reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.303 - Prior Authorization

Current through Register 1525, July 5, 2024
In certain instances, the MassHealth agency requires providers
				to obtain prior authorization to provide medical services. These instances are
				identified in the billing instructions, program regulations, associated lists
				of service codes and service descriptions, provider bulletins, and other
				written issuances from the MassHealth agency. Such information including, but
				not limited to, the MassHealth Drug List is available on the MassHealth website
				at
www.mass.gov/druglist
, and
				copies may be obtained upon request. The provider must submit all
				prior-authorization requests in accordance with the MassHealth agency
				instructions. Prior authorization determines only the medical necessity of the
				authorized service, and does not establish or waive any other prerequisites for
				payment, such as member eligibility or resort to health-insurance
				payment.
(A) The MassHealth agency
			 acts on appropriately completed and submitted requests for prior authorization
			 within the following time periods.
(1) For
			 pharmacy services - by telephone or other telecommunication device within 24
			 hours of the request for prior authorization. The MassHealth agency will
			 authorize at least a 72-hour supply of a prescription drug to the extent
			 required by federal law. (
See
42 U.S.C.
			 1396r-8(d)(5).)
(2) For transportation to medical services -
			 within seven calendar days after a request for service, or the number of days,
			 if less than seven, necessary to avoid any serious and imminent risk to the
			 health or safety of the member that might arise if the MassHealth agency did
			 not act before the full seven days have elapsed.
(3) For independent nurse services - within
			 14 calendar days after a request for service.
(4) For durable medical equipment - within 15
			 calendar days after a request for service.
(5) For all other MassHealth services -
			 within 21 calendar days after a request for service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.304 - Claim Submission: Signature Requirement

Current through Register 1525, July 5, 2024
Every CMS-1500 claim form submitted for payment must be signed
				by the provider that provided the service or the provider's agent on behalf of
				the provider that provided the service. A provider that accepts payment of a
				claim is presumed to have authorized the submission of the claim on his or her
				behalf.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.307 - Unacceptable Billing Practices

Current through Register 1525, July 5, 2024
(A) No
			 provider may claim payment in a way that may result in payment that exceeds the
			 maximum allowable amount payable for such service under the applicable payment
			 method.
(B) Without limiting the
			 generality of
			 130 CMR
			 450.307(A), the following
			 billing practices are forbidden:
(1) duplicate
			 billing, which includes the submission of multiple claims for the same service,
			 for the same member, by the same provider or multiple providers;
(2) overstating or misrepresenting services,
			 including submitting separate claims for services or procedures provided as
			 components of a more-comprehensive service for which a single rate of payment
			 is established; and
(3) submitting
			 claims under an individual practitioner's provider ID/service location number
			 for services for which the practitioner is otherwise entitled to
			 compensation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.309 - Time Limitation on Submission of Claims: General Requirements

Current through Register 1525, July 5, 2024
(A) In accordance with M.G.L. c. 118E, §
			 38, all claims must be received by the MassHealth agency within 90 days from
			 the date of service or the date of the explanation of benefits from another
			 insurer. When a service is provided continuously on consecutive dates, the date
			 from which the 90-day deadline is measured is the latest date of
			 service.
(B) For claims that are
			 not submitted within the 90-day period but that meet one of the exceptions
			 specified below, a provider must request a waiver of the billing deadline (a
			 90-day waiver) pursuant to the billing instructions provided by the MassHealth
			 agency. The exceptions are as follows:
(1) a
			 medical service was provided to a person who was not a member on the date of
			 service, but was later enrolled as a member for a period that includes the date
			 of service;
(2) a medical service
			 was provided to a member who failed to inform the provider in a timely fashion
			 of the member's eligibility for MassHealth; and
(3) other exceptions that are expressly
			 authorized by the MassHealth agency pursuant to a MassHealth transmittal letter
			 or provider bulletin.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.313 - Time Limitation on Submission of Claims: Claims for Members with Health Insurance

Current through Register 1525, July 5, 2024
If a provider delays submitting a claim in order to bill a
				member's health insurer (
see
130 CMR 450.316 through 450.318 ),
				the claim will have been timely submitted if it is received:
(A) no later than the
			 90th day after the date of the notice of final
			 disposition by the health insurer (if more than one insurer is involved, the
			 submission period will be measured from the latest final disposition, and the
			 period for making requests will be measured from the date of the notice of
			 final disposition from the previous insurer); and
(B) no later than 18 months after the date of
			 service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.314 - Final Deadline for Submission of Claims

Current through Register 1525, July 5, 2024
(A)
			 If the MassHealth agency has denied a claim that was initially submitted within
			 the 90-day deadline, the provider may resubmit the claim with appropriate
			 corrections or supporting information.
(B) The MassHealth agency, pursuant to M.G.L.
			 c. 118E, § 38, will not pay any claim submitted or resubmitted for
			 services provided more than 12 months before the date of submission or
			 resubmission, except as provided in
			 130
			 CMR 450.313 and
			 450.323.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.316 - Third-party Liability: Requirements

Current through Register 1525, July 5, 2024
All resources available to a member, including but not limited
				to all health and casualty insurance, must be coordinated and applied to the
				cost of medical services provided by MassHealth.
(See
42 CFR
				Part 433, Subpart D.) Except to the extent prohibited by
				42 U.S.C.
				1396a(a) 25(E) or (F), all
				providers must make diligent efforts to obtain payment first from other
				resources, including casualty payer payments, so that the MassHealth agency
				will be the payer of last resort. The MassHealth agency will not pay a provider
				and will recover any payments to a provider if it determines that, among other
				things, the provider has not made such diligent efforts. Under no circumstances
				may a provider bill a member for any amount for a MassHealth-covered service,
				except as provided by
				130 CMR
				450.130.
(A) "Diligent efforts" is defined as making
			 every effort to identify and obtain payment from all other liable parties,
			 including insurers. Diligent efforts include, but are not limited to:
(1) determining the existence of health
			 insurance by asking the member if he or she has other insurance and by using
			 insurance databases available to the provider;
(2) verifying the member's other health
			 insurance coverage, currently known to the MassHealth agency through the
			 eligibility verification system (EVS) on each date of service and at the time
			 of billing;
(3) submitting claims
			 to all insurers with the insurer's designated service code for the service
			 provided;
(4) complying with the
			 insurer's billing and authorization requirements;
(5) appealing a denied claim when the service
			 is payable in whole or in part by an insurer; and
(6) returning any payment received from the
			 MassHealth agency after any available third-party resource has been identified.
			 The provider must bill all available third-party resources before resubmitting
			 a claim to the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.317 - Third-party Liability: Payment Limitations on Other Health Insurance Claim Submissions

Current through Register 1525, July 5, 2024
(A) Subject to
			 compliance with all conditions of payment, for members who have other health
			 insurance in addition to MassHealth, the MassHealth agency's liability is the
			 lesser of:
(1) the member's liability,
			 including coinsurance, deductibles, and copayments, as reported on the
			 explanation of benefits or remittance advice from the insurer; or
(2) the provider's charges or maximum
			 allowable amount payable under the MassHealth agency's payment methodology,
			 whichever is less, minus the insurance payments.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.318 - Third-party Liability: Payment Limitations on Medicare Crossover Claim Submissions

Current through Register 1525, July 5, 2024
(A) A crossover is
			 defined as a claim for a member who has Medicare in addition to MassHealth,
			 where Medicare has made a payment or has approved an amount that was applied to
			 the member's deductible.
(B) To
			 obtain crossover payment, a provider must
(1)
			 bill the Medicare fiscal intermediary or carrier, as applicable, in accordance
			 with their billing rules, including using the appropriate Medicare claim form
			 and format;
(2) accept assignment
			 according to Medicare instructions; and
(3) follow the MassHealth agency's billing
			 instructions relating to crossover claims.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.321 - Third-party Liability: Waivers

Current through Register 1525, July 5, 2024
The MassHealth agency may waive any requirements of
				130 CMR
				450.316 through
				450.318,
				as applied to any provider, to institute information-gathering projects and to
				evaluate methods of exercising the third-party liability recovery options
				described in
				42 CFR 433.139.
				The MassHealth agency will grant waivers only for projects that are likely to
				increase the efficient and economical collection of third-party resources and
				will state the extent of any waiver in the documents establishing such
				projects.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.323 - Appeals of Erroneously Denied or Underpaid Claims

Current through Register 1525, July 5, 2024
Pursuant to M.G.L. c. 118E, § 38, the MassHealth agency
				has established the following procedures for appealing claims that the provider
				believes were denied in error or underpaid. The MassHealth agency's Final
				Deadline Appeals Board has exclusive jurisdiction to review appeals submitted
				by providers of claims for payment that were, as a result of MassHealth agency
				error, denied or underpaid, and that cannot otherwise be timely
				resubmitted.
(A)
Criteria
			 for Filing an Appeal
. All requests for appeals submitted to the
			 MassHealth agency for review must be submitted electronically in a format
			 designated by the MassHealth agency, unless the provider has been approved for
			 an electronic claim submission waiver as specified in
			 130 CMR
			 450.302(A)(3). To file an
			 appeal with the MassHealth agency's Final Deadline Appeals Board, the provider
			 must meet all of the following criteria.
(1)
			 The provider must have submitted the original claim in a timely manner,
			 pursuant to
			 130
			 CMR 450.309 through
			 450.314.
(2) The provider must have exhausted all
			 available corrective actions outlined in the billing instructions provided by
			 the MassHealth agency.
(3) The date
			 of service for which the appeal is submitted must exceed the filing time limit
			 of 12 months, unless third-party insurance is involved, in which case the
			 filing time limit is 18 months (the final billing deadline).
(4) Claims for dates of service more than 36
			 months after the date of service are not eligible for an appeal.
(5) The provider must file the appeal within
			 30 days after the date on the remittance advice that first denied the claim for
			 exceeding the final billing deadline.
(6) The provider must demonstrate that the
			 claim was, as a result of MassHealth agency error, denied or
			 underpaid.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.324 - Payment of Claims

Current through Register 1525, July 5, 2024
The MassHealth agency will make electronic payments payable
				only to the provider, except as required by law or at the MassHealth agency's
				discretion.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.331 - Billing Agencies

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency processes claims that are submitted by a billing agent on behalf of a
			 provider. At the written request of a provider, the MassHealth agency may also
			 mail payments and remittance advices to a billing agent, but such payments are
			 payable to the provider only, and in no event are payable to the billing agent.
			 The MassHealth agency does not make payments to a billing agent.
(B) The MassHealth agency recognizes a
			 billing agent solely and strictly as the provider's agent. A billing agent is
			 not considered a "provider" by the MassHealth agency. A provider's use of a
			 billing agent does not relieve the provider of any responsibility imposed
			 elsewhere in these regulations for the claims that the provider submits or that
			 are submitted on the provider's behalf. Any provider that engages a billing
			 agent for the preparation and submission of claims to the MassHealth agency is
			 fully responsible to the MassHealth agency for all acts by such billing agent
			 with actual or apparent authority to perform such acts, notwithstanding any
			 contrary provisions in any agreement between the provider and the billing
			 agent. In case of any violations of laws, rules, or regulations, or of the
			 provider contract arising out of the acts of the billing agent, the provider is
			 fully liable as though they were the provider's own acts.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.401 - Introduction

Current through Register 1525, July 5, 2024
All urgent care clinics participating in MassHealth must comply
				with all MassHealth regulations including, but not limited to, 130 CMR 455.000,
				and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in 130 CMR 455.000 have the meanings
				given in 130 CMR 455.402, unless the context clearly requires a different
				meaning. The reimbursability of services defined in 130 CMR 455.000 is not
				determined by these definitions, but by application of 130 CMR 455.000, and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Primary
or
Elective
				Care
- medical care required by individuals or families that is
				appropriate for the maintenance of health and the prevention of illness.
Primary
or
Elective Care
includes, but is not limited to, physical examination, diagnosis and management
				of illness, ongoing health maintenance, accident prevention, and referral when
				necessary.
Urgent Care
- a term defined in
				105 CMR
				140.000:
Licensure of Clinics
.
Urgent Care Clinic (UCC)
- an entity
				licensed as a clinic by the Massachusetts Department of Public Health (DPH)
				pursuant to M.G.L. c. 111, § 51, and
				105 CMR
				140.000:
Licensure of Clinics
, if in
				state, or by the licensing authority of its own state, if out of state, that is
				not part of a hospital and that possesses its own legal identity, maintains its
				own patient records, administers its own budget and personnel, and is organized
				primarily for the purpose of rendering urgent care.
Urgent Care Visit
- an in-person
				encounter between an eligible member and a licensed practitioner (such as a
				physician or nurse practitioner) or other medical professional under the
				direction of a licensed practitioner for the provision of urgent care as
				defined in 130 CMR 455.402.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency covers UCC 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 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 455.000 - Urgent Care Clinic Services › Section 455.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in 130 CMR 455.000 will be
				made only to providers of UCC services who are participating in MassHealth on
				the date of service.
(A)
In-State
. To participate in MassHealth, a UCC located
			 in Massachusetts must
(1) operate under a
			 clinic license issued by the Massachusetts Department of Public Health pursuant
			 to
			 105 CMR
			 140.000:
Licensure of Clinics
;
			 and
(2) have a signed provider
			 contract with the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.405 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
(A) The Executive
			 Office of Health and Human Services (EOHHS) determines the payment rate for UCC
			 services in accordance with
			 101
			 CMR 317.00:
Rates for Medicine
			 Services
,
			 101
			 CMR 318.00:
Rates for Radiology
			 Services
, and
			 101
			 CMR 320.00:
Clinical Laboratory
			 Services
.
(B) Payment is
			 subject to the conditions, exclusions, and limitations set forth in 130 CMR
			 455.000, and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.406 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency has designated certain services in Subchapter 6 of the
Urgent
			 Care Clinic 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 455.406(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, an operative report or pathology report. 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.
See
130 CMR 455.407
			 for report requirements.
(B) 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) the policies, procedures, and practices
			 of other third-party insurers, both governmental and private;
(4) other standards and criteria as may be
			 adopted by EOHHS or the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.407 - Report Requirements

Current through Register 1525, July 5, 2024
A general written report or a discharge summary must accompany
				the claim for payment for any service that is listed in Subchapter 6 of the
Urgent Care Clinic Manual
as requiring a report or individual
				consideration (I.C.), or if the code is for an unlisted service. This report
				must be sufficiently detailed to enable the MassHealth agency to assess the
				extent and nature of the service.
Each urgent care clinic must provide a copy of the medical
				record of each urgent care visit to the MassHealth member at the end of the
				urgent care visit or as soon as available and, with the member's consent,
				provide a facsimile or electronically transmitted copy of the medical record of
				the urgent care visit to the member's primary care provider, if any. Such
				copies or transmission must be provided at no charge to the member. In the
				event that the member has a primary care provider, the urgent care clinic shall
				provide the member with the name and contact information of such primary care
				provider, in a manner to be prescribed by the MassHealth agency. In the event
				that the member does not have a primary care provider, the urgent care clinic
				shall
(1) notify the MassHealth agency
			 that the member does not have a primary care provider, using a form that will
			 be prescribed by the MassHealth agency; and
(2) provide the member with the names of
			 primary care providers who participate in MassHealth and practice in the
			 member's municipality of residence or an adjacent municipality, in a manner to
			 be prescribed by the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.413 - Covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for medically necessary urgent care
				identified in Subchapter 6 of the
Urgent Care Clinic
				Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.414 - Non-covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for the following
				services:
(A) services performed for
			 experimental, unproven, cosmetic or otherwise medically unnecessary procedure
			 or treatment;
(B) the treatment of
			 male or female infertility (including, but not limited to, laboratory tests,
			 drugs, and procedures associated with such treatment);
(C) services otherwise identified in the
			 MassHealth regulations at 130 CMR 455.000 or
			 130 CMR 450.000:
Administrative and Billing Regulations
as not payable;
			 or
(D) otherwise payable service
			 codes when those codes are used to bill for circumstances that are not payable
			 pursuant to 130 CMR 455.414.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.415 - Urgent Care Visits

Current through Register 1525, July 5, 2024
The following restrictions and limitations apply to urgent care
				visits as defined in 130 CMR 455.402.
Treatments
or
Procedures
. The UCC may bill for an urgent care visit,
				a treatment, or a procedure, but may not bill for more than one of these
				services provided to the same member on the same date when the services are
				performed in the same location. X-rays, laboratory tests, and certain
				diagnostic tests identified in Subchapter 6 of the
Urgent Care Clinic
				Manual
may be billed in addition to an urgent care
				visit.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.416 - Laboratory Services: Introduction

Current through Register 1525, July 5, 2024
The MassHealth agency only pays UCCs for those laboratory
				services listed in Subchapter 6 of the
Urgent Care Clinic
				Manual
. The MassHealth agency pays a UCC for 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 the restrictions and limitations described in 130 CMR 455.000, and
				130 CMR 450.000:
Administrative and Billing Regulations
. In order for a UCC to
				be paid for any laboratory service, a written request for that service from an
				authorized prescriber must be present in the member's medical
				record.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.417 - Laboratory Services

Current through Register 1525, July 5, 2024
A UCC may claim payment for the laboratory services listed in
				Subchapter 6 of the
Urgent Care Clinic Manual
only when all of
				the following conditions are met.
(A)
			 The laboratory services are performed in the UCC.
(B) The laboratory tests are performed on
			 properly and regularly calibrated equipment, and daily controls are carried
			 out.
(C) The UCC has been certified
			 by the Centers for Medicare & Medicaid Services (CMS) for performing
			 in-house clinical laboratory services, based on the criteria set forth in the
			 Clinical Laboratory Improvement Amendments (CLIA) of 1988, as it may be
			 amended. In addition, the UCC's 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 UCC must make the results of the proficiency testing
			 programs available to the MassHealth agency and the Attorney General's Medicaid
			 Fraud Division upon request or during an on-site visit.
(D) If the UCC is located in-state, the UCC
			 has been approved by the Massachusetts Department of Public Health to perform
			 in-house clinical laboratory services. If the UCC is located out-of-state, in
			 addition to meeting the requirements of 130 CMR 455.404(B), 455.417(A) through
			 (C), and
			 130 CMR
			 450.109:
Out-of-state
			 Services
, the UCC must also meet its own state's requirements for
			 performing in-house clinical laboratory services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.418 - Laboratory Services: Service Limitations

Current through Register 1525, July 5, 2024
(A)
			 The MassHealth agency does not pay a UCC for services listed as non-covered
			 services or for which payment limits apply in accordance with the MassHealth
			 Independent Clinical Laboratory Manual at
			 130 CMR 401.000:
Independent Clinical Laboratory
.
(B) The MassHealth agency does not pay a UCC
			 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).
(C) The MassHealth agency
			 does not pay a UCC for the professional component of a clinical laboratory
			 service. The MassHealth agency will pay a UCC for the professional component of
			 an anatomical service, as provided in Subchapter 6 of the
Urgent Care
			 Clinic Manual
(for example, bone marrow analysis or analysis of a
			 surgical specimen).
(D) In no event
			 may a UCC bill or be paid separately for each of the tests included in a
			 profile or panel test (as defined herein) when a profile or panel test has
			 either been performed by that UCC or requested by an authorized person. A
			 profile or panel test is defined as any group of tests, whether performed
			 manually, automatedly, or semiautomatedly, that is ordered for a specified
			 member on a specified day and has at least one of the following
			 characteristics.
(1) The group of tests is
			 designated as a profile or panel by the UCC performing the tests.
(2) The group of tests is performed by the
			 UCC at a usual and customary fee that is lower than the sum of that UCC's usual
			 and customary fees for the individual tests in that group.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.419 - Laboratory Services: Services Performed by Outside Laboratories

Current through Register 1525, July 5, 2024
(A) A UCC may not bill the MassHealth agency
			 for laboratory services provided outside the UCC. In this case, the testing
			 laboratory should bill the MassHealth agency directly for those
			 services.
(B) When sending a
			 specimen to an outside laboratory, the UCC must include the member's MassHealth
			 identification number and the UCC's MassHealth provider number.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.420 - Radiology Services: Introduction

Current through Register 1525, July 5, 2024
The MassHealth agency will pay for the radiology services in
				Subchapter 6 of the
Urgent Care Clinic Manual
only when the
				services are provided at the written request of a licensed physician or
				dentist. All radiology equipment used in providing these services must be
				inspected and approved by the Massachusetts Department of Public
				Health.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.421 - Radiology Services: Service Limitations

Current through Register 1525, July 5, 2024
(A)
Definitions
.
Global Fee
- the rate of payment for
				the two components of a radiology service: the professional component and the
				technical component.
Professional Component
- the component
				of a radiology service for interpreting a diagnostic test or image.
Technical Component
- the component of
				a radiology service for the cost of rent, equipment, utilities, supplies,
				administrative and technical salaries and benefits, and other overhead
				expenses.
(B)
Payment of the Global Fee
. The MassHealth agency will
			 pay a UCC the global fee for performing a radiology service at the UCC when one
			 of the following conditions is met.
(1) The
			 UCC owns or leases the equipment for providing the technical component of the
			 service, employs a technician to provide the technical component of the
			 service, and employs a board-certified or board-eligible radiologist to provide
			 the professional component of the service.
(2) The UCC employs a board-certified or
			 board-eligible radiologist to provide the professional component of the service
			 and the UCC subcontracts with a licensed Medicare-certified entity to provide
			 the technical component of the service.
(3) The UCC subcontracts with a licensed
			 Medicare-certified entity to provide the professional and technical component
			 of the service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 455.000 - Urgent Care Clinic Services › Section 455.422 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) The urgent care
			 clinic is responsible for ensuring the medical necessity of the services and
			 maintaining test results in the member's health record. Payment for any service
			 listed in 130 CMR 455.000 is conditioned upon its full and complete
			 documentation in the member's medical record and must be maintained for at
			 least six years. Payment for maintaining the member's medical record is
			 included in the fee for the service.
(B) In order for a medical record to document
			 completely a service or services to a member, that record must set forth the
			 nature, extent, quality, and necessity of care provided to the member. When the
			 information contained in a member's medical record is not sufficient to
			 document the service for which payment is claimed by the provider, the
			 MassHealth agency will disallow payment for the claimed service.
(C) The MassHealth agency may at its
			 discretion request, and upon such request the UCC must provide, any and all
			 medical records of members corresponding to or documenting the services
			 claimed, in accordance with M.G.L. c. 118E, § 38, and
			 130 CMR
			 450.205:
Recordkeeping and
			 Disclosure
. The MassHealth agency may produce, or at its option may
			 require the UCC to produce, photocopies of medical records instead of actual
			 records when compliance with 130 CMR 455.422(C) would otherwise result in
			 removal of medical records from the UCC's office.
(D) The medical record must include, but is
			 not limited to
(1) the date of each
			 service;
(2) the member's name,
			 address, telephone number, date of birth, and MassHealth identification
			 number;
(3) the name, title, and
			 signature of the person performing the service;
(4) the member's medical history;
(5) the diagnosis or chief
			 complaint;
(6) a written order for
			 the tests or treatment to be performed and the respective results;
(7) the name of the supervising
			 physician;
(8) clear indication of
			 all findings, whether positive or negative, on examination;
(9) any medications administered or
			 prescribed, including strength, dosage, and regimen;
(10) a description of any treatment
			 given;
(11) recommendations for
			 additional treatments or consultations, when applicable;
(12) pertinent findings on examination;
			 and
(13) any medical goods or
			 supplies dispensed or prescribed.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.401 - Nursing Facility Services: Introduction

Current through Register 1525, July 5, 2024
130 CMR
				456.000 establishes the requirements for nursing
				facility services under MassHealth. All nursing facilities participating in
				MassHealth must comply with the regulations governing MassHealth including, but
				not limited to,
				130 CMR
				456.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth pays for nursing facility services only when
			 provided to eligible MassHealth members, subject to the restrictions and
			 limitations in MassHealth regulations. MassHealth's regulations at
			 130
			 CMR 450.105:
Coverage Types
specifically state which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of Emergency Aid to the Elderly, Disabled and
			 Children
. For information on covered services for recipients of
			 Emergency Aid to the Elderly, Disabled and Children,
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 456.000 - Long Term Care Services › Section 456.404 - Requirements for Provider Participation: In-state

Current through Register 1525, July 5, 2024
To be eligible to participate in MassHealth, a nursing facility
				located in Massachusetts must
(A) be
			 licensed by the Massachusetts Department of Public Health to operate such a
			 facility;
(B) be continuously
			 certified by the Massachusetts Department of Public Health as meeting the
			 federal requirements for participation in MassHealth in accordance with Title
			 XIX of the Social Security Act and the Medicare program under Title XVIII of
			 the Social Security Act to the extent required under
			 130
			 CMR 456.406;
(C) participate in the Medicare program under
			 Title XVIII of the Social Security Act to the extent required under
			 130
			 CMR 456.406;
(D) enter into a provider agreement with
			 MassHealth;
(E) accept MassHealth
			 payments as payment in full for nursing facility services pursuant to
			 130
			 CMR 450.203:
Payment in
			 Full
; and
(F) agree to
			 periodic inspections, by MassHealth or its designee, that assess compliance
			 with 130 CMR
			 456.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.405 - Requirements for Provider Participation: Out-of-state

Current through Register 1525, July 5, 2024
To be eligible to participate in MassHealth, an out-of-state
				nursing facility must
(A) be licensed
			 by the appropriate state licensing authority to operate such a
			 facility;
(B) be continuously
			 certified by the state survey agency as meeting the federal requirements for
			 participation in Medicaid in accordance with Title XIX of the Social Security
			 Act and the Medicare program under Title XVIII of the Social Security Act to
			 the extent required under
			 130
			 CMR 456.406;
(C) participate in the Medicare program under
			 Title XVIII of the Social Security Act to the extent required under
			 130
			 CMR 456.406;
(D) enter into a provider agreement with
			 MassHealth;
(E) accept MassHealth
			 payments as payment in full for nursing facility services pursuant to
			 130
			 CMR 450.203:
Payment in
			 Full
; and
(F) agree to
			 periodic inspections, by MassHealth or its designee, that assess compliance
			 with 130 CMR
			 456.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.406 - Medicare Certification Requirement

Current through Register 1525, July 5, 2024
Nursing facilities must be certified for participation in the
				Medicare program pursuant to Title XVIII of the Social Security Act, as amended
				from time to time, and regulations promulgated thereunder. If a facility or
				institution has only one unit licensed to provide skilled-nursing care, then
				that unit must be Medicare certified. A facility with more than one unit
				licensed to provide skilled-nursing care may have one non-Medicare-certified
				unit. For a facility that was a MassHealth provider as of October 1, 1990,
				failure to comply with this requirement may result in an imposition of an
				administrative fine by the MassHealth agency, or may result in the facility's
				suspension from participation in MassHealth. For any facility applying to be a
				MassHealth provider after October 1, 1990, including facilities built after
				October 1, 1990, and facilities participating in MassHealth on October 1, 1990,
				that subsequently changed owners, failure to comply with this requirement will
				preclude such facility from participating in MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.407 - Clinical Authorization of Nursing Facility Services

Current through Register 1525, July 5, 2024
(A) Clinical authorization for nursing
			 facility services may be for a specified or indefinite length of stay.
			 Authorizations for an indefinite length of stay may be subject to review by the
			 MassHealth agency or its agent to ensure that conditions for payment continue
			 to be met. A clinical authorization is required
(1) before the first date of service delivery
			 for which the nursing facility is seeking payment from MassHealth;
(2) when a member is transferred from one
			 nursing facility to another nursing facility;
(3) when a member who is hospitalized is to
			 be admitted to a different nursing facility from the one the member resided in
			 before the hospital admission;
(4)
			 when a member who has been hospitalized for over six months seeks to be
			 readmitted to the nursing facility where the member resided before hospital
			 admission; and
(5) when a nursing
			 facility determines that a member has discharge potential, or the member may no
			 longer meet the clinical eligibility criteria described in
			 130
			 CMR 456.409.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.408 - Conditions for Payment

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for nursing facility services if all of the following conditions
			 are met.
(1) The MassHealth agency or its
			 designee has determined that individuals 22 years of age or older meet the
			 nursing facility services requirements of
			 130
			 CMR 456.409 or the multidisciplinary medical
			 review team coordinated by the Department of Public Health has determined that
			 individuals 21 years of age or younger meet the criteria of
			 130
			 CMR 519.006(A):
Eligibility Requirements
.
(2) The MassHealth agency or its designee has
			 determined that community care is either not available or not appropriate to
			 meet the individual's needs.
(3)
			 The requirements for the pre-admission screening and resident review (PASRR)
			 process in
			 130
			 CMR 456.410 and as required by sub-regulatory
			 guidance have been met. Failure to follow applicable PASRR rules will result in
			 denial of MassHealth payments to the nursing facility for MassHealth members
			 during the period of noncompliance pursuant to
			 42 CFR
			 483.122
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.410 - The Preadmission Screening and Resident Review (PASRR) Process for Intellectual Disability (ID), Developmental Disability (DD), and/or Serious Mental Illness (SMI)

Current through Register 1525, July 5, 2024
(A)
Introduction
. Pursuant to
			 42 U.S.C.
			 1396r(e)(7)
et
			 seq
. and 42 CFR
			 483.100
et seq
., each
			 individual, regardless of payment source, seeking admission to a nursing
			 facility must be screened before admission to a nursing facility to identify
			 individuals who have or are suspected to have ID, DD, and/or SMI.
(B)
PASRR Level I
			 Screening
.
(1) A Level I
			 screening using the EOHHS PASRR Level I Screening form (Level I Screening Form)
			 must be completed prior to admission for all individuals seeking admission to a
			 nursing facility, regardless of payment source.
(2) The Level I Screening Form must also be
			 completed for resident reviews, upon a significant change in condition, and in
			 any other circumstance required by EOHHS in sub-regulatory guidance. The
			 completed Level I Screening Form must be submitted to the appropriate PASRR
			 authority (DDS or its designee for ID or DD; DMH or its designee for SMI) and
			 be kept in the resident's medical record at the facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.411 - Review of Need for Continuing Care in a Nursing Facility

Current through Register 1525, July 5, 2024
(A) When a nursing facility determines during
			 any of the quarterly reviews required by the Omnibus Budget Reconciliation Act
			 of 1987 (OBRA 87) and implemented by regulations at
			 42 CFR
			 483.20 that the member has discharge
			 potential, then the facility must notify MassHealth or its agent.
(B) When the nursing facility is notified by
			 MassHealth or its agent that the member no longer meets the conditions for
			 payment criteria under
			 130
			 CMR 456.408(A), the nursing
			 facility must initiate the nursing facility's discharge plan for the member in
			 collaboration with MassHealth or its agent. All discharges must be in
			 accordance with the federal requirements found at
			 42 CFR
			 483.15(c) and with
			 130
			 CMR 456.701 through
			 456.704.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.412 - Notification and Right of Appeal

Current through Register 1525, July 5, 2024
(A)
			 MassHealth or its agent will notify the member or applicant and the referral
			 source or nursing facility who submitted the request for institutional services
			 on the member's behalf of the approval or denial of the request for
			 authorization of nursing facility services. If authorization for nursing
			 facility services is denied, the notification will contain the following
			 information:
(1) the reason for the
			 denial;
(2) the explanation of the
			 member's right to appeal; and
(3) a
			 description of the appeal procedure.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.413 - Resident Rights

Current through Register 1525, July 5, 2024
A nursing facility must inform any resident or applicant for
				admission, regardless of payment method, of all rights the person has as a
				resident of the facility, including but not limited to, the resident rights
				provided for under 42 CFR
				483.10.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.414 - Mobility Systems

Current through Register 1525, July 5, 2024
A nursing facility is responsible for the provision of mobility
				systems for members residing in the facility. However, MassHealth will pay a
				durable medical equipment (DME) provider, in accordance with
				130
				CMR 409.415(A):
MassHealth Members Residing in Nursing Facilities
, for the
				purchase, rental, or repair of medically necessary mobility systems and
				positioning seating systems, except for equipment described in
				130
				CMR 409.415(A)(1)  when
				being purchased solely for the full-time use of a member while residing in the
				nursing facility. The nursing facility in which the member resides is
				responsible for payment to the DME provider for the first $500 towards the
				purchase of the mobility system unless the member has a written discharge plan
				in accordance with
				130
				CMR 409.415(A)(1)(b). For
				custom positioning seating systems, the nursing facility must check its
				existing inventory for a wheelchair base that can be used for a customized
				seating system for the sole use of the member. In circumstances in which the
				nursing facility has a base, the nursing facility is not responsible for the
				$500.00.