reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.405 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The MassHealth agency pays for physician 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
				433.000. EOHHS fees for physician services are
				contained in the following chapters of the Code of Massachusetts
				Regulations:
(A)
								101 CMR 315.00:
Vision Care Services and Ophthalmic Services
(B)
								101 CMR
			 316.00:
Surgery and Anesthesia
			 Services
(C)
								101
			 CMR 317.00:
Medicine
(D)
								101
			 CMR 318.00:
Radiology
(E)
								101
			 CMR 320.00:
Clinical Laboratory
			 Services
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.406 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency has designated certain services in Subchapter 6 of the
Physician
			 Manual
as requiring individual consideration. This means that the
			 MassHealth agency will establish the appropriate rate for these services based
			 on the standards and criteria set forth in 130 CMR 433.406(B). Providers
			 claiming payment for any service requiring individual consideration must submit
			 with such claim a report that includes a detailed description of the service,
			 and is accompanied by supporting documentation that may include, but is not
			 limited to, an operative report, pathology report, or in the case of a
			 purchase, a copy of the supplier's invoice. The MassHealth agency does not pay
			 claims for services requiring individual consideration unless it is satisfied
			 that the report and documentation submitted by the provider are adequate to
			 support the claim.
See
130 CMR
			 433.410 for report requirements.
(B) The MassHealth agency determines the
			 appropriate payment for a service requiring individual consideration in
			 accordance with the following standards and criteria:
(1) the amount of time required to perform
			 the service;
(2) the degree of
			 skill required to perform the service;
(3) the severity and complexity of the
			 member's disease, disorder, or disability;
(4) any applicable relative-value
			 studies;
(5) any complications or
			 other circumstances that the MassHealth agency deems relevant;
(6) the policies, procedures, and practices
			 of other third-party insurers;
(7)
			 the payment rate for drugs as set forth in the MassHealth pharmacy regulations
			 at
			 130 CMR
			 406.000:
Pharmacy
; and
(8) for drugs or supplies, a copy of the
			 invoice from the supplier showing the actual acquisition cost.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.407 - Service Limitations: Professional and Technical Components of Services and Procedures

Current through Register 1525, July 5, 2024
Additional limitations are set forth in
				130 CMR
				433.413 and
				433.437.
(A)
Definitions
.
(1)
Professional
			 Component
- the component of a service or procedure representing
			 the physician's work interpreting or performing the service or
			 procedure.
(2)
Technical Component
- the component of a service or
			 procedure representing the cost of rent, equipment, utilities, supplies,
			 administrative and technical salaries and benefits, and other overhead expenses
			 of the service or procedure, excluding the physician's professional
			 component.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.408 - Prior Authorization, Orders, Referrals, and Prescriptions

Current through Register 1525, July 5, 2024
(A)
Introduction
.
(1) Subchapter 6 of the
Physician
			 Manual
lists codes that require prior authorization as a prerequisite
			 for payment. The MassHealth agency does not pay for services if billed under
			 any of these codes, unless the provider has obtained prior authorization from
			 the MassHealth agency before providing the service.
(2) A 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.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.409 - Recordkeeping (Medical Records) Requirements

Current through Register 1525, July 5, 2024
(A) Payment for any service listed in
			 130 CMR
			 433.000 is conditioned upon its full and complete
			 documentation in the member's medical record. Payment for maintaining the
			 member's medical record is included in the fee for the service.
(B) In order for a medical record to document
			 completely a service or services to a member, that record must set forth the
			 nature, extent, quality, and necessity of care provided to the member. When the
			 information contained in a member's medical record is not sufficient to
			 document the service for which payment is claimed by the provider, the
			 MassHealth agency will disallow payment for the claimed service.
(C) The MassHealth agency may at its
			 discretion request, and upon such request the physician must provide, any and
			 all medical records of members corresponding to or documenting the services
			 claimed, in accordance with M.G.L. c. 118E, § 38, and
			 130 CMR
			 450.205:
Recordkeeping and
			 Disclosure
. The MassHealth agency may produce, or at its option may
			 require the physician to produce, photocopies of medical records instead of
			 actual records when compliance with 130 CMR 433.409(C) would otherwise result
			 in removal of medical records from the physician's office or other place of
			 practice.
(D)
(1) Medical records corresponding to office,
			 home, nursing facility, hospital outpatient department, and emergency
			 department services provided to members must include the reason for the visit
			 and the data upon which the diagnostic impression or statement of the member's
			 problem is based, and must be sufficient to justify any further diagnostic
			 procedures, treatments, and recommendations for return visits or referrals.
			 Specifically, these medical records must include, but may not be limited to,
			 the following:
(a) the member's name and date
			 of birth;
(b) the date of each
			 service;
(c) the name and title of
			 the person performing the service, if the service is performed by someone other
			 than the physician claiming payment for the service;
(d) the member's medical history;
(e) the diagnosis or chief
			 complaint;
(f) clear indication of
			 all findings, whether positive or negative, on examination;
(g) any medications administered or
			 prescribed, including strength, dosage, and regimen;
(h) a description of any treatment
			 given;
(i) recommendations for
			 additional treatments or consultations, when applicable;
(j) any medical goods or supplies dispensed
			 or prescribed;
(k) any tests
			 administered and their results; and
(l) for members younger than 21 years old who
			 are being treated by a physician or psychiatric clinical nurse specialist, a
			 CANS completed during the initial behavioral-health assessment and updated at
			 least once every 90 days thereafter.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.410 - Report Requirements

Current through Register 1525, July 5, 2024
(A)
General Report
. A general written report or a
			 discharge summary must accompany the physician's claim for payment for any
			 service that is listed in Subchapter 6 of the
Physician Manual
as requiring a report or individual consideration (I.C.), or if the
			 code is for an unlisted service. This report must be sufficiently detailed to
			 enable the MassHealth agency to assess the extent and nature of the
			 service.
(B)
Operative
			 Report
. For surgery procedures designated in Subchapter 6 of the
Physician Manual
as requiring individual consideration, the
			 provider must attach operative notes to the claim. An operative report must
			 state the operation performed, the name of the member, the date of the
			 operation, the preoperative diagnosis, the postoperative diagnosis, the names
			 of the surgeon and surgical assistants, and the technical procedures
			 performed.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.411 - 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 as described in
				130 CMR
				433.429, the physician or psychiatric
				clinical nurse specialist 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 433.000 - Physician Services › Section 433.412 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				physician 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
				433.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.413 - Office Visits: Payment Limitations

Current through Register 1525, July 5, 2024
(A)
Time Limit
. Payment for office visits is limited to
			 one visit per day per member per physician.
(B)
Office Visit and
			 Treatment/Procedure
. The physician may bill for either an office
			 visit or a treatment/procedure, but may not bill for both an office visit and a
			 treatment/procedure for the same member on the same date when the office visit
			 and the treatment/procedure are performed in the same location. This limit does
			 not apply to a significant, separately identifiable office visit provided by
			 the same physician on the same day as the treatment/procedure. This limitation
			 does not apply to tobacco cessation counseling services provided by a physician
			 or a qualified staff member under the supervision of a physician on the same
			 day as a visit. This limitation does not apply to a treatment/procedure that is
			 performed as a result of an Early and Periodic Screening, Diagnosis and
			 Treatment (EPSDT) visit (
see
130
			 CMR 450.140:
Early and Periodic
			 Screening, Diagnosis and Treatment (EPSDT) Services: Introduction
); in
			 such a case, the physician may bill for both an EPSDT visit and a
			 treatment/procedure. Examples of treatment/procedures are suturing, suture
			 removal, aspiration of a joint, and cast application or removal. X-rays,
			 laboratory tests, and certain diagnostic tests may be billed for in addition to
			 an office visit.
(C)
Immunization or Injection
.
(1) The physician may bill for either an
			 office visit or vaccine administration, but may not bill for both an office
			 visit and vaccine administration for the same member on the same date when the
			 office visit and the vaccine administration are performed in the same location.
			 This limitation does not apply to a significant, separately identifiable office
			 visit provided by the same physician on the same day as the vaccine was
			 administered.
(2) The MassHealth
			 agency pays for the cost of the injectable material unless the Massachusetts
			 Department of Public Health distributes the injectable material free of
			 charge.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.414 - Outpatient Hospital Services: Payment

Current through Register 1525, July 5, 2024
(A)
Time Limit
. Payment for outpatient hospital visits is
			 limited to one outpatient hospital visit per day per member per
			 physician.
(B)
Visit
			 and Treatment/Procedure
.
(1) The
			 physician may bill for either a hospital outpatient visit, or for a
			 treatment/procedure during a hospital outpatient visit, but may not bill for
			 both a visit and a treatment/procedure for the same member on the same date at
			 the same hospital. This limitation does not apply to a significant, separately
			 identifiable outpatient hospital visit provided by the same physician on the
			 same day as the procedure or other service.
(2) The MassHealth agency pays either a
			 physician or an outpatient hospital, but not both, for physician services
			 provided in an outpatient hospital setting. The MassHealth agency does not
			 separately pay a hospital for other professional services provided in an
			 outpatient hospital setting.
(3) An
			 outpatient hospital setting includes a hospital's outpatient department,
			 emergency department, HLHC, and any other satellite of the hospital. A hospital
			 outpatient visit includes a visit to any outpatient hospital setting.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.415 - Inpatient Hospital Services: Service Limitations and Screening Requirements

Current through Register 1525, July 5, 2024
(A) Hospital
			 inpatient visit fees apply to visits by physicians to members hospitalized in
			 acute, chronic, or rehabilitation hospitals. Payment is limited to one visit
			 per day per member for the length of the member's hospitalization.
(B) The MassHealth agency does not routinely
			 pay for visits to members who have undergone or who are expected to undergo
			 surgery, since the allowable surgical fees include payment for the provision of
			 routine inpatient preoperative and postoperative care. In unusual
			 circumstances, however, the MassHealth agency does pay for such
			 visits.
(C) The MassHealth agency
			 pays only the attending physician for inpatient hospital visits, with the
			 following exceptions.
(1) The MassHealth
			 agency pays for a consultation by a physician other than the attending
			 physician. (
See
130 CMR
			 433.418 for regulations about
			 consultations.)
(2) If it is
			 necessary for a physician other than the attending physician to treat a
			 hospitalized member, the other physician's services are payable. An explanation
			 of the necessity of such visits must be attached to the claim. The MassHealth
			 agency will review the claim and determine appropriate payment to the other
			 physician.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.416 - Nursing Facility Visits: Service Limitations

Current through Register 1525, July 5, 2024
(A)
Requirement for Approval of
			 Admission
. The MassHealth agency seeks to ensure that a MassHealth
			 member receives nursing facility services only when available alternatives do
			 not meet the member's need, and that every member receiving nursing facility
			 services is placed appropriately according to the medical eligibility criteria,
			 in accordance with
			 130 CMR
			 456.409 through
			 456.411.
(B)
Service
			 Limitations
. Payment for a visit by a physician to members in
			 nursing facilities or rest homes is limited to one visit per member per month,
			 except in an emergency. Any medically necessary care required for the follow-up
			 of a condition during the month must be billed as subsequent nursing facility
			 care.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.418 - Consultations: Service Limitations

Current through Register 1525, July 5, 2024
The MassHealth agency pays for only one initial consultation
				per member per case episode. Additional consultation visits per episode are
				payable as follow-up consultations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.419 - Certified Nurse Midwife Services

Current through Register 1525, July 5, 2024
(A)
General
. 130 CMR 433.419 applies specifically to
			 certified nurse midwives (also known as nurse midwives). In general, however,
			 subject to compliance with state and federal law, the requirements and
			 limitations elsewhere in
			 130 CMR
			 433.000 that apply to physicians also apply to
			 certified nurse midwives, such as service and payment limitations,
			 recordkeeping and reporting requirements, and prior-authorization and other
			 conditions of coverage.
(B)
Conditions of Payment
. The MassHealth agency pays a
			 certified nurse midwife or group practice for certified nurse midwife services
			 when
(1) the services are limited to the scope
			 of practice authorized by state law or regulation (including but not limited to
			 244 CMR:
Board of Registration in Nursing
or of the state
			 licensing agency of another state in which the services are
			 provided);
(2) the certified nurse
			 midwife or group practice is not an employee of the hospital or other facility
			 in which the certified nurse midwife services were performed, or is not
			 otherwise paid by the hospital or facility for the service;
(3) the certified nurse midwife participates
			 in MassHealth pursuant to the requirements of 130 CMR 433.419(C));
			 and
(4) for an out-of-state
			 certified nurse midwife the requirements of
			 130 CMR 433.403(C)
			  are met.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.420 - Obstetric Services: Introduction

Current through Register 1525, July 5, 2024
The MassHealth agency offers two methods of payment for
				obstetric services: the fee-for-service method and the global-fee method. Fee
				for service requires submission of claims for services as they are performed
				and is available to a provider for all covered obstetric services. The global
				fee is available only when the conditions specified in
				130 CMR
				433.421 are met.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.421 - Obstetric Services: Global-fee Method of Payment

Current through Register 1525, July 5, 2024
(A)
Definitions
.
(1)
Coverage
			 Provider
. a physician, certified nurse midwife, physician
			 assistant, or certified nurse practitioner that is either a member of the same
			 group practice as the Primary Provider, or who is in a separate practice from
			 the Primary Provider and has a back-up coverage arrangement with the Primary
			 Provider.
(2)
Global
			 Fee
. a single inclusive fee for all prenatal and postpartum
			 visits, and the delivery. The global fee is available only when the conditions
			 in 130 CMR 433.421 are met.
(3)
Non-coverage Provider
. any provider that has no
			 employment, contractual, or practice-coverage relationship with the Primary
			 Provider, or his or her practice.
(4)
Primary
			 Provider
. a physician or certified nurse midwife who has assumed
			 responsibility for performing or coordinating a minimum of six prenatal visits,
			 the delivery, and a minimum of one postpartum visit for a member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.424 - Obstetric Services: Fee-for-service Method of Payment

Current through Register 1525, July 5, 2024
The fee-for-service method of payment is always available to a
				provider for obstetric services covered by the MassHealth agency as an
				alternative to the global fee referenced in
				130 CMR
				433.421. If the global-fee requirements in
				130 CMR
				433.421 are not met, the provider or
				providers may claim payment from the MassHealth agency only on a
				fee-for-service basis, as specified in 130 CMR 433.424(A) through (D).
(A) When there is no primary provider for the
			 obstetric services performed for the member, each provider may claim payment
			 only on a fee-for-service basis.
(B) If the pregnancy is terminated by an
			 event other than a delivery, each provider involved in performing obstetric
			 services for the member may claim payment only on a fee-for-service
			 basis.
(C) When a certified
			 nurse-midwife is the primary provider and a physician performs a cesarean
			 section, the certified nurse-midwife may claim payment for the prenatal visits
			 only on a fee-for-service basis. The operating physician may claim payment for
			 the cesarean section only on a fee-for-service basis.
(D) When additional services (for example,
			 ultrasound or special tests) are performed, the provider may claim payment for
			 these only on a fee-for-service basis.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.425 - Ophthalmology Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for ophthalmic materials in
				accordance with the vision care regulations at
				130 CMR
				402.000:
Vision Care Services
. The
				MassHealth agency pays for eye examinations subject to the following
				limitations.
(A)
Comprehensive Eye Examinations
.
(1) The MassHealth agency does not pay for a
			 comprehensive eye examination if the service has been provided
(a) within the preceding 12 months, for a
			 member younger than 21 years old; or
(b) within the preceding 24 months, for a
			 member 21 years of age or older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.426 - Audiology Services: Service Limitations

Current through Register 1525, July 5, 2024
The MassHealth agency pays for audiology services only when
				they are provided either by a physician, or by an audiologist licensed or
				certified in accordance with
				130 CMR
				426.404:
Provider
				Eligibility
who is employed by a physician. This limitation does not
				apply to an audiometric hearing test, pure-tone, air only.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.427 - Allergy Testing: Service Limitations

Current through Register 1525, July 5, 2024
(A)
			 The MassHealth agency pays for allergy testing only when performed by or under
			 the direction of a physician, certified nurse practitioner or clinical nurse
			 specialist, or by a physician assistant under a physician's supervision. All
			 fees include payment for physician observation and interpretation of the tests
			 in relation to the member's history and physical examination. An initial
			 consultation and allergy testing for a member may be billed by the same
			 provider on the same date of service.
(B) The MassHealth agency does not pay for
			 more than three blood tests and pulmonary function tests (such as spirometry
			 and expirogram) used only for diagnosis and periodic evaluation per member per
			 year.
(C) Immunotherapy and
			 desensitization (extracts) are covered services. The provider must indicate the
			 amount and anticipated duration of the supply for immunotherapy and
			 desensitization (extracts) on the claim form.
(D) The MassHealth agency pays for follow-up
			 office visits for injections and reevaluation as office visits.
(E) The MassHealth agency pays for
			 sensitivity tests only once per member per year, regardless of the type of
			 tests performed or the number of visits required.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.428 - Psychiatric Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Covered Services
. The MassHealth agency pays a
			 physician or a psychiatric clinical nurse specialist (PCNS) for the psychiatry
			 services described in 130 CMR 433.428 and
			 130 CMR
			 433.429.
(B)
Non-covered
			 Services
.
(1)
Nonphysician and Non-PCNS Services
. Except as
			 permitted in Section 603 of Subchapter 6 of the
Physician
			 Manual
, the MassHealth agency does not pay a physician or PCNS for
			 services provided by a social worker, psychologist, or other nonphysician
			 mental health professional employed or supervised by the physician or
			 PCNS.
(2)
Research and
			 Experimental Treatment
. The MassHealth agency does not pay for
			 research or experimental treatment. This includes, but is not limited to, any
			 method not generally accepted or widely used in the field, or any session
			 conducted for research rather than for a member's clinical need.
(3)
Nonmedical
			 Services
. The MassHealth agency does not pay a physician or PCNS
			 for nonmedical services including, but not limited to, the following:
(a) vocational rehabilitation
			 services;
(b) educational
			 services;
(c) 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
			 payable);
(d) street-worker
			 services (information, referral, and advocacy to certain age populations;
			 liaison with other agencies; role modeling; and community organization);
(e) life-enrichment services
			 (ego-enhancing services such as workshops or educational courses provided to
			 functioning persons); and
(f)
			 biofeedback.
(4)
Nonmedical Programs
. The MassHealth agency does not
			 pay for diagnostic and treatment services that are provided as an integral part
			 of a planned and comprehensive program that is organized to provide primarily
			 nonmedical or other non-covered services. Such programs include freestanding
			 alcohol or drug detoxification programs, freestanding methadone maintenance
			 programs, residential programs, day activity programs, drop-in centers, and
			 educational programs.
(5)
Psychological Testing
. The MassHealth agency does not
			 pay for psychological testing provided by a physician or a PCNS.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.429 - Psychiatric Services: Scope of Services

Current through Register 1525, July 5, 2024
130 CMR 433.429 describes the services that a physician or a
				psychiatric clinical nurse specialist (PCNS) may provide, including the
				limitations imposed on those services by the MassHealth agency. For all
				psychotherapeutic services, the majority of time must be spent as personal
				interaction with the member; a minimal amount of time must be spent for the
				recording of data.
(A)
Individual Psychotherapy
. The MasssHealth agency pays
			 a physician or PCNS for individual psychotherapy provided to a member only when
			 the physician or PCNS treats the member. This service includes
			 diagnostics.
(B)
Family
			 and Couple Therapy
. The MassHealth agency pays for therapy
			 provided simultaneously in the same session to more than one member of the same
			 family or to a couple whose primary complaint is the disruption of their
			 marriage, family, or relationship. Payment is limited to one fee per session,
			 regardless of the number of family members present or the presence of a
			 co-therapist.
(C)
Group
			 Psychotherapy
.
(1) Payment is
			 limited to one fee per group member with a maximum of 12 members per group
			 regardless of the number of staff members present.
(2) The MassHealth agency does not pay for
			 group therapy when it is performed as an integral part of a psychiatric day
			 treatment program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.430 - Dialysis: Service Limitations

Current through Register 1525, July 5, 2024
(A)
Medicare Coverage
. Medicare is the primary source of
			 payment for medical care to persons of any age who have chronic renal disease
			 and who require hemodialysis or a kidney transplant. Members being treated for
			 chronic renal disease must be referred to a MassHealth Enrollment Center or
			 their Social Security Administration office to determine Medicare
			 eligibility.
(B)
Service Limitations
. The MassHealth agency pays for
			 hemodialysis only to hospitalized members who are
(1) being dialyzed for acute renal
			 failure;
(2) receiving initial
			 dialysis for chronic renal failure prior to continuing chronic maintenance
			 dialysis; or
(3) receiving dialysis
			 for complications of chronic maintenance dialysis.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.431 - Physical Medicine: Service Limitations

Current through Register 1525, July 5, 2024
(A)
			 The services listed in 130 CMR 433.431 are payable only when the physician
			 prescribes the needed therapy, and the services are provided by the physician
			 or by a licensed physical or occupational therapist employed by the physician,
			 subject to all general conditions of payment including the requirement to
			 obtain prior authorization as described in
			 130 CMR
			 433.408.
(B) Physical medicine services include, but
			 are not limited to, superficial or deep-heat modalities, therapeutic exercise,
			 traction, hydrotherapy, prosthetics and orthotics training, activities of daily
			 living and ambulation training, range of motion, and manual muscle strength
			 assessment. Other restorative services are covered by MassHealth in accordance
			 with
			 130 CMR 430.000:
Rehabilitation Center Services
and 432.000:
Therapist
			 Services
.
(C)
(1) The MassHealth agency pays for the
			 establishment of a maintenance program and the training of the member, member's
			 family, or other persons to carry it out, as part of a regular treatment visit,
			 not as a separate service. The MassHealth agency does not pay for performance
			 of a maintenance program, except as provided in 130 CMR 433.431(C)(2).
(2) In certain instances, the
			 specialized knowledge and judgment of a licensed physician or licensed
			 therapist may be required to perform services that are part of a maintenance
			 program, to ensure safety or effectiveness that may otherwise be compromised
			 due to the member's medical condition. At the time the decision is made that
			 the services must be performed by a licensed physician or a licensed therapist,
			 all information that supports the medical necessity for performance of such
			 services by a licensed physician or licensed therapist, rather than a
			 nonphysician or non-therapist, must be documented in the medical
			 record.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.432 - Other Medical Procedures

Current through Register 1525, July 5, 2024
(A)
Cardiovascular and Other Vascular Studies
. Fees for
			 cardiovascular services and other vascular studies include payment for
			 laboratory procedures, interpretations, and physician services (except surgery
			 and anesthesia services), unless otherwise stated. These services may be billed
			 for in addition to an office visit.
(B)
Cardiac
			 Catheterization
. Fees for cardiac catheterization are for the
			 physician's services only and include payment for the usual preassessment of
			 the cardiac problem and the recording of intracardiac pressure.
(C)
Pulmonary
			 Procedures
. Fees for pulmonary procedures include payment for
			 laboratory procedures, interpretations, and physician's services. These
			 services may be billed for in addition to an office visit.
(D)
Dermatological Special
			 Procedures
. These services may be billed for in addition to an
			 office visit.
(E)
Unlisted Procedures
. Providers may bill for unlisted
			 procedures only if there is no "Not otherwise classified" code.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.433 - Certified Nurse Practitioner Services

Current through Register 1525, July 5, 2024
(A)
General
. 130 CMR 433.433 applies specifically to
			 certified nurse practitioners (also known as nurse practitioners). In general,
			 however, subject to compliance with state and federal law, the requirements and
			 limitations elsewhere in
			 130 CMR
			 433.000 that apply to physicians also apply to
			 certified nurse practitioners, such as service and payment limitations,
			 recordkeeping and reporting requirements, and prior-authorization and other
			 conditions of coverage.
(B)
Conditions of Payment
. The MassHealth agency pays
			 either an independent certified nurse practitioner or group practice (in
			 accordance with 130 CMR 433.433(C) ), or the physician employer of a
			 nonindependent certified nurse practitioner (in accordance with 130 CMR
			 433.433(E) ), for certified nurse practitioner services when:
(1) the services are limited to the scope of
			 practice authorized by state law or regulation (including but not limited to
			 244 CMR:
Board of Registration in Nursing
or of the state
			 licensing agency of another state in which the services are
			 provided);
(2) the certified nurse
			 practitioner or group practice is not an employee of the hospital or other
			 facility in which the certified nurse practitioner services were performed, or
			 is not otherwise paid by the hospital or facility for the service;
(3)
(a) in
			 the case of payment claimed by an independent certified nurse practitioner, or
			 a group practice, the certified nurse practitioner participates in MassHealth
			 pursuant to the requirements of 130 CMR 433.433(C); or
(b) in the case of payment claimed by a
			 physician employer of a nonindependent certified nurse practitioner, the
			 conditions of 130 CMR 433.433(E) are met; and
(4) for an out-of-state certified nurse
			 practitioner the requirements of
			 130 CMR 433.403(C)
			  are met.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.434 - Physician Assistant Services

Current through Register 1525, July 5, 2024
(A)
General
. 130 CMR 433.434 applies specifically to
			 physician assistants. In general, however, subject to compliance with state and
			 federal law, the requirements and limitations elsewhere in
			 130 CMR
			 433.000 that apply to physicians also apply to
			 physician assistants, such as service and payment limitations, recordkeeping
			 and reporting requirements, and prior-authorization and other conditions of
			 coverage. Services provided by a physician assistant must be limited to the
			 scope of practice authorized by state law or regulation (including but not
			 limited to
			 263 CMR 5.00:
Scope
			 and Practice and Employment of Physician Assistants
).
(B)
Conditions of
			 Payment
. In accordance with 263 CMR:
Board of Registration
			 of Physician Assistants
, the MassHealth agency does not pay physician
			 assistants directly. The MassHealth agency pays a group practice employer of a
			 physician assistant for physician assistant services. Physician assistant
			 services are payable when:
(1) the services
			 are limited to the scope of practice authorized by state law or regulation
			 (including but not limited to 263 CMR:
Board of Registration of
			 Physician Assistants
or of the state licensing agency of another state
			 in which the services are provided);
(2) the physician assistant or group practice
			 is not an employee of the hospital or other facility in which the physician
			 assistant services were performed, or is not otherwise paid by the hospital or
			 facility for the service;
(3) the
			 services are provided pursuant to a formal supervisory arrangement with a
			 physician, as further described in
			 263 CMR 5.00:
Scope
			 and Practice and Employment of Physician Assistants
and 130 CMR
			 433.434(D);
(4) the physician
			 assistant participates in MassHealth pursuant to the requirements of 130 CMR
			 433.434(C); and
(5) for an
			 out-of-state physician assistant the requirements of
			 130 CMR 433.403(C)
			  are met.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.435 - Tobacco Cessation Services

Current through Register 1525, July 5, 2024
(A)
Introduction
. MassHealth members are eligible to
			 receive tobacco cessation counseling services described in 130 CMR 433.435(B)
			 and pharmacotherapy treatment, including nicotine replacement therapy (NRT), in
			 accordance with
			 130 CMR
			 406.000:
Pharmacy Services
.
(B)
Tobacco Cessation Counseling
			 Services
.
(1) MassHealth covers a
			 total of 16 group and individual counseling sessions per member per 12-month
			 cycle, without prior authorization. These sessions may be any combination of
			 group and individual counseling. All individual counseling sessions must be at
			 least 30 minutes, except for intake sessions, which must be at least 45
			 minutes. Intake sessions are limited to two per member per 12-month cycle,
			 without prior authorization.
(a) Individual
			 counseling consists of face-to-face tobacco cessation counseling services
			 provided to an individual member by a MassHealth-qualified provider of tobacco
			 cessation services as set forth in 130 CMR 433.435(B) and (C).
(b) Group tobacco treatment counseling
			 consists of a scheduled professional counseling session with a minimum of three
			 and a maximum of 12 members and has a duration of at least 60 to 90
			 minutes.
(c) Individual and group
			 counseling also includes collaboration with and facilitating referrals to other
			 healthcare providers to coordinate the appropriate use of medications,
			 especially in the presence of medical or psychiatric comorbidities.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.436 - Radiology Services: Introduction

Current through Register 1525, July 5, 2024
The MassHealth agency pays for radiology services only when the
				services are provided at the written request of a licensed physician. All
				radiology equipment used in providing these services must be inspected and
				approved by the Massachusetts Department of Public Health.
(A)
Services Provided by an
			 Independent Diagnostic Testing Facility (IDTF)
. The MassHealth
			 agency pays an IDTF as defined in
			 130 CMR 433.401 for
			 applicable diagnostic tests in accordance with the independent diagnostic
			 testing facility regulations at
			 130 CMR 431.000:
Independent Diagnostic Testing Services
.
(B)
Radiology Recordkeeping
			 (Medical Records) Requirements
. In addition to complying with the
			 general recordkeeping requirements (
see
130 CMR
			 433.409 ), the physician must keep suitable
			 records of radiology services performed. All X-rays must be labeled adequately
			 with the following:
(1) the member's
			 name;
(2) the date of the
			 examination;
(3) the nature of the
			 examination; and
(4) left and right
			 designations and patient position, if not standard.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.437 - Radiology Services: Service Limitations

Current through Register 1525, July 5, 2024
See
also the general limitations described at
				130
				CMR 433.407.
(A)
Diagnostic
			 Interpretations
. When a physician provides the professional
			 component (interpretation) of a diagnostic radiology service in a hospital
			 inpatient or outpatient setting, the MassHealth agency pays for those services
			 in accordance with the EOHHS fee schedule. The MassHealth agency does not pay
			 for the interpretation of an X-ray that was previously read and taken in the
			 same hospital. However, the MassHealth agency does pay a physician for
			 interpreting an X-ray that was previously read and taken in a different
			 hospital.
(B)
Therapeutic Interpretations
. When a physician provides
			 the professional component (interpretation) of a therapeutic radiology service
			 in a hospital inpatient or outpatient setting, the MassHealth agency pays for
			 those services in accordance with the EOHHS fee schedule.
(C)
Surgical Introductions and
			 Interpretations
. The MassHealth agency pays a physician for
			 performing surgical introductions and interpretations of films performed in a
			 hospital inpatient or outpatient setting, with the following restrictions.
(1) Only one surgical introduction per
			 operative session is payable in accordance with the EOHHS fee
			 schedule.
(2) In a single operative
			 session:
(a) no more than three additional
			 surgical introductions using the same puncture site are payable, each in
			 accordance with the EOHHS fee schedule; and
(b) no more than three additional selective
			 vascular studies using the same puncture site are payable, each at the maximum
			 allowable fee.
(3)
			 Interpretations are payable in accordance with the EOHHS fee schedule, up to a
			 maximum of three.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.438 - Clinical Laboratory Services: Introduction

Current through Register 1525, July 5, 2024
Clinical laboratory services necessary for the diagnosis,
				treatment, and prevention of disease and for the maintenance of the health of a
				member are payable under MassHealth.
(A)
Provider
			 Eligibility
. The MassHealth agency pays for laboratory tests only
			 when they are performed on a member by a physician, certified nurse
			 practitioner, certified nurse midwife, certified registered nurse anesthetist,
			 psychiatric clinical nurse specialist, clinical nurse specialist, or physician
			 assistant, or by an independent clinical laboratory certified by
			 Medicare.
(B)
Payment
. The MassHealth agency pays a physician,
			 certified nurse practitioner, certified nurse midwife, certified registered
			 nurse anesthetist, psychiatric clinical nurse specialist, clinical nurse
			 specialist, or group practice employer of such practitioners or of a physician
			 assistant only for laboratory tests performed in the practitioner's office. If
			 an independent clinical laboratory performs laboratory tests for a member, the
			 MassHealth agency pays only the laboratory for those services.
(C)
Information with
			 Specimen
. A physician who sends a specimen to an independent
			 clinical laboratory participating in MassHealth must also send the following.
(1) a signed request for the laboratory
			 services to be performed;
(2) the
			 member's MassHealth identification number; and
(3) the physician's name, address and
			 provider number.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.439 - Clinical Laboratory Services: Service Limitations

Current through Register 1525, July 5, 2024
(A)
Specimen
			 Collections
. The MassHealth agency does not pay a physician for
			 routine specimen collection and preparation for the purpose of clinical
			 laboratory analysis (for example, venipunctures; urine, fecal, and sputum
			 samples; Pap smears; cultures; and swabbing and scraping for removal of
			 tissue).
(B)
Professional Component of Laboratory Services
. The
			 MassHealth agency does not pay a physician for the professional component of a
			 clinical laboratory service. The MassHealth agency pays a physician for the
			 professional component of an anatomical service (for example, bone marrow
			 analysis or analysis of a surgical specimen).
(C)
Calculations
.
			 The MassHealth agency does not pay a physician for calculations such as red
			 cell indices, A/G ratio, creatinine clearance, and those ratios calculated as
			 part of a profile. Payment for laboratory services includes payment for all
			 aspects involved in an assay.
(D)
Profile (or Panel) Tests
.
(1) A profile or panel test is defined as any
			 group of tests, whether performed manually, automatedly, or semiautomatedly,
			 that is ordered for a specified member on a specified day and has at least one
			 of the following characteristics.
(a) The
			 group of tests is designated as a profile or panel by the physician performing
			 the tests.
(b) The group of tests
			 is performed by the physician at a usual and customary fee that is lower than
			 the sum of the physician's usual and customary fees for the individual tests in
			 that group.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.440 - Acupuncture

Current through Register 1525, July 5, 2024
(A)
Introduction
.
			 MassHealth members are eligible to receive acupuncture for the treatment of
			 pain as described in 130 CMR 433.440(C), for use as an anesthetic as described
			 in
			 130 CMR
			 433.454(C), and for use for
			 detoxification as described in
			 130 CMR
			 418.406(C)(3):
Substance Abuse Treatment: Acupuncture
			 Detoxification
.
(B)
General
. 130 CMR 433.440 applies specifically to
			 physicians and midlevel practitioners who are licensed practitioners of
			 acupuncture.
(C)
Acupuncture for the Treatment of Pain
. MassHealth
			 provides a total of 20 sessions of acupuncture for the treatment of pain per
			 member per year without prior authorization. If the member's condition,
			 treatment, or diagnosis changes, the member may receive more sessions of
			 medically-necessary acupuncture treatment with prior authorization.
(D)
Provider Qualifications for
			 Acupuncture
. MassHealth pays for acupuncture services only when
			 the provider rendering the service is:
(1) a
			 physician; or
(2) a midlevel
			 practitioner who is licensed in acupuncture by the Massachusetts Board of
			 Registration in Medicine under
			 243
			 CMR 5.00:
The Practice of
			 Acupuncture
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.441 - Pharmacy Services: Drugs Dispensed in Pharmacies

Current through Register 1525, July 5, 2024
Coverage of drugs and medical supplies dispensed to MassHealth
				members by MassHealth pharmacy providers, and related prescription requirements
				for prescribing prescribers, are governed by
				130 CMR
				406.000:
Pharmacy
				Services
.