reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.478 - Mental Health Services: Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) The hospital outpatient department must
			 obtain, upon the initiation of treatment, written authorization from each
			 member or the member's legal guardian to release information obtained by the
			 provider to hospital staff, federal and state regulatory agencies, and, when
			 applicable, referral providers, to the extent necessary to carry out the
			 purposes of the program and to meet regulatory requirements, including provider
			 audits.
(B) In addition to the
			 information required in
			 130 CMR
			 410.409, each member's record must include
			 the following information:
(1) the member's
			 case number, address, telephone number, sex, age, marital status, next of kin,
			 and school or employment status (or both);
(2) the date of initial contact and, if
			 applicable, the referral source;
(3) a report of a physical examination
			 performed within six months (if such an examination has not been performed in
			 that period, one must be given within 30 days after the member's request for
			 services or, if the member refuses to be examined, the record must document the
			 reasons for the exam postponement);
(4) the name and address of the member's
			 primary physician or medical clinic (a physician or medical clinic must be
			 recommended if there is not one currently attending the member);
(5) a description of the nature of the
			 member's condition;
(6) the
			 relevant medical, social, educational, and vocational history;
(7) a comprehensive functional assessment of
			 the member;
(8) the clinical
			 impression of the member and a diagnostic formulation, including a specific
			 diagnosis using the current International Classification of Diseases, Clinical
			 Modification (ICD) or the
American Psychiatric Association's Diagnostic
			 and Statistical Manual
(DSM) diagnosis codes;
(9) the member's treatment plan, updated as
			 necessary, including long-range goals, short-term objectives, and the proposed
			 schedule of therapeutic activities;
(10) a schedule of dates for utilization
			 review to determine the member's progress in accomplishing goals and
			 objectives;
(11) the name,
			 qualifications, and discipline of the primary therapist;
(12) a written record of utilization reviews
			 by the primary therapist;
(13)
			 documentation of each visit, including the member's response to treatment,
			 written and signed by the person providing the service, and including the
			 therapist's discipline and degree;
(14) all information and correspondence
			 regarding the member, including appropriately signed and dated consent
			 forms;
(15) a medication-use
			 profile;
(16) when the member is
			 discharged, a discharge summary; and
(17) for members under the age of 21, a CANS
			 completed during the initial behavioral-health assessment and updated at least
			 every 90 days thereafter.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.479 - Mental Health Services: Service Limitations

Current through Register 1525, July 5, 2024
(A)
Provision of Services
.
(1) The MassHealth agency will pay for
			 diagnostic and treatment services only when a professional staff member
			 personally provides these services to the member or the member's family, or
			 personally consults with a professional outside of the hospital outpatient
			 department. The services must be provided to the member on an individual
			 basis.
(2) The MassHealth agency
			 will pay for only one session of the types of services listed in 130 CMR
			 410.479(C) through (H) provided to an individual member on one date of service.
			 Return visits on the same date of service are not reimbursable.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.480 - Mental Health Services: Child and Adolescent Needs and Strengths (CANS) Data Reporting

Current through Register 1525, July 5, 2024
For each Child and Adolescent Needs and Strengths (CANS)
				conducted, the hospital must report data collected during the assessment to the
				MassHealth agency, in the manner and format specified by the MassHealth
				agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.481 - Vision Care Services

Current through Register 1525, July 5, 2024
(A)
Introduction
. Vision care services are the
			 professional care of the eyes for purposes of diagnosing and correcting
			 refractive errors, analyzing muscular anomalies, and determining pathological
			 conditions. They include eye examinations, vision training, and the
			 prescription and dispensing of ophthalmic materials. Professional and technical
			 services must be provided in accordance with the established standards of
			 quality and health care necessity recognized by the vision care industry and
			 licensing agencies in Massachusetts.
(B)
Provision of Vision Care
			 Services
. The MassHealth agency pays for vision care services,
			 including the dispensing of ophthalmic materials, provided to MassHealth
			 members by an acute hospital outpatient department, HLHC or other hospital
			 satellite clinic. These services must be furnished in accordance with, and
			 coverage of such services and related prescription requirements for authorized
			 prescribers are governed by
			 130 CMR
			 402.000:
Vision Care Services
.
			 Payment is subject to the conditions, exclusions, and limitations set forth in
			 130 CMR
			 402.000.
(C)
Payment
. Acute
			 hospital outpatient departments and HLHCs are paid pursuant to
			 101 CMR
			 315.000:
Vision Care Services and Ophthalmic
			 Materials
for services described as ophthalmic materials dispensing in
			 Subchapter 6 of the
Vision Care Manual
. All other vision care
			 services provided by an acute hospital outpatient department, HLHC or other
			 hospital satellite clinic are paid according to the outpatient hospital payment
			 methodology established by the signed MassHealth provider agreement.
(D)
Prior
			 Authorization
.
(1) For certain
			 vision care services specified in
			 130 CMR
			 402.000:
Vision Care Services
, the
			 MassHealth agency requires the provider to obtain prior authorization as a
			 prerequisite to payment.
(2) All
			 prior authorization requests must be submitted in accordance with the
			 instructions in Subchapter 5 of the
Outpatient Hospital
			 Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.401 - Introduction

Current through Register 1525, July 5, 2024
All psychologists participating in MassHealth must comply with
				the regulations of the MassHealth agency including, but not limited to,
				regulations set forth in
				130 CMR
				411.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency covers psychologist services only
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in
			 130 CMR
			 411.000 and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
. The regulations at
			 130
			 CMR 450.105:
Coverage Types
specifically state, for each MassHealth coverage type, which services are
			 covered and which members are eligible to receive those services.
(2)
Recipients of the Emergency
			 Aid to the Elderly, Disabled and Children Program
. For information
			 on covered services for recipients of the Emergency Aid to the Elderly,
			 Disabled and Children (EAEDC) 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 411.000 - Psychologist Services › Section 411.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR
				411.000 is made only to providers who are
				participating in MassHealth as of the date of service. The eligibility
				requirements are as follows.
(A)
In State
. A psychologist is eligible to participate in
			 MassHealth only if the psychologist is licensed to practice by the
			 Massachusetts Board of Registration of Psychologists, with a specialization
			 listed in clinical or counseling psychology, neuropsychology, or a closely
			 related specialty, and is a Medicare provider.
(B)
Out of State
. A
			 psychologist located outside of Massachusetts is eligible to participate in
			 MassHealth only if the psychologist is licensed to practice by his or her
			 state's appropriate board of registration, and is a Medicare provider.
			 Out-of-state psychological services are covered only as provided in
			 130
			 CMR 450.109:
Out-of-state
			 Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.405 - Payable Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for medically necessary services
				personally provided by an eligible psychologist, subject to the restrictions
				and limitations in
				130 CMR
				411.000.
(A)
			 The MassHealth agency pays for medically necessary services provided in any
			 suitable location, such as the psychologist's office, the member's place of
			 residence, other facility, or by telehealth.
(B) The MassHealth agency pays for the
			 following services personally provided by an eligible psychologist:
(1) psychological assessment, including:
(a) intelligence assessment;
(b) personality assessment; and
(c) neuropsychological assessment
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.407 - Nonpayable Circumstances

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay a psychologist for services
				provided under any of the following circumstances.
(A) The psychologist provided the service in
			 a facility approved by the MassHealth agency and is paid by the facility to
			 provide that service, whether or not the cost of the service is included in the
			 MassHealth agency's rate of payment for that facility.
(B) The psychologist provided the service in
			 a facility that is organized to provide primarily nonmedical services and is
			 paid by the facility to provide the service.
(C) The psychologist already received or will
			 receive payment for the service from the Commonwealth, county, or
			 municipality.
(D) Under comparable
			 circumstances, the psychologist does not customarily bill patients who do not
			 have health insurance.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.408 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The Executive Office of Health and Human Services (EOHHS)
				determines the maximum allowable fees for psychologist services as set forth in
				101 CMR
				329.00:
Rates for Psychiological and Licensed
				Independent Clinical Social Work Services
. The fees include payment
				for the complete cost of psychological assessments of the member including
				scoring the test, interpreting the results, writing the report, and other
				psychological diagnostic and treatment services. Payment is always subject to
				the conditions, exclusions, and limitations set forth in
				130 CMR
				411.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
. Payment for a service is made at the lower of the
				following:
(A) the psychologist's
			 usual and customary charge to the general public for the same or similar
			 service; or
(B) the maximum
			 allowable fee listed in the applicable EOHHS fee schedule.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.409 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				psychologist 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
				411.000 and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.410 - Orders

Current through Register 1525, July 5, 2024
The MassHealth agency pays a psychologist for psychological
				assessment when the following conditions are met:
(A) A qualified individual responsible for
			 providing services to the member orders the psychological assessment. This
			 ensures that the service is provided within the context of an overall service
			 plan. A qualified individual includes a physician, psychologist, physician
			 assistant, nurse practitioner, clinical nurse specialist, psychiatric clinical
			 nurse specialist, or licensed independent clinical social worker who is either
			 practicing independently, or as staff of a community health center, mental
			 health center or hospital. Any other individual or entity wishing to order
			 psychological assessment (such as therapists or other staff at clinics, day
			 habilitation centers, intermediate care facilities for individuals with
			 intellectual disabilities, hospitals, schools, courts, group homes, or state
			 agencies) must coordinate with a qualified individual to obtain the necessary
			 order.
(B) Upon request by the
			 MassHealth agency, the provider must provide documentation that psychological
			 assessment was initiated and provided in accordance with
			 130
			 CMR 411.410(A)(1). The
			 MassHealth agency may deny or recover payment if the provider fails to provide
			 such documentation to the MassHealth agency when requested.
(C) The MassHealth agency pays a psychologist
			 for psychological assessment for the purposes of determining or redetermining
			 eligibility for the EAEDC Program pursuant to
			 130
			 CMR 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
, only if a physician or
			 qualified individual on the staff of a community health center orders such
			 assessment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.412 - Procedures for Psychological Assessment

Current through Register 1525, July 5, 2024
As a prerequisite to payment, the psychologist must:
(A) interact directly with the member during
			 assessment, with the exception noted in
			 130
			 CMR 411.414(C);
(B) personally administer and score the test,
			 with the exception noted in
			 130
			 CMR 411.414(C);
(C) personally evaluate the responses to the
			 test;
(D) write a report of the
			 evaluation results in a manner that communicates useful information to the
			 individual or agency ordering such assessment; and
(E) forward a copy of the comprehensive
			 report to the ordering individual or agency without additional charge to the
			 MassHealth agency, ordering individual or agency, or member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.414 - Service Limitations

Current through Register 1525, July 5, 2024
(A)
Frequency of Psychological Assessment
. The MassHealth
			 agency does not pay for a psychological assessment if the psychologist or
			 another MassHealth provider has provided the same type of psychological
			 assessment (intelligence, neuropsychological, or personality) to the member
			 within the preceding six months, unless the following conditions exist and are
			 documented in the billing provider's medical record:
(1) Psychological assessment is provided in
			 order to ascertain changes relating to suicidal, homicidal, traumatic, or
			 neurological conditions of the member; or
(2) Psychological assessment is provided in
			 order to ascertain changes following specialized treatment or interventions
			 such as electroconvulsive therapy (ECT) or inpatient psychiatric
			 treatment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 412.000 - Renal Dialysis Clinic Services › Section 412.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 412.000 establishes
				the Division's requirements for providers of renal dialysis clinic services.
				All providers of renal dialysis clinic services participating in MassHealth
				must comply with 130 CMR governing MassHealth including but not limited to
				130 CMR 412.000 and
				450.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 412.000 - Renal Dialysis Clinic Services › Section 412.404 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The Division covers renal dialysis clinic services only
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in
			 130 CMR 412.000, 450.00 and
			 501.00 through 522.00.
			 130 CMR 450.105
			 specifically states, for each MassHealth coverage type, which services are
			 covered and which members are eligible to receive those services.
(2)
Recipients of the Emergency
			 Aid to the Elderly, Disabled and Children Program
. For information
			 on covered services for recipients of the Emergency Aid to the Elderly,
			 Disabled and Children Program, see
			 130 CMR
			 450.106.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 412.000 - Renal Dialysis Clinic Services › Section 412.405 - Provider Eligibility

Current through Register 1525, July 5, 2024
A renal dialysis clinic must be a participant in MassHealth on
				the date of service in order to be e ligible for payment .
(A)
In-State
			 Providers
. To be eligible for participation as a MassHealth
			 provider, a renal dialysis clinic must be :
(1) located and doing business in the
			 Commonwealth of Massachusetts;
(2)
			 enrolled as a Medicare provider; and
(3) licensed as an out-of-hospital dialysis
			 unit by the Massachusetts Department of Public Health, Bureau of Hospital
			 Facilities.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 412.000 - Renal Dialysis Clinic Services › Section 412.408 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The Massachusetts Division of HealthCare Finance and Policy
				determines the maximum allowable fees for renal dialysis clinic services.
				Payment is always subject to the conditions, exclusions, and limitations set
				forth in
				130 CMR 450.000. The
				maximum allowable fees for renaldialysis clinic services are the lowest of the
				following:
(A) the clinic's usual and
			 customary fee;
(B) the clinic's
			 actual charge submitted; or
(C) the
			 maximum allowable fee listed in the applicable Division of Health Care Finance
			 and Policy fee schedule.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 412.000 - Renal Dialysis Clinic Services › Section 412.409 - Covered Services

Current through Register 1525, July 5, 2024
(A)
Renal Dialysis
. The Division covers medically
			 necessary renal dialysis for eligible MassHealth members. Renal dialysis
			 includes all services, supplies, and routine laboratory tests as specified in
			 Subchapter 6 of the
Renal Dialysis Clinic Manual
.
(B)
Prescribed
			 Drugs
. The Division limits payment to dialysis clinics for
			 prescribed drugs to those specified in the service codes and descriptions in
			 Subchapter 6 of the
Renal Dialysis Clinic Manual
.
(C)
Training for Home
			 Dialysis
. The Division pays for home dialysis training, including
			 self-dialysis (hemodialysis, intermittent peritonealdialysis, and continuous
			 cycling peritoneal dialysis) and continuous ambulatory peritoneal dialysis
			 training only where the MassHealth member attends such training at the clinic
			 site.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.401 - Introduction

Current through Register 1525, July 5, 2024
All speech and hearing centers participating in MassHealth must
				comply with MassHealth regulations, including but not limited to
				130 CMR 413.000 and
				450.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers audiological and hearing aid services
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in
			 130 CMR 413.000 and
			 450.000.
			 130 CMR 450.105
			 specifically states, for each MassHealth coverage type, which services are
			 covered and which members are eligible to receive those services.
(2)
Recipients of the Emergency
			 Aid to the Elderly, Disabled, and Children Program
. For
			 information on covered services for recipients ofthe Emergency Aid to the
			 Elderly, Disabled and
Children Program,
see
130 CMR
				450.106.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
In
			 State
. To be eligible to participate in MassHealth, a speech and
			 hearing center must currently:
(1) be
			 licensed by the Massachusetts Department of Public Health;
(2) be certified by the American
			 Speech-Language-Hearing Association (ASHA);
(3) not be a part of a hospital;
(4) provide authorized speech, hearing, or
			 language services provided by a licensed, certified audiologist or a licensed,
			 certified speech therapist who does not bill separately from such facility for
			 professional services; and
(5) meet
			 the requirements of
			 130 CMR
			 450.212.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.405 - Services Provided by Out-of-state Providers

Current through Register 1525, July 5, 2024
Inaccordance with
				42 CFR
				431.52(b), the MassHealth
				agency pays for out-of-state speech and hearing center services only in the
				following circumstances.
(A) Services
			 are needed and the member's health would be endangered if the member were
			 required to travel to his or her state of residence.
(B) The MassHealthagency determines, on the
			 basis of medical advice, that the needed services, or necessary supplementary
			 resources, are more readily available in another state.
(C) As a general practice, members in a
			 particular locality use medical resources in another state.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.406 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The MassHealth agency pays the lowest of the following for
				speech and language pathology services, audiological services, hearing aids,
				and related batteries and accessories:
(A) the speech and hearing center's usual and
			 customary fee;
(B) the charge the
			 speech and hearing center has submitted to the MassHealth agency on the claim
			 form; or
(C) the maximum fee listed
			 in the applicable fee schedule of the Massachusetts Division of Health Care
			 Finance and Policy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.407 - Individual Consideration

Current through Register 1525, July 5, 2024
Services designated "I.C." in the list of service codes and
				descriptions in Subchapter 6 of the
Speech and Hearing Center
				Manual
are given individual consideration to determine the amount of
				payment. The amount of payment is determined by using the following
				criteria:
(A) the time required to
			 perform the procedure;
(B) the
			 degree of skill required to perform the procedure;
(C) the severity or complexity of the
			 member's hearing disorder or disability;
(D) the policies, procedures, and practices
			 of other third-party purchasers of health care; and
(E) the reasonable and customary practices of
			 speech and hearing centers.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.408 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) Services
			 designated "P.A." in the list of service codes and descriptions in Subchapter 6
			 of the
Speech and Hearing Center Manual
require prior
			 authorization from the MassHealth agency. Such services include, but are not
			 limited to:
(1) more than 35 speech and
			 language pathology visits, including group-therapy visits, for a member in a
			 12-month period; and
(2) continuing
			 therapy when payment has been discontinued by any other third-party payer,
			 including Medicare.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.416 - Payable Services

Current through Register 1525, July 5, 2024
(A)
Comprehensive Evaluation
. Payment for a comprehensive
			 evaluation includes the preparation of a written report for the member's
			 medical record that contains at least the following information:
(1) the member's name and address;
(2) the name of the referring licensed
			 physician or licensed nurse practitioner;
(3) a detailed treatment plan prescribing the
			 type, amount, frequency, and duration of the therapy and indicating the
			 diagnosis, anticipated goals, and location where therapy will take place, or
			 the reason treatment is not indicated;
(4) a description of any conferences with the
			 member, the member's family, the member's clinician, or other interested
			 persons;
(5) other health-care
			 evaluations, as indicated;
(6) a
			 description of the member's psychosocial and health status that includes:
(a) the present effects of the disability on
			 the member and his or her family;
(b) a brief history, the date of onset, and
			 any past treatment of the disability;
(c) the member's level of functioning, both
			 current and before onset of the disability, if applicable; and
(d) any other significant physical or mental
			 disability that may affect therapy;
(7) assessment of articulation,
			 stimulability, voice, fluency, and receptive and expressive language;
(8) documentation of the member's cognitive
			 functioning;
(9) a description of
			 the member's communication needs and motivation for treatment;
(10) the therapist's signature and the date
			 of the evaluation; and
(11) the
			 prognosis.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.417 - Nonpayable Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for any of the following
				services:
(A) services provided by any
			 person under the supervision of the speech therapist or audiologist;
(B) indirect services such as staff meetings,
			 staff supervision, member screening, and development or use of instructional
			 texts and reusable treatment materials;
(C) nonmedical services such as vocational,
			 social, and recreational services;
(D) research or experimental
			 treatment;
(E) mental health
			 services; and
(F) the rental of
			 hearing aids.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.418 - Service Limitations

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays the speech and hearing centers for no more than one individual
			 treatment and one group therapy session per member per day.
(B) The MassHealth agency does not pay for a
			 treatment claimed for the same date of service as a comprehensive evaluation,
			 since the evaluation fee includes payment for both a written report and for any
			 treatment provided at the time of the evaluation.
(C) The MassHealth agency pays speech and
			 hearing centers for providing therapy services in a Medicare-certified
			 long-term-care facility only in the following circumstances.
(1) The member is not covered under Medicare
			 Part A or B.
(2) The member is
			 covered under Medicare, the facility has submitted the claim to Medicare, and
			 Medicare has denied payment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.419 - Medical Referral Requirements

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays only for those treatments and evaluations for which the
			 speech and hearing center has obtained written referral from a licensed
			 physician or licensed nurse practitioner. The referral must include the
			 following information:
(1) a complete
			 diagnosis of the member;
(2) the
			 date of onset of the disability for which therapy is recommended;
(3) a statement of previous treatment, if
			 any;
(4) the date of the member's
			 last physical examination;
(5) the
			 reason for the referral;
(6) the
			 date of the referral; and
(7) the
			 physician's or nurse practitioner's signature and address.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 413.000 - Speech And Hearing Center Services › Section 413.420 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
The speech and hearing center must maintain a health-care
				service record for each member for a period of at least four years following
				the date of service. The record must contain all pertinent information about
				the services provided, including the date of service and the dates on which
				materials were ordered and dispensed. The record must include the
				following:
(A) a licensed physician's
			 or licensed nurse practitioner's written and dated referral for evaluation and
			 referral for treatment, if applicable;
(B) the written comprehensive evaluation
			 report (see
			 130 CMR 413.416(A)
			  );
(C) the name, address, and telephone number
			 of the member's primary care physician; and
(D) at least weekly documentation of the
			 following:
(1) the date or dates of which
			 speech therapy or aural rehabilitation was provided;
(2) the specific therapeutic procedures and
			 methods used;
(3) the member's
			 response to treatment;
(4) any
			 changes in the member's condition;
(5) the problems encountered or changes in
			 the treatment plan or goals, if any;
(6) the location where the service was
			 provided, if different from that in the evaluation report;
(7) the amount of time spent in treatment;
			 and
(8) the speech therapist's
			 signature.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.401 - Introduction

Current through Register 1525, July 5, 2024
130
				CMR 414.000 states the requirements for the payment of
				nursing services provided by an independent nurse participating in MassHealth
				and apply to nurses who contract independently with MassHealth. All independent
				nurses participating in MassHealth must comply with MassHealth regulations
				including, but not limited to,
				130
				CMR 414.000 and
				450.000:
Administrative and Billing Regulations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency covers nursing services provided by
			 independent nurses only when provided to eligible MassHealth members, subject
			 to the restrictions and limitations described in MassHealth regulations at
			 130
			 CMR 414.000 and
			 450.000:
Administrative and Billing Regulations.
130 CMR 450.105:
Coverage Types
specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
To participate in MassHealth as a MassHealth independent nurse
				provider, a nurse must
(A) be licensed
			 and in good standing as a nurse by the board of registration in nursing for the
			 state in which the nursing services are provided;
(B) meet all provider eligibility
			 requirements at
			 130 CMR
			 450.212:
Provider Eligibility:
			 Eligibility Criteria
, including
			 130 CMR
			 450.212(A)(6);
(C) sign a MassHealth provider contract and
			 receive a MassHealth provider number. The MassHealth agency does not pay an
			 independent nurse for nursing services provided before the date on which the
			 nurse is approved by the MassHealth agency to participate in MassHealth;
			 and
(D) notify the MassHealth
			 agency in writing within 14 days of any change in any of the information
			 submitted in the provider application in accordance with
			 130 CMR
			 450.223(B).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.408 - Continuous Skilled Nursing Services

Current through Register 1525, July 5, 2024
(A)
Member Eligibility for Continuous Skilled Nursing
			 Services
. A member is clinically eligible for MassHealth coverage
			 of continuous skilled nursing (CSN) services when all of the following criteria
			 are met:
(1) there is a clearly identifiable,
			 specific medical need for a nursing visit of more than two continuous
			 hours;
(2) the CSN services require
			 the skills of a registered nurse or of a licensed practical nurse in accordance
			 with 130 CMR 414.408(B); and
(3)
			 the CSN services are medically necessary to treat an illness or injury in
			 accordance with
			 130 CMR
			 414.409(D).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.409 - Conditions of Payment

Current through Register 1525, July 5, 2024
(A)
Place of Service
. The MassHealth agency pays for
			 nursing services to a member who meets the clinical criteria in
			 130 CMR
			 414.408 and resides in a noninstitutional
			 setting, which may include, without limitation, a homeless shelter or other
			 temporary residence or a community setting. In accordance with
			 42 CFR
			 440.70(c), the MassHealth
			 agency does not pay for nursing services provided in a hospital, nursing
			 facility, intermediate care facility for the mentally retarded, or any other
			 institutional setting providing medical, nursing, rehabilitative, or related
			 care.
(B)
Service
			 Limitation
. The MassHealth agency does not pay an independent
			 nurse for a nursing visit of less than two continuous hours in
			 duration.
(C)
Limit of
			 Hours
. The MassHealth agency does not pay an independent nurse for
			 more than 60 hours of nursing care provided during any consecutive seven-day
			 period or for more than 12 hours within a 24-hour period, regardless of the
			 number of MassHealth members receiving care from the independent
			 nurse.
(D)
Medical
			 Necessity Requirement
. In accordance with
			 130 CMR
			 450.204:
Medical Necessity
,
			 the MassHealth agency pays for only those nursing services that are medically
			 necessary.
(E)
Plan of
			 Care
. The MassHealth agency pays only for nursing services
			 provided pursuant to a plan of care authorized by a physician and that meets
			 the plan of care requirements at
			 130 CMR
			 414.412(B).
(F)
Continuous Skilled Nursing
			 (CSN)
. The MassHealth agency pays for CSN services when
(1) the member meets the clinical eligibility
			 criteria for CSN services as stated in
			 130 CMR
			 414.408;
(2) the CSN services are provided under an
			 individualized plan of care developed for the member in accordance with
			 130 CMR 414.412;
			 and
(3) prior authorization for CSN
			 services has been obtained from the MassHealth agency or its designee, in
			 accordance with
			 130 CMR
			 414.413.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.410 - Multiple-patient Care

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for one nurse to provide CSN services simultaneously to more than
			 one member, but not more than three members, if
(1) the members have been determined by the
			 MassHealth agency or its designee to meet the criteria listed at
			 130 CMR
			 414.408;
(2) the members receive services in the same
			 household and during the same time period;
(3) the MassHealth agency or its designee has
			 determined that it is appropriate for one nurse to provide nursing services to
			 the members simultaneously; and
(4)
			 the independent nurse has received a separate prior authorization from the
			 MassHealth agency or its designee for each member as described in
			 130 CMR
			 414.413.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.412 - Plan of Care

Current through Register 1525, July 5, 2024
All nursing services must be provided under an individualized
				plan of care developed for the member. The physician must sign the plan of care
				before services are provided to the member.
(A)
Providers Qualified to
			 Establish a Plan of Care
.
(1) The
			 member's physician must establish a written plan of care and recertify, sign,
			 and date the plan of care every 60 calendar days.
(2) The independent nurse may establish an
			 additional plan of care, when appropriate, that may be incorporated into the
			 physician's plan of care, or be prepared separately. The additional plan of
			 care does not substitute for the physician's plan of care.
(3) If an independent nurse is co-vending a
			 case with other providers, each provider is responsible for ensuring that the
			 member's medical record includes each independent nurse and each home health
			 agency's own plan of care, including their own set of written physician's
			 orders.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.413 - Prior Authorization Requirements

Current through Register 1525, July 5, 2024
(A)
			 Prior Authorization must be obtained from the MassHealth agency or its designee
			 as a prerequisite for payment for CSN services and before services are provided
			 to the member. Without such prior authorization, CSN services will not be paid
			 by the MassHealth agency.
(B) 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.
(C) The MassHealth agency or its designee
			 will conduct the assessment of need for CSN services and coordinate other
			 MassHealth community long-term-care services for the member, as appropriate.
			 When the MassHealth agency or its designee conducts an assessment of need for
			 CSN services and authorizes CSN services for the member, the member will select
			 the independent nurse who will be responsible for providing CSN services. The
			 MassHealth agency or its designee will provide written notification of its
			 assessment to the member, and if applicable, the independent nurse selected by
			 the member.
(D) The MassHealth
			 agency or its designee will specify on the prior authorization for CSN services
			 the number of CSN hours that have been determined to be medically necessary and
			 that are authorized for the member per calendar week and the duration of the
			 prior authorization. Any CSN hours provided to the member by the independent
			 nurse that exceed what the MassHealth agency or its designee has authorized in
			 a calendar week are not payable by MassHealth.
(E) If the frequency of the nursing services
			 needs to be adjusted because the member's medical needs have changed, the
			 independent nurse must contact the MassHealth agency or its designee to request
			 an adjustment to the prior authorization.
(F) Prior authorization for CSN services may
			 be approved for more than one home health agency or independent nurse, or both,
			 provided that
(1) each provider is authorized
			 only for a specified portion of the member's total hours; and
(2) the sum total of the combined hours
			 approved for co-vending providers does not exceed what the MassHealth agency or
			 its designee has determined to be medically necessary and authorized for the
			 member per calendar week.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.414 - Notice of Approval or Denial of Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Notice of
			 Approval
. For all approved prior authorization requests for
			 nursing services, the MassHealth agency or its designee sends written notice to
			 the member and the independent nurse specifying the frequency, duration, and
			 intensity of care authorized, and the effective date of the
			 authorization.
(B)
Notice of Denial or Modification and Right of Appeal
.
(1) For all denied or modified prior
			 authorization requests, the MassHealth agency or its designee notifies both the
			 member and the independent nurse of the denial or modification, reason, right
			 to appeal, and appeal procedure.
(2) A member may request a fair hearing from
			 the MassHealth agency if the MassHealth agency or its designee denies or
			 modifies a prior authorization request. The member must request a fair hearing
			 in writing within 30 days after the date of the denial or modification. The
			 Office of Medicaid Board of Hearings conducts the hearing in accordance with
			 130 CMR 610.000:
MassHealth: Fair Hearing Rules.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.416 - Overtime

Current through Register 1525, July 5, 2024
(A) The MassHealth agency pays an overtime
			 rate for nursing services provided by an independent nurse only in the case of
			 a documented emergency and for a short-term basis, not to exceed 30 consecutive
			 calendar days, and when all of the following conditions are met:
(1) prior authorization for overtime has been
			 obtained from the MassHealth agency or its designee;
(2) nursing services are provided by the same
			 independent nurse and exceed 40 hours in a given calendar week for one
			 MassHealth member; and
(3)
			 documentation from a minimum of two home health agencies or independent nurses
			 has been provided that demonstrates, to the satisfaction of the MassHealth
			 agency or its designee, that the independent nurse has attempted to find other
			 nurses to fill the nursing hours that exceed 40 hours for the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.418 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
(A) Independent
			 nurse providers must accept MassHealth payment in full for nursing services
			 according to the rates and regulations established by the Division of Health
			 Care Finance and Policy (DHCFP) as set forth in 114. 3 CMR 50.00:
Home
			 Health Services.
Payments are subject to the conditions, exclusions,
			 and limitations set forth in
			 130
			 CMR 414.000 and
			 450.000:
Administrative and Billing Regulations.
(B) The payments made by the MassHealth
			 agency to the independent nurse constitute payment in full for nursing services
			 as well as for all administrative duties relating to such services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.419 - Denial of Services and Administrative Review

Current through Register 1525, July 5, 2024
(A) A failure or refusal by an independent
			 nurse to furnish services that have been ordered by the member's attending
			 physician and that are within the range of payable services is not an action by
			 the MassHealth agency or its designee that a member may appeal, but such
			 failure or refusal constitutes a violation of
			 130
			 CMR 414.000 for which administrative sanctions may be
			 imposed.
(B) When an independent
			 nurse believes that services ordered by the attending physician are not payable
			 under
			 130
			 CMR 414.000, the independent nurse must refer the
			 matter to the MassHealth agency for a payment decision. If and to the extent
			 the MassHealth agency determines that the ordered services are payable, the
			 independent nurse must provide those services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 415.000 establishes
				the requirements for the provision of services by acute inpatient hospitals
				under MassHealth. The word "hospital" in
				130 CMR 415.000 refers
				specifically to an acute inpatient hospital or unit only, unless the context
				clearly indicates otherwise. The MassHealth agency pays for inpatient hospital
				services that are medically necessary and appropriately provided as defined by
				130 CMR
				450.204:
Medical Necessity
.
				The quality of such services must meet professionally recognized standards of
				care.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for acute inpatient hospital
			 services only when provided to MassHealth members, subject to the restrictions
			 and limitations described in MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.