reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.406 - Covered Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for medically necessary orthotics and orthotic services pursuant to
			 the governing of the
Orthotics Manual
, Subchapter 6; the
			 Prosthetics Payment and Coverage Guidelines Tool; and any other guidance issued
			 by the MassHealth agency or its designee. MassHealth covers orthotics that are
			 appropriate for use in the member's home or any setting in which normal life
			 activities take place in the community, subject to the requirements of
			 130 CMR
			 442.000, and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
, including
			 130
			 CMR 450.204:
Medical
			 Necessity
.
(B)
Therapeutic Shoes for Diabetics, Inserts and
			 Modifications
. MassHealth covers therapeutic shoes for diabetics,
			 inserts and modifications under the following conditions, subject to compliance
			 with 130 CMR
			 442.000 and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
(1) MassHealth covers
			 therapeutic shoes for diabetics only when prescribed by a DO or MD.
(2) In all cases, the member must have a
			 documented diagnosis of diabetes mellitus and meet one or more of the following
			 conditions:
(a) previous amputation of the
			 other foot, or part of either foot;
(b) history of previous foot ulceration of
			 either foot;
(c) history of
			 pre-ulcerative calluses of either foot;
(d) peripheral neuropathy with evidence of
			 callus formation of either foot;
(e) foot deformity of either foot (must
			 clearly indicate the foot deformity); or
(f) poor circulation in either
			 foot.
(3) For non-custom
			 therapeutic shoes for diabetics, the shoe must meet all of the following
			 guidelines in addition to the member meeting the requirements of 130 CMR
			 442.406(B)(2):
(a) contain a full length,
			 heel-to-toe filler that when removed provides a minimum of 
			 3/16" of additional
			 depth used to accommodate custom molded or customized inserts;
(b) be made from leather or suitable material
			 of equal quality;
(c) have some
			 form of shoe closure; and
(d) be
			 available in full and half sized with a minimum of three widths so that the
			 shoe is graded to the size and width of the upper portion of the shoe according
			 to the American Standard last sizing schedule or its equivalent. This includes
			 a shoe with or without an internally seamless toe.
(4) For custom-molded therapeutic shoes for
			 diabetics, the shoe must meet all of the following guidelines, in addition to
			 the member meeting the requirements of 130 CMR 442.406(B)(2):
(a) be constructed over a positive model of
			 the member's foot;
(b) be made from
			 leather or suitable material of equal quality;
(c) have removable inserts that can be
			 altered or replaced as the member's condition warrants; and
(d) have some form of shoe closure.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.407 - Service Limitations

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				orthotics subject to the service limitations set forth in
				130 CMR
				442.000; the
Orthotics Manual
,
				Subchapter 6; and the MassHealth Orthotics and Prosthetics Payment and Coverage
				Guidelines Tool, subject to the Early and Periodic Screening, Diagnosis, and
				Treatment provisions set forth in
				130
				CMR 450.144(A):
EPSDT Services: Diagnosis and Treatment
.
(A)
Nonstandard Size (Width or
			 Length)
. A provider may bill an additional charge for a
			 nonstandard size for off-the-shelf, medical-grade orthopedic shoes once per
			 pair.
(B)
Split-size
			 Change
. A provider may bill a split-size charge for off-the-shelf,
			 medical-grade orthopedic shoes once per pair.
(C)
Custom-molded Shoe
			 Inserts
. When a manufacturer offers a custom-molded shoe that
			 includes the insert, the provider of orthotics must not bill separately for the
			 initial insert.
(D)
Closure Modification
. When a manufacturer offers an
			 off-the-shelf shoe that comes standard with either lace or velcro enclosures,
			 the provider of orthotics must choose the appropriate shoe to meet the member's
			 needs, and not bill separately for closure modification.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.408 - Non-covered Services

Current through Register 1525, July 5, 2024
MassHealth does not pay for any of the following:
(A) any orthotics for which, under comparable
			 circumstances, the provider of orthotics does not customarily bill private
			 patients who do not have health insurance;
(B) nonmedical items: items that are used
			 primarily and customarily for a nonmedical purpose are not considered
			 orthotics, even if the item has a medically related use;
(C) therapeutic shoes for diabetics that are
			 not listed on the PDAC Product Classification List, with an associated HCPCS
			 code;
(D) an additional charge for
			 nonstandard size (width or length) in custom-molded shoes;
(E) orthotics that are not provided in
			 accordance with the MassHealth Orthotics and Prosthetics Payment and Coverage
			 Guidelines tool, or other guidance issued by the MassHealth agency or its
			 designee;
(F) orthotics that are
			 not reasonably 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;
(G) orthotics that are not
			 listed as covered services in Subchapter 6 of the
Orthotics
			 Manual
and the MassHealth Orthotics and Prosthetics Payment and
			 Coverage Guidelines Tool or any other guidance issued by the MassHealth agency
			 or its designee, unless prior authorization has been issued by the MassHealth
			 agency or its designee;
(H)
			 orthotics provided to members in facilities that are not permissible under
			 130
			 CMR 442.410;
(I) repairs that do not meet the requirements
			 of 130 CMR 442.411 and
			 130
			 CMR 442.410 (if applicable);
(J) orthotics that are experimental or
			 investigational in nature as described in
			 130
			 CMR 450.204(E):
Medical Necessity
; and
(K) orthotics furnished through a
			 consignment/stock and bill closet (unless permitted by specific MassHealth
			 guidance).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.409 - Prescribing Provider Orders and Other Documentation Requirements

Current through Register 1525, July 5, 2024
(A)
Initial Orders
.
			 The initial order may be written, verbal, or electronically transmitted (in
			 accordance the applicable federal and state laws, rules and guidance) by the
			 member's prescriber. A verbal initial order must be simultaneously documented
			 in writing by an employee of the provider of orthotics.
(1) The verbal, written, or electronically
			 transmitted initial order must include:
(a)
			 the date the provider of orthotics obtains or receives the initial order from
			 the prescribing provider;
(b) a
			 general description of the orthotic service that is the subject of the initial
			 order
(c) the member's
			 name;
(d) the name of prescribing
			 provider giving the initial order; and
(e) the name and title of the employee of the
			 provider of orthotics who obtained or received the initial order, and in the
			 case of a verbal initial order, documented the initial order in
			 writing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.410 - Orthotic Services Provided to Members in Facilities

Current through Register 1525, July 5, 2024
(A)
Nursing
			 Facilities
. MassHealth pays for the purchase and repair of
			 orthotics provided for the personal exclusive use of a member residing in a
			 nursing facility.
(B)
Hospitals
. MassHealth does not pay orthotics providers
			 for the purchase or repair of orthotics provided to a hospitalized member,
			 except for orthotics that are prescribed for home use after discharge. The
			 orthotics provider must document the member's discharge plan in the member's
			 record. Documentation must indicate that the date of discharge was the date the
			 claim was submitted for the purchase or repair of the prescribed
			 item.
(C)
Intermediate
			 Care Facilities for the Intellectually Disabled (ICF/IID)
.
(1) MassHealth pays orthotics providers for
			 the purchase and repair of custom-fabricated orthotics provided for the
			 personal exclusive use of a member residing in an ICF/IID only if the
			 customization precludes the use of the item by subsequent residents in that
			 institution.
(2) MassHealth does
			 not pay orthotic providers for the purchase or repair of orthotics that are not
			 custom fabricated provided to a member residing in an ICF/IID, except for
			 therapeutic shoes for diabetics, modifications and inserts, and associated
			 repairs, provided for the personal exclusive use of a member residing in the
			 ICF/IID.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.411 - Repairs of Orthotic Products

Current through Register 1525, July 5, 2024
(A)
			 MassHealth covers repairs subject to prior authorization under
			 130
			 CMR 442.412(F). MassHealth
			 may cover, at its discretion, repair of an item only if the repair is less than
			 the cost to replace the item.
(B)
			 The provider of orthotics is liable for the quality of the workmanship and
			 parts, and for ensuring that repaired item is in proper working
			 condition.
(C) The provider of
			 orthotics must exhaust all manufacturer warrantees before submitting claims for
			 repairs to orthotics to the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.412 - Prior Authorization

Current through Register 1525, July 5, 2024
The orthotics provider must obtain prior-authorization (PA)
				from MassHealth or its designee for all orthotics or orthotic services
				identified as subject to PA in the MassHealth Orthotics and Prosthetics Payment
				and Coverage Guidelines Tool or other guidance specified by MassHealth or its
				designee, or as otherwise required by
				130 CMR
				442.000 and
				130
				CMR 450.303:
Prior
				Authorization
. Prior authorization is a determination of medical
				necessity only, and does not establish or waive any other prerequisites for
				payment, such as member eligibility or requirements to seek payment from other
				liable parties.
(A)
Documentation of Medical Necessity
.
(1) PA requests must include:
(a) a completed MassHealth Prior
			 Authorization Request form (the MassHealth PA-1 form adopted by MassHealth or
			 its designee);
(b) a detailed
			 written order that meets the requirements of
			 130
			 CMR 442.409(B);
(c) for all orthotics that are identified as
			 requiring individual consideration (IC) in the pricing regulation,
			 101 CMR
			 334.00:
Protheses, Prosthetic Devices and
			 Orthotic Devices
and which are also identified as subject to prior
			 authorization in the Orthotics and Prosthetics Payment and Guidelines Tool,
			 Subchapter 6, or in other guidance issued by MassHealth or its designee:
1. a copy of the original invoice, if
			 applicable, that reflects all discounts to be applied to determine the
			 provider's adjusted acquisition cost as defined in
			 101
			 CMR 334.02:
Prostheses, Prosthetic
			 Devices and Orthotic Devices
; or
2. if the item has not been purchased by the
			 provider at the time of the prior authorization request, or when the item being
			 purchased is not an item that the provider normally purchases within its scope
			 of business, MassHealth will accept a quote from the provider's supplier. The
			 quote must be on the supplier's letterhead or form and must be addressed to the
			 provider; and
3. any additional
			 assessments of the member or other necessary information requested by the
			 MassHealth agency or its designee, in support of the request for prior
			 authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.413 - Medical Necessity Criteria

Current through Register 1525, July 5, 2024
(A) All
			 orthotics covered by MassHealth must meet the medical necessity requirements
			 set forth in
			 130 CMR
			 442.000, and
			 450.204:
Medical
			 Necessity
, in the Orthotics and Prosthetics Payment and Coverage
			 Guidelines Tool, and in any other medical necessity guidelines for specific
			 orthotics issued by MassHealth or its designee.
(B) For items covered by MassHealth, for
			 which there is no MassHealth item-specific medical necessity guideline and for
			 which there is a Medicare LCD policy developed by CMS indicating Medicare
			 coverage of the item under at least some circumstances, the provider must
			 demonstrate medical necessity of the item consistent with the Medicare LCD.
			 However, if the provider believes the orthotic is medically necessary even
			 though it does not meet the criteria established by the LCD, the provider must
			 demonstrate medical necessity under
			 130
			 CMR 450.204:
Medical
			 Necessity
.
(C) For an item
			 covered by MassHealth, for which there is no MassHealth item-specific medical
			 necessity guideline and for which there is a Medicare LCD indicating that the
			 item is not covered by Medicare, the provider must demonstrate medical
			 necessity under
			 130
			 CMR 450.204:
Medical
			 Necessity
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.414 - Medicare and Other Third-party Coverage

Current through Register 1525, July 5, 2024
(A)
			 For members with Medicare and other third-party-liability coverage,
see
130
			 CMR 450.316 through
			 450.318.
(B) When Medicare or another third-party
			 payer denies a claim for orthotic services, the provider is required to have a
			 MassHealth prior authorization (PA) in place for all orthotics the MassHealth
			 agency, or its designee identifies as subject to PA in the MassHealth Orthotics
			 and Prosthetics Payment and Coverage Guidelines Tool or other guidance
			 specified by MassHealth or its designee, or as otherwise required by
			 130 CMR
			 442.000 or
			 130
			 CMR 450.303:
Prior
			 Authorization
.
(C) The
			 MassHealth agency, or its designee, may request documentation of a provider's
			 diligent efforts to collect payment from Medicare or other liable parties,
			 including documentation of compliance with Medicare's billing and authorization
			 requirements. If documentation requested by the MassHealth agency, or its
			 designee is not received within the timeframe specified, or the documentation
			 is incomplete or does not support payment by MassHealth, the associated claims
			 will be denied. If the MassHealth agency determines that a provider did not
			 make diligent efforts to bill other insurances and that other liable parties
			 should have been billed, the provider will be subject to audits.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.416 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				orthotics or orthotic 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
				442.000, and with prior authorization pursuant to
				130
				CMR 442.412.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.419 - Quality Management and Program Integrity

Current through Register 1525, July 5, 2024
Orthotics providers shall comply with applicable CMS and
				MassHealth quality standards and participate in any quality measurement program
				requirements established by the MassHealth agency, including making any
				necessary data available and providing access to the provider's place of
				business upon request by MassHealth or its designee.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.420 - Conditions of Payment

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for orthotics in accordance with the applicable payment methodology
			 and rate schedule established by EOHHS at
			 101 CMR
			 334.00:
Prostheses, Prosthetic Devices and
			 Orthotic Devices
.
(B)
			 Providers of orthotics must accept MassHealth payment as payment in full for
			 orthotics and orthotic services according to the rates established by EOHHS at
			 101 CMR
			 334.00:
Prostheses, Prosthetic Devices and
			 Orthotic Devices
.
(C)
			 Payments are subject to the conditions, exclusions, and limitations set forth
			 in 130 CMR
			 442.000 and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
(D) An
			 Initial Order is not a condition of payment. As set forth in 130 CMR
			 442.420(D)(1) through (5), a Detailed Written Order is a condition of payment.
			 MassHealth pays for orthotics only if:
(1)
			 the MassHealth agency, or its designee determines that the orthotics are
			 medically necessary;
(2) the member
			 meets the clinical eligibility criteria for the orthotics;
(3) the provider has obtained a detailed
			 written order in accordance with
			 130
			 CMR 442.409;
(4) the provider has obtained prior
			 authorization, if necessary, in accordance with the requirements set forth in
			 130
			 CMR 442.412; and
(5) the provider has diligently sought
			 payment from all other liable parties in accordance with
			 130
			 CMR 442.405(I)  and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.421 - Claims for Items Priced at Individual Consideration

Current through Register 1525, July 5, 2024
The MassHealth agency will not accept a quote attached to a
				claim for orthotics that are identified in
				101 CMR
				334.00:
Prostheses, Prosthetic Devices and
				Orthotic Devices
; the Orthotics and Prosthetics Payment and Guidelines
				Tool; or in other guidance issued by MassHealth, as requiring individual
				consideration (I.C.). For items designated as I.C., the provider must:
(A) attach the actual manufacturer's invoice
			 dated within six months of the prior authorization request to the claim
			 submission;
(B) not accept a
			 printed invoice or order from a manufacturer's web site; and
(C) keep a copy of the quote and the invoice
			 on file.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.424 - Delivery of Orthotics

Current through Register 1525, July 5, 2024
(A)
Proof of Delivery
. Orthotics providers must maintain
			 proof of delivery (POD) in the member's medical record. POD documentation must
			 be made available to the MassHealth agency upon request. Orthotic providers may
			 use one of three methods to deliver orthotics to the member: direct delivery;
			 delivery
via
shipping; or delivery in anticipation of hospital
			 discharge. The orthotics provider, in conjunction with the member or their
			 designee, will determine the method of delivery.
(B)
Timelines of
			 Delivery
. The orthotics provider must ensure that orthotics are
			 delivered within a reasonable time after receipt of the detailed written order
			 and any required documentation or approval for the item. This includes
			 referring the member to another orthotics provider, when timely delivery cannot
			 be made by the current orthotics provider. The MassHealth agency, or its
			 designee, reserves the right to issue additional subregulatory guidance on
			 reasonableness of delivery times for customized orthotics and specific orthotic
			 items.
(C)
Direct
			 Delivery
. The orthotics provider may deliver the orthotic product
			 directly to the member or dispense the product to the member at the provider's
			 service location. In this case the POD must be a signed and dated delivery
			 slip. The POD documentation must include:
(1)
			 member's name;
(2) sufficiently
			 detailed description to identify the item(s) being delivered (such as, brand
			 name, HCPCS code, narrative description);
(3) quantity delivered;
(4) date delivered; and
(5) member (or member's designee) signature
			 and date of signature. The date of signature on the delivery slip must be the
			 date that the orthotic product was received by the member or member's
			 designee.
(6) In instances of
			 direct delivery, for purposes of filing a claim for payment, the date of
			 service on the claim must be the date the member received the orthotics, as
			 evidenced by the date of the member's (or member's designee) signature on the
			 delivery slip.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 442.000 - Orthotics Services › Section 442.425 - Prohibited Marketing Activities

Current through Register 1525, July 5, 2024
An orthotic provider shall not:
(A) with the knowledge that a member is
			 enrolled in a MassHealth capitated program, engage in any practice that would
			 reasonably be expected to have the effect of steering or encouraging the member
			 to disenroll from the MassHealth capitated program in order to retain the
			 provider to provide services on a fee-for-service basis; or
(B) offer to a member, or his or her family
			 or caregivers, in-person or through marketing, any inducement to retain the
			 provider to provide orthotic services, such as a financial incentive, reward,
			 gift, meal, discount, rebate, giveaway, or special opportunity;
(C) pay a "finder's fee" to any third-party
			 in exchange for referring a member to the orthotic provider; or
(D) engage in any unfair or deceptive acts or
			 practices in connection with any marketing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 447.000 establishes the requirements for the provision
				and payment of acupuncture services under MassHealth. All acupuncturists
				participating in MassHealth must comply with MassHealth regulations including,
				but not limited to, 130 CMR 447.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in 130 CMR 447.000 have the meanings
				given in 130 CMR 447.402, unless the context clearly requires a different
				meaning. The reimbursability of services defined in 130 CMR 447.000 is not
				determined by these definitions, but by application of 130 CMR 447.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Acupuncture
. The insertion of metal
				needles through the skin at certain points on the body, with or without the use
				of herbs, with or without the application of an electric current, and with or
				without the application of heat to the needles, skin, or both.
Dry Needling
. The use of solid needles
				to treat muscle pain by stimulating and breaking muscular knots and
				bands.
Office Visit
. A visit by a MassHealth
				member to an acupuncturist's office for evaluation and management services
				performed by a MassHealth-enrolled acupuncturist.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for acupuncture services only
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each coverage type,
			 which services are covered and which members are eligible to receive those
			 services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
The MassHealth agency pays only acupuncturists who are
				participating in MassHealth on the date of service. Acupuncturists must meet
				the following eligibility requirements.
(A)
In-state
			 Providers
. To be eligible to participate in MassHealth, an
			 in-state acupuncturist must
(1) be licensed as
			 a provider of acupuncture by the Massachusetts Board of Registration in
			 Medicine under
			 243
			 CMR 5.00:
The Practice of
			 Acupuncture
; and
(2) be an
			 active MassHealth provider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.405 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The Executive Office of Health and Human Services (EOHHS)
				determines the payment rate for acupuncture services in accordance with
				101
				CMR 317.00:
Rates for Medicine
				Services
. Payment is subject to the conditions, exclusions, and
				limitations set forth in 130 CMR 447.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.406 - Reporting Requirements

Current through Register 1525, July 5, 2024
Acupuncturists who furnish services to MassHealth members must
				report the results of these services to the member's primary care provider or
				Primary Care Clinician (PCC) in writing. The acupuncturist may report the
				results of treatment initially by telephone, but he or she must then submit a
				written report of the initial consultation and subsequent periodic
				reevaluations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.407 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				acupuncture services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnostic and Treatment (EPSDT) Services: Introduction,
without regard to service limitations described in 130 CMR 447.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.413 - Covered Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for medically necessary acupuncture for the treatment of pain and
			 for use for detoxification as described in
			 130 CMR
			 418.406(D)(4):
Acupuncture Detoxification
. Services must address the
			 patient's condition and if no clinical benefit is appreciated after four
			 sessions, then the treatment plan must be reevaluated. Further acupuncture
			 treatment is not considered medically necessary if the patient does not
			 demonstrate meaningful improvement in symptoms.
(B) The MassHealth agency will pay for one
			 office visit per member every four weeks. A provider may bill the MassHealth
			 agency for both an office visit and acupuncture treatment rendered to a member
			 on the same day in accordance with 130 CMR 447.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.414 - Non-covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for the following:
(A) dry needling;
(B) acupuncture for purposes other than those
			 identified in 130 CMR 447.413(A);
(C) performing, administering, or dispensing
			 any experimental, unproven, cosmetic, or otherwise medically unnecessary
			 procedure or treatment;
(D) the
			 treatment of male or female infertility (including, but not limited to,
			 laboratory tests, drugs, and procedures associated with such treatment);
			 or
(E) otherwise payable service
			 codes when those codes are used to bill for circumstances that are not payable
			 under 130 CMR 447.414.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.415 - Service Limitations

Current through Register 1525, July 5, 2024
The MassHealth agency limits payment for acupuncture services
				to a total of 20 treatments per member per calendar year, without prior
				authorization. Acupuncture treatments above these limits require prior
				authorization in accordance with 130 CMR 447.416.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.416 - Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Services that Require Prior Authorization
. The
			 MassHealth agency requires that the acupuncturist obtain prior authorization as
			 a prerequisite to payment for more than 20 treatments per member per calendar
			 year.
(B)
Submission
			 Requirement
. The acupuncturist must submit all prior authorization
			 requests in accordance with the billing instructions in Subchapter 5 of the
Acupuncture Manual
. Prior authorization determines only the
			 medical necessity of the authorized service, and does not establish or waive
			 any other prerequisites for payment, such as member eligibility, or resort to
			 health insurance payment.
See
130 CMR
			 450.303:
Prior Authorization
for additional information about prior authorization.
(C)
Notice of Approval or Denial
			 of Prior Authorization
.
(1)
Notice of Approval
. For all approved prior
			 authorization requests for acupuncture services, the MassHealth agency sends
			 written notice to the member and the acupuncturist about the frequency,
			 duration, and intensity of care authorized, and the effective date of
			 authorization.
(2)
Notice of Denial or Modification and Right of Appeal
.
(a) For all denied or modified prior
			 authorization requests, the MassHealth agency notifies both the member and the
			 acupuncturist of the denial or modification and the reason. In addition, the
			 member will receive information about the member's right to appeal and the
			 appeal procedure.
(b) A member may
			 request a fair hearing from the MassHealth agency if it denies or modifies a
			 prior authorization request. The member must request a fair hearing in writing
			 within 30 days after the date of receipt of the notice of denial or
			 modification. The MassHealth Board of Hearings will conduct the hearing in
			 accordance with
			 130 CMR 610.000:
MassHealth: Fair Hearing Rules
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 447.000 - Acupuncture Services › Section 447.417 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) Federal and
			 state regulations require that all MassHealth providers maintain complete
			 written medical records of all patients who are MassHealth members. Medical
			 records must comply with the provisions of
			 233
			 CMR 4.04:
Insurance Requirements for
			 Limited Liability Companies and Limited Liability Partnerships
. All
			 records must be kept for a minimum of six years after the date of service.
			 Payment for maintaining the member's medical record is included in the fee for
			 acupuncture services. Each medical record must contain sufficient information
			 to document fully the nature, extent, quality, and necessity of the care
			 furnished to the member for each date of service claimed for payment. If the
			 documentation is not sufficient to justify the service for which payment is
			 claimed by the provider, the MassHealth agency will not pay for the service or,
			 if payment has been made, may consider such payment to be an overpayment
			 subject to recovery in accordance with
			 130 CMR 450.000:
Administrative and Billing Regulations
.
(B) The medical records must contain the
			 following:
(1) MassHealth member
			 identification, including name, address, telephone number, date of birth, and
			 the MassHealth member's identification number;
(2) a complete medical history;
(3) examination results, including a
			 description of the chief complaint and diagnosis;
(4) a written referral from the member's
			 primary care provider or PCC;
(5)
			 copies of all prior authorization requests for out-of-state services;
(6) the date and nature of each visit,
			 including a complete description of services furnished, written and signed by
			 the acupuncturist;
(7) when more
			 than one visit is indicated, a treatment plan for future visits written and
			 signed by the acupuncturist, which is updated on an ongoing basis to reflect
			 changes in the member's presenting symptoms;
(8) upon completion of treatment, a summary
			 of the treatment and the member's current condition;
(9) recommendations for additional treatment,
			 signed and dated by the acupuncturist; and (10) if the medical record or any
			 component included therein is released for use by another party, the medical
			 record must also contain a release form signed by the member. Release of the
			 medical record to MassHealth for authorized use does not require the member's
			 consent.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				448.000 establishes requirements for participation of
				community behavioral health centers in MassHealth. All community behavioral
				health centers participating in MassHealth must comply with the MassHealth
				regulations, including but not limited to,
				130 CMR
				448.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. MassHealth covers community
			 behavioral 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) For information on verifying member
			 eligibility and coverage type,
see
130
			 CMR 450.107:
Eligible Members and the
			 MassHealth Card
.
(D) 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 448.000 - Community Behavioral Health Center Services › Section 448.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A) A center is
			 eligible to participate only if the center is
(1) physically located within the
			 Commonwealth of Massachusetts;
(2)
			 enrolled as a Medicare provider;
(3) enrolled 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 community behavioral
			 health center services;
(4)
			 licensed by DPH as
(a) a clinic with a mental
			 health service designation and a substance use disorder service designation;
			 or
(b) a hospital or hospital
			 satellite that provides outpatient mental health and substance use disorder
			 services;
(5) certified
			 by the DPH Bureau of Substance Addiction Services through a Certificate of
			 Approval for Substance Use Disorder services for outpatient counseling and
			 outpatient withdrawal management; and
(6) holding a current Clinical Laboratory
			 Improvement Amendments (CLIA) certificate of waiver.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.405 - Provider Enrollment Process

Current through Register 1525, July 5, 2024
(A) A separate,
			 complete application for enrollment as a community behavioral health center
			 must be submitted for each clinic location. 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 the regulations in
			 130 CMR
			 448.000.
(1) Based on
			 the information in the enrollment application, information known to the
			 MassHealth agency about the applicant, and 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 will 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 448.000 - Community Behavioral Health Center Services › Section 448.406 - Required Notifications and Reports

Current through Register 1525, July 5, 2024
(A)
Annual Report
. Each community behavioral health center
			 must submit a completed annual report, on forms furnished by the MassHealth
			 agency, and file them with the MassHealth agency annually. 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 Center
			 Administrative and Clinical Management Staff identified in
			 130
			 CMR 448.413(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 independently
			 licensed;
(3) a statement
			 describing the current language capacities, capacity to provide services to
			 specialized populations, and utilization of trauma-informed modalities of the
			 center;
(4) written attestation
			 that the center is in compliance with
			 130 CMR
			 448.000; and
(5) any other information that the MassHealth
			 agency may request.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.407 - Revocation of Enrollment and Sanctions

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency has the right to review a community behavioral health center's continued
			 compliance with the conditions for enrollment referred to in
			 130
			 CMR 448.405 and the reporting requirements in
			 130
			 CMR 448.406 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:
Administrative and Billing
			 Regulations
, as applicable.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.408 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for community behavioral health center services with rates set by
			 the Executive Office of Health and Human Services (EOHHS), subject to the
			 conditions, exclusions, and limitations set forth in
			 130 CMR
			 448.000. EOHHS fees for community behavioral health
			 center services are contained in
			 101 CMR
			 305.00:
Rates for Behavioral Health Services
			 Provided in Community Behavioral Health Centers
.
(B)
Administrative
			 Operations
. Payment by the MassHealth agency for community
			 behavioral health center services includes payment for administrative
			 operations and for all aspects of service delivery not explicitly included in
			 130 CMR
			 448.000, such as, but not limited to
(1) completion of member registration and
			 intake, which may be completed on a telephonic or walk-in basis, and must
			 include accumulating and recording at least the minimally required member
			 information necessary to facilitate diagnostic evaluation services, including
			 the members' presenting concern, and for referral to an appropriate provider or
			 service;
(2) communication with
			 members or other parties that may include processes for appointment reminders
			 or coordination of care;
(3) staff
			 supervision or consultation with another staff member within the community
			 behavioral health center;
(4)
			 providing information for the coordination of referrals; and
(5) recordkeeping.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.409 - Nonreimbursable Services

Current through Register 1525, July 5, 2024
(A)
Nonmedical Services
. The MassHealth agency does not
			 pay community behavioral 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); and
(5) life enrichment services (ego enhancing
			 services such as workshops or educational courses provided to functioning
			 persons).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.410 - 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
			 must 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 448.000 - Community Behavioral Health Center Services › Section 448.411 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				community behavioral health center services for EPSDT eligible members in
				accordance with
				130
				CMR 450.140
et seq
., without
				regard to service limitations described in
				130 CMR
				448.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.412 - 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 448.415, and as part of the treatment
			 plan in accordance with
			 130
			 CMR 448.412(A)(3). A center
			 must have the capacity to provide at least the services set forth in
			 130
			 CMR 448.412(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 448.412(A)(7).
(1)
Intake Services
.
			 Intake services must be completed on the initial date of service. Intake must
			 include
(a) a brief assessment to determine
			 appropriate services; and
(b)
			 triage to appropriate services.