necessity must be submitted with the
				prior-authorization request (see
				130 CMR
				427.409 ). For services that do not require
				prior authorization, this documentation must be kept in the recipient record
				for review pursuant to
				130 CMR
				450.205. In addition, all services must meet
				Division regulations regarding cost and alternative available treatment at
				130 CMR
				427.407 through
				427.411
				and
				427.420
				through
				427.422.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.441 - Clinical Requirements: Oxygen Therapy Equipment

Current through Register 1525, July 5, 2024
(A)
Requirements for
			 Coverage
. Oxygen therapy equipment is reimbursable for the
			 treatment of severe lung diseases (for example, chronic bronchitis, emphysema,
			 and interstitial lung disease) that cause hypoxemia and where oxygen therapy
			 can reasonably be expected to correct the patient's hypoxemia .
(B)
Laboratory
			 Evidence.
(1) The initial
			 prior-authorization request for oxygen therapy equipment in the home must
			 include laboratory evidence of chronic hypoxemia. This evidence must be in the
			 form of an arterialblood gas analysis (PaO 2 : 55 torr
			 while breathing room air) or an oximetry reading (SaO 2
			 : 88% while breathing room air).
(2) The arterial blood gas analysis or
			 oximetry reading must reflect the recipient's baseline and stable blood-oxygen
			 status. The reading must be performed as close as possible to the time of
			 discharge from the hospital or close to the set up time of the equipment in the
			 home.
(3) The test for evidence of
			 hypoxemia must be performed while the recipient is in a resting state and
			 breathing room air. Prior authorization will be deferred for services based on
			 tests performed while the recipient is breathing supplemental oxygen unless the
			 physician can certify that removing the oxygen from the patient could be life
			 threatening.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.442 - Clinical Requirements: Respiratory Therapy Equipment - Apnea Monitor

Current through Register 1525, July 5, 2024
(A)
Requirements for
			 Coverage
. The Division pays for apnea monitoring for certain
			 infants at high risk for sudden death. A pneumogram or multichannel sleep study
			 is not required, but may serve to document one or more of the following
			 requirements:
(1) infants with one or more
			 documented severe apparent life-threatening events (ALTEs) requiring
			 mouth-to-mouth resuscitation or vigorous stimulation;
(2) symptomatic pre-term infants (exhibiting
			 pathologic apnea or bradycardia associated with cyanosis, marked pallor, or
			 hypotonia at the time of discharge);
(3) a sibling of two or more victims of
			 sudden infant death syndrome (SIDS);
(4) a sibling of one SIDS victim, if both the
			 primary care provider and the parents agree that monitoring is indicated and
			 agree that if the infant has one or two continuous months without significant
			 numbers of alarms or episodes of apnea (that is, without requiring vigorous
			 stimulation or resuscitation) monitoring will be discontinued;
(5) central hypoventilation documented by
			 oximetry; and
(6) other conditions
			 in which the infant is at an extraordinarily high risk for sudden death that
			 monitoring can help prevent.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.443 - Clinical Requirements: Respiratory Therapy Equipment - Oximetry

Current through Register 1525, July 5, 2024
(A)
Requirements for
			 Use.
(1)
Spot
			 Checks
. Spot checks are reimbursable when used to document the
			 presence of hypoxemia and to quantitate the response of arterial oxyhemoglobin
			 saturation to therapeutic intervention when hypoxemia is transient and
			 unpredictable even in the presence of supplemental oxygen.
(2)
Continuous
.
			 Continuous oximetry is reimbursable when hypoxemia (SaO
			 2 is less than 90% or decreases 5% from baseline) is
			 transient, variable, and unpredictable, even in the presence of supplemental
			 oxygen, and occurs frequently on a regular basis, so that it requires frequent
			 changes in the supplemental oxygen in response to and to correct hypoxemic
			 episodes.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				428.000 states the requirements and procedures for the
				purchase and repair of prosthetic devices, customized equipment, and supplies
				under MassHealth. All providers of prosthetic services participating in
				MassHealth must comply with the regulations governing MassHealth, including,
				but not limited to MassHealth regulations set forth in
				130 CMR
				428.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers prosthetic services only when provided
			 to eligible MassHealth members, subject to the restrictions and limitations in
			 130 CMR
			 428.000 and
			 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.
(2)
Age Limitations
.
			 In addition to any other restrictions and limitations set forth in
			 130 CMR
			 428.000 and
			 450.000:
Administrative and Billing Regulations
., MassHealth covers
			 prosthetic services only when provided to eligible MassHealth members, subject
			 to the age limitations set forth in Subchapter 6 of the
Prosthetics
			 Manual
.
(3)
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 428.000 - Prosthetics Services › Section 428.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
Provider Participation Requirements
. Payment for
			 services described in
			 130 CMR
			 428.000 is made to providers who are participating in
			 MassHealth as prosthetic providers; to providers also enrolled as MassHealth
			 participating DME providers; OXY providers, or orthotic 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
			 428.000. Participating prosthetic providers must
			 continue to meet provider eligibility participation requirements throughout the
			 period of their provider contract with the MassHealth agency.
(B)
In State
. To
			 participate in MassHealth, a provider with a service facility in Massachusetts
			 must:
(1) primarily engage in the business of
			 providing prosthetic and repair services to the public;
(2) meet all state and local requirements for
			 engaging in such business;
(3) be
			 or employ a prosthetist currently certified by the American Board for
			 Certification in Orthotics, Prosthetics, and Pedorthics Inc. (ABC), or the
			 Board of Certification/ Accreditation, International (BOC), unless the provider
			 intends to solely provide breast prostheses and accessories, in which case the
			 provider must employ, for each service facility location, at least one
			 full-time certified mastectomy fitter, who is currently certified by the ABC or
			 BOC.
(4) be a Medicare
			 Provider;
(5) have a service
			 facility that is physically accessible to MassHealth members during reasonable
			 business hours;
(6) maintain a
			 visible sign identifying the business and hours of operation;
(7) maintain a primary business telephone
			 listed under the name of the business in a local directory. The exclusive use
			 of a pager, answering machine, or cell phone is prohibited; and
(8) obtain a provider number from MassHealth
			 and, if the provider intends solely to provide breast prostheses and
			 accessories, be designated by the MassHealth agency as a specialty provider of
			 certified mastectomy fitter services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.405 - Provider Responsibility

Current through Register 1525, July 5, 2024
(A) The provider
			 must ensure that all prosthetic equipment and supplies are:
(1) clean (sterilized when
			 appropriate);
(2) in proper working
			 condition;
(3)
			 functional;
(4) free from defects;
			 and
(5) new and unused at the time
			 of purchase.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.406 - Covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for only those prosthetic services
				listed in, and subject to the service limitations set forth in, Subchapter 6 of
				the
Prosthetics Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.407 - Service Limitations

Current through Register 1525, July 5, 2024
The service limitations set forth in Subchapter 6 of the
Prosthetics Manual
apply, subject to the Early and Periodic
				Screening, Diagnosis, and Treatment provisions set forth in
				130
				CMR 450.144:
EPSDT Services:
				Diagnosis and Treatment
(A).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.408 - Noncovered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for any of the
				following:
(A) any prosthetic services
			 for which, under comparable circumstances, the provider does not customarily
			 bill private patients who do not have health insurance;
(B) nonmedical prosthetic services. Equipment
			 that is used primarily and customarily for a nonmedical purpose is not
			 considered medical equipment, even if such equipment has a medically related
			 use;
(C) storage of prosthetic
			 equipment or associated items; and
(D) prosthetic services that are not both
			 medically necessary in accordance with
			 130
			 CMR 450.204:
Medical
			 Necessity
and reasonable for the treatment of a member's condition.
			 This includes services that:
(1) cannot
			 reasonably be expected to make a meaningful contribution to the treatment of a
			 member's condition or the performance of the member's activities of daily
			 living; and
(2) are more costly
			 than a medically comparable and suitable alternative or that serve essentially
			 the same purpose as equipment already available to the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.409 - Prescription Requirements

Current through Register 1525, July 5, 2024
(A) The purchase of
			 prosthetic equipment requires a written prescription signed by a licensed
			 physician or an independent nurse practitioner. The prescription must be
			 written on the prescriber's prescription form and must include the following
			 information:
(1) the member's name and
			 address;
(2) the member's
			 MassHealth identification number;
(3) specific identification of the prescribed
			 item;
(4) medical justification for
			 the use of the item, including the member's diagnosis;
(5) the prescriber's address and telephone
			 number; and
(6) the date on which
			 the prescription was signed by the prescriber.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.410 - Prosthetic Equipment Provided to Institutionalized Members

Current through Register 1525, July 5, 2024
(A)
Nursing
			 Facilities
. The MassHealth agency pays prosthetic providers for:
(1) the purchase and repair of prosthetic
			 equipment; and
(2) prosthetic
			 supplies provided for the personal full-time use of a member residing in a
			 nursing facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.411 - Repairs of Prosthetic Equipment

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays for all repair services on an individual-consideration
			 basis as described in
			 130
			 CMR 428.421.
(B) The provider of repair services is liable
			 for the quality of the workmanship and parts, and for ensuring that repaired
			 equipment is in proper working condition.
(C) The provider of repair services must
			 exhaust all manufacturer warrantees before submitting claims for repairs to
			 prosthetic equipment to the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.412 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) Services that
			 require prior authorization as a prerequisite for payment are identified in
			 130 CMR
			 428.000 or are listed in Subchapter 6 of the
Prosthetics Manual
with the designation (P.A.) appearing after
			 the service description. To determine if prior authorization is required, the
			 provider should review both
			 130 CMR
			 428.000 and Subchapter 6. Prior authorization
			 determines only the medical necessity of the prescribed item or service and
			 does not waive any other prerequisites to payment such as member eligibility or
			 resort to health-insurance payment.
(B) The provider must request prior
			 authorization in accordance with the billing instructions in Subchapter 5 of
			 the
Prosthetics Manual
. Before determining the medical
			 necessity of an item or service for which prior authorization is requested, the
			 MassHealth agency may, at its discretion, require the prescriber to submit an
			 assessment of the member's condition and the objectives of the requested
			 service. The MassHealth agency may also, at its discretion, require an
			 evaluation by a licensed prosthetist to determine whether the requested
			 prosthetic service is useful to the member, given the member's physical
			 condition and physical environment.
(C)
(1) The
			 MassHealth agency will send notification to the member and the provider of the
			 following prior-authorization decisions:
(a)
			 approval;
(b) modification;
			 or
(c) denial.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.413 - Procedure for Requesting Prior Authorization

Current through Register 1525, July 5, 2024
(A) The provider must obtain prior
			 authorization from the MassHealth agency before providing any service that
			 requires prior authorization. The provider must submit the Request for Prior
			 Authorization within 90 days of the date of service requested on the
			 prescription.
(B) The Request for
			 Prior Authorization must document the adjusted acquisition cost
			 (
see
130
			 CMR 428.422) and the medical necessity of the
			 requested service. The Request for Prior Authorization must contain the
			 following documentation:
(1) a copy of the
			 invoice or invoices from the manufacturer for the equipment, disclosing all
			 discounts;
(2) a copy of a current
			 prescription that must not be older than 90 days from the requested date of
			 service (
see
130
			 CMR 428.409 for information that must be
			 included in the prescription);
(3)
			 if requested by the MassHealth agency, a current prosthetic evaluation for the
			 equipment, performed independently of the provider by a licensed physician or
			 prosthetist;
(4) the date or
			 projected date of service;
(5) the
			 projected duration of need for the equipment; and
(6) if replacing existing equipment, the date
			 the existing equipment was purchased.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.414 - Medicare Coverage

Current through Register 1525, July 5, 2024
(A) For Medicare and
			 third-party-liability coverage,
see
130
			 CMR 450.316 through
			 450.318.
(B) For Medicare-covered services that are
			 provided to members who receive Medicare Part B benefits, the MassHealth agency
			 does not require prior authorization.
(C) When Medicare denies a claim for
			 prosthetic services or considers the services uncovered, the MassHealth agency
			 requires prior authorization for those services that would require prior
			 authorization for members without Medicare.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.415 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				prosthetics 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
				428.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.420 - Payment for Prosthetic Services

Current through Register 1525, July 5, 2024
(A) Payment
			 to a provider for prosthetic equipment and supplies is subject to the
			 conditions and limitations in
			 130 CMR
			 428.000 and
			 450.000:
Administrative and Billing Regulations
, and will be the lower
			 of:
(1) the provider's usual and customary
			 charge to the general public; or
(2) the fee set forth in the schedule of
			 maximum allowable fees established by the Massachusetts Executive Office of
			 Health and Human Services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.421 - Individual Consideration

Current through Register 1525, July 5, 2024
When the rate of payment for the purchase or repair of certain
				prosthetic equipment has not been established by the Executive Office of Health
				and Human Services, the MassHealth agency pays for the service based on
				individual consideration, subject to all other conditions of payment. Such
				items are identified in Subchapter 6 of the
Prosthetics Manual
by the designation (I.C.) next to the description of the item or service. The
				MassHealth agency determines the rate of payment for an
				individual-consideration item or service based on the provider's report of
				services and a current invoice that indicates the provider's adjusted
				acquisition cost as defined in
				130
				CMR 428.421 and
				428.422. Payment for the
				fitting of a prosthesis is included in the adjusted acquisition cost. Providers
				must maintain adequate records to document the individual consideration claim
				and must provide these documents to the MassHealth agency and the Attorney
				General's Medicaid Fraud Control Unit upon demand (
see
130
				CMR 450.205:
Recordkeeping and
				Disclosure
). Payment to a provider for an individual consideration
				claim is the lower of:
(A) the
			 provider's usual and customary charge to the general public; or
(B) the adjusted acquisition cost of the item
			 plus a markup not to exceed:
(1) 70% for any
			 item whose adjusted acquisition cost is less than $100;
(2) 50% for any item whose adjusted
			 acquisition cost is $100 or greater and less than $200;
(3) 45% for any item whose adjusted
			 acquisition cost is $200 or greater and less than $300; or
(4) 40% for any item whose adjusted
			 acquisition cost is $300 or greater.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.422 - Adjusted Acquisition Cost

Current through Register 1525, July 5, 2024
(A) The provider
			 must disclose all discounts, as defined in
			 130
			 CMR 428.402, and must reflect such discounts
			 in the provider's claim for payment pursuant to M.G.L. c. 118E, § 41, and
			 U.S.C. § 1320a-7b(b)(3)(A). Any provider who fails to disclose and pass on
			 any discounts to the MassHealth agency may be subject to civil and criminal
			 penalties, including imprisonment, in accordance with state and federal
			 laws.
(B)
(1) Except where the manufacturer is the
			 provider, the adjusted acquisition cost must not exceed the manufacturer's
			 current wholesale price and must be evidenced by the purchase price of the
			 equipment or goods listed on a copy of the supplier's invoice.
(2) Where the manufacturer is the provider,
			 the adjusted acquisition cost must not exceed the actual cost of manufacturing
			 the items.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 428.000 - Prosthetics Services › Section 428.423 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
The provider must keep a record of all prosthetic services,
				nursing facility visits, and the medical necessity of such services provided to
				a member for the period of time required by
				130
				CMR 450.205:
Recordkeeping and
				Disclosure
. This record must include the following:
(A) a prescription for all
			 purchases;
(B) a copy of the
			 approved prior-authorization request for all prosthetic services requiring
			 prior authorization;
(C) an
			 acknowledgment of receipt, signed by the member or the member's representative,
			 of prescribed equipment or supplies, including:
(1) the date of receipt of equipment or
			 supplies;
(2) the condition of the
			 equipment or supplies (for example, whether it is in proper working order or is
			 damaged);
(3) the manufacturer,
			 brand name, model number, and serial number of the equipment or
			 supplies;
(4) for repair services,
			 a complete description of the service, including the manufacturer, brand name,
			 model number, and serial number of the repaired item; and
(5) next to the signature, an explanation of
			 the representative's relationship to the member by the individual acknowledging
			 receipt. This individual cannot be associated with either the provider or the
			 delivery service.
(a) For routine delivery of
			 supplies, the member must acknowledge receipt at least monthly.
(b) A signature stamp may be used by or on
			 behalf of a MassHealth member whose disability inhibits the member's ability to
			 write. A signature stamp may only be used by a member or the member's
			 representative, provided that the stamp is used by the member in his or her
			 normal course of conducting business. A signature stamp cannot be used by
			 anyone associated with either the provider or the delivery service;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				429.000 establishes requirements for participation of
				mental health centers in MassHealth and governs mental health centers operated
				by freestanding clinics and satellite clinics. All mental health centers
				participating in MassHealth must comply with the MassHealth regulations,
				including but not limited to,
				130 CMR
				429.000, and
				130 CMR
				450.000:
Administrative and Billing
				Regulations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. MassHealth covers mental health
			 center services only when provided to eligible MassHealth members, subject to
			 the restrictions and limitations described in the MassHealth agency's
			 regulations. Covered services for each MassHealth coverage type are set forth
			 in 130 CMR 450.105:
Coverage Types.
(B)
Members 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)
Information on Verifying
			 Member Eligibility and Coverage Type
.
See
130
			 CMR 450.107:
Eligible Members and the
			 MassHealth Card.
(D)
Limitations
. For limitations on mental health disorder
			 and substance use disorder services provided to members enrolled with a
			 MassHealth managed care provider,
see
130 CMR
			 450.105:
Coverage Types
and
			 130
			 CMR 450.124:
Behavioral Health
			 Services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
In-state
. Each center operated by a freestanding
			 clinic or a satellite clinic is eligible to participate only if the center is:
(1) enrolled as a Medicare
			 provider;
(2) enrolled and actively
			 participating with the MassHealth agency as a billing provider as evidenced by
			 the issuance of a Provider Identification and Service Location (PIDSL) number
			 for the provision of mental health center services at that location;
			 and
(3) licensed by the
			 Massachusetts Department of Public Health (DPH). The MassHealth agency may
			 waive the clinic licensure requirement for centers that are:
(a) operated by a local department of public
			 health; and
(b) comply with
			 130
			 CMR 429.404(A)(2).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.405 - Provider Enrollment Process

Current through Register 1525, July 5, 2024
(A) A separate,
			 complete application for enrollment as a mental health center must be submitted
			 for each parent clinic and each satellite clinic operated by the parent clinic
			 that operates under a different tax identification number than the parent
			 clinic. The applicant must submit the appropriate provider enrollment
			 application to the MassHealth agency. The MassHealth agency may request
			 additional information or perform a site inspection to evaluate the applicant's
			 compliance with
			 130 CMR
			 429.000.
(1) Based on
			 the information in the enrollment application, information known to the
			 MassHealth agency about the applicant, and on the findings from any site
			 inspection deemed necessary, the MassHealth agency will determine whether the
			 applicant is eligible for enrollment.
(2) The MassHealth agency will notify the
			 applicant of the determination in writing within 60 days of the MassHealth
			 agency receiving a completed application. An application shall not be
			 considered complete until the applicant has responded to all MassHealth
			 requests for additional information, and MassHealth has completed any required
			 site inspection.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.406 - Required Notifications and Reports

Current through Register 1525, July 5, 2024
(A)
Annual Report
. Each mental health center must submit a
			 completed annual report, on forms furnished by the MassHealth agency, and file
			 them with the MassHealth agency by September 30th of
			 each year. The report must include at minimum:
(1) A statement that the program has reviewed
			 and updated, as necessary, its written policies and procedures during the
			 reporting period. Each program must provide a copy of the program's written
			 policies and procedures as requested by the MassHealth agency.
(2) A list of all Center Administrative and
			 Clinical Management Staff as listed in
			 130
			 CMR 429.422(C)  that
			 includes the following information: staff name, license number, type of
			 license, and board certification, if applicable, and a list of the clinical
			 supervisor for any clinical staff who are unlicensed or not independently
			 licensed;
(3) a statement
			 describing the role of the psychiatrist;
(4) a statement describing the current
			 language capacities, capacity to provide services to specialized populations,
			 and utilization of evidenced-based modalities of the program;
(5) written attestation that the center is in
			 compliance with
			 130 CMR
			 429.000; and
(6) any other information that the MassHealth
			 agency may request.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.407 - Revocation of Enrollment and Sanctions

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency has the right to review a mental health center's continued compliance
			 with the conditions for enrollment referred to in
			 130
			 CMR 429.405 and the reporting requirements in
			 130
			 CMR 429.406 upon reasonable notice and at any
			 reasonable time during the center's hours of operation. The MassHealth agency
			 has the right to revoke the enrollment, subject to any applicable provisions of
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations,
if such review reveals that the center has failed to or
			 ceased to meet such conditions.
(B)
			 If the MassHealth agency determines that there exists good cause for the
			 imposition of a lesser sanction than revocation of enrollment, it may withhold
			 payment, temporarily suspend the center from participation in MassHealth, or
			 impose some other lesser sanction as the MassHealth agency sees fit, pursuant
			 to the processes set forth in
			 130 CMR
			 450.000, as applicable.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.408 - In-State Providers: Maximum Allowable Fees

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for mental health center services with rates set by EOHHS, subject
			 to the conditions, exclusions, and limitations set forth in
			 130 CMR
			 429.000. EOHHS fees for mental health center services
			 are contained in
			 101 CMR
			 306.00:
Rates of Payment for Mental Health
			 Services Provided in Community Health and Mental Health Centers.
(1) In the event that the center has a
			 sliding scale charge structure, the maximum published charges will be
			 considered the center's usual charge to the general public, provided the
			 following conditions are met:
(a) the center's
			 full charges must be published in a fee schedule;
(b) the center's revenues must be based on
			 the application of full charges with allowances noted for reduction of
			 fees;
(c) the center's procedure
			 for reduction of fees must be in accordance with written policies;
			 and
(d) the center must maintain
			 sufficient information to document the amount of the reductions.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.409 - Out-of-state Providers: Maximum Allowable Fees

Current through Register 1525, July 5, 2024
Payment to a mental health center located out-of-state shall be
				in accordance with the applicable rate schedule of its state's medical
				assistance program, or its equivalent, and is always subject to the applicable
				conditions, exclusions, and limitations set forth in
				130 CMR
				429.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.410 - Nonreimbursable Services

Current through Register 1525, July 5, 2024
(A)
Nonmedical Services
. The MassHealth agency does not
			 pay mental health centers for nonmedical services. These services include, but
			 are not limited to, the following:
(1)
			 vocational rehabilitation services;
(2) sheltered workshops (a program of
			 vocational counseling and training in which participants receive paid work
			 experience or other supervised employment);
(3) educational services;
(4) recreational services (play therapy, the
			 use of play activities with a child in an identified treatment setting as an
			 alternative to strictly verbal expression of conflicts and feelings, is not
			 considered a recreational service and is reimbursable);
(5) life enrichment services (ego enhancing
			 services such as workshops or educational courses provided to functioning
			 persons); and
(6) other services
			 such as providing information, referral, and advocacy to certain age
			 populations, liaising with other agencies, role modeling, and community
			 organization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.411 - Site Inspections

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency may, at any time, conduct announced or unannounced site inspections of
			 any center to determine compliance with applicable regulations. Such site
			 inspections need not pertain to any actual or suspected deficiency in
			 compliance with the regulations.
(B) After any site inspection where
			 deficiencies are observed, the MassHealth agency will prepare a written site
			 inspection report. The site inspection report will include the deficiencies
			 found, and the period within which the deficiency must be corrected. The center
			 shall submit a corrective action plan, within the timeframe set forth by the
			 MassHealth agency, for each of the deficiencies cited in the report, including
			 the specific corrective steps to be taken, a timetable for these steps, and the
			 date by which full compliance will be achieved. The MassHealth agency will
			 review the corrective action plan and will accept the corrective action plan
			 only if it conforms to these requirements.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.412 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary mental
				health center 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
				429.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.421 - Scope of Services

Current through Register 1525, July 5, 2024
(A)
Required Services
. Each center must have services
			 available to treat a wide range of behavioral health disorders, including
			 co-occurring substance use disorders. All services must be clinically
			 determined to be medically necessary and appropriate and must be delivered by
			 qualified staff in accordance with
			 130
			 CMR 429.424, and as part of the treatment
			 plan in accordance with
			 130
			 CMR 429.421(A)(2). A center
			 must have the capacity to provide at least the services set forth in
			 130
			 CMR 429.421(A). In certain
			 rare circumstances, the MassHealth agency may waive the requirement that the
			 center directly provide one or more of these services if the center has a
			 written referral agreement with another source of care to provide such
			 services, and makes such referrals according to the provisions of
			 130
			 CMR 429.421(A)(6).
(1)
Diagnostic Evaluation
			 Services
.
(a) Diagnostic
			 Evaluation Services that must occur on a member's initial date of service shall
			 include:
1. Identification of the member's
			 presenting complaint or problem at the time of assessment; and
2. A risk assessment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.423 - Supervision, Training, and Other Staff Requirements

Current through Register 1525, July 5, 2024
(A)
Staff Supervision Requirements
.
(1)
Unlicensed or Not
			 Independently Licensed Staff
. All professionals who are
			 unlicensed, who are in a profession without licensure, or who are not
			 independently licensed or certified as a peer supervisor must receive Direct
			 and Continuous Supervision. Direct and Continuous Supervision may be provided
			 using telehealth technology.
(2)
Independently Licensed and Certified Peer Supervisor
			 Staff
. All independently licensed professionals and certified peer
			 supervisors must receive supervision in accordance with center policy.
			 Supervision may be provided using telehealth technology.
(3) The supervising clinician is primarily
			 responsible for the care of the member. For any care delivered by a
			 professional under supervision there must be documentation in the clinical
			 chart that the chart was reviewed by the supervising clinician.
(4) All supervision must be documented in
			 files accessible for review by the MassHealth agency. Supervision notes must,
			 at a minimum, contain information regarding frequency of supervision, format of
			 supervision, supervisor's signature and credentials, and general content of
			 supervision session.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.424 - Qualifications of Professional and Paraprofessional Staff Members Authorized to Render Billable Mental Health Center Services

Current through Register 1525, July 5, 2024
A center may only bill for medically necessary services
				provided by a professional or paraprofessional staff member qualified as
				follows.
(A)
Psychiatrists
			 and Medical Professionals
.
(1) At
			 least one staff psychiatrist must meet the requirements set forth in
			 130
			 CMR 429.422.
(2) Additional psychiatrists must be licensed
			 physicians in their second year of a psychiatric residency program accredited
			 by the Accreditation Council for Graduate Medical Education.
(3) Psychiatrists and prescribers must have
			 the appropriate Drug Enforcement Administration (DEA) and Department of Public
			 Health (DPH) registrations for the prescribing of controlled
			 substances.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.431 - Operating Procedures

Current through Register 1525, July 5, 2024
(A) A professional
			 staff member authorized to render billable mental health center services as
			 described in
			 130
			 CMR 429.424, must conduct a comprehensive
			 evaluation of each member prior to initiation of therapy. For members younger
			 than 21 years old, a CANS must be completed during the initial
			 behavioral-health assessment before the initiation of therapy and be updated at
			 least every 90 days thereafter by a CANS-certified provider, as described in
			 130
			 CMR 429.424.
(B) The center must accept a member for
			 treatment, refer the member for treatment elsewhere, or both, if the intake
			 evaluation substantiates a mental or emotional disorder.
(C) One professional staff member must assume
			 primary responsibility for each member (the primary therapist).
(D) The center program must make provisions
			 for responding to persons needing services on a walk-in basis.
(E) The center must take appropriate steps to
			 facilitate uninterrupted and coordinated member care whenever it refers a
			 member elsewhere for treatment not available at the center or for subsequent
			 treatment.
(F) Before referring a
			 member elsewhere, the center must, with the member's consent, send a summary of
			 or the actual record of the member to that referral provider prior to
			 initiation of therapy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.432 - Treatment Planning and Case Review

Current through Register 1525, July 5, 2024
A multidisciplinary team composed of mental health
				professionals, in accordance with
				105 CMR 140.530:
Staffing
, must conduct treatment planning, assessments, and
				case review for each member as follows.
(A) The multidisciplinary team must conduct
			 case review according to
			 105 CMR 140.540:
Case Review
; must prepare a treatment plan that complies with
			 105 CMR
			 140.520(C);
Personnel Qualifications
; and must establish criteria for
			 determining when termination of treatment is appropriate.
(B)  For members younger than 21 years old,
			 the multidisciplinary team must ensure that the CANS has been completed at the
			 initial behavioral-health assessment and is updated at least every 90 days
			 thereafter.
(C) The
			 multidisciplinary team must review each case at termination of treatment and
			 prepare a termination summary that describes the course of treatment and the
			 aftercare program or resources in which the member is expected to
			 participate.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.433 - Coordination of Medical Care

Current through Register 1525, July 5, 2024
A mental health center must coordinate behavioral health
				disorder treatment with medical care for MassHealth members. If a member has
				not received a physical exam within 12 months of the date of intake, the mental
				health center must advise the member that one is needed. If the member does not
				have an existing relationship with a physician, the mental health center must
				assist the member in contacting the MassHealth agency's customer service
				toll-free line to receive help in selecting a physician. If the member declines
				a physical examination, the member's record must document the member's
				preference and any stated reason for that preference.