reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.447 - Drugs Administered in the Office (Provider-administered Drugs)

Current through Register 1525, July 5, 2024
(A) Drugs and biologicals dispensed in the
			 office are payable, subject to the exclusions and service limitations at
			 130 CMR
			 433.404,
			 433.406,
			 and
			 130 CMR
			 406.413(B):
Drug
			 Exclusions
and (C):
Service Limitations
.
(B) The MassHealth agency does not pay a
			 provider separately for drugs that are considered routine and integral to the
			 delivery of a provider's professional services in the course of diagnosis or
			 treatment. Such drugs are commonly provided without charge or are included in
			 the provider's fee for the service.
(C) The MassHealth agency does not pay
			 separately for any oral drugs dispensed in the office for which the provider
			 has not requested and received prior authorization from the MassHealth agency,
			 with the exception of oral vaccines and oral radiopharmaceuticals, which do not
			 require prior authorization.
(D)
			 Claims for drugs and biologicals that are listed in Subchapter 6 of the
Physician Manual
must include the name of the drug or
			 biological, strength, dosage, and number of HCPCS units dispensed, NDC code,
			 NDC units and NDC unit of measurement. In addition, for drugs and/or
			 biologicals that are listed as requiring individual consideration in Subchapter
			 6 of the
Physician Manual
, a copy of the invoice showing the
			 actual acquisition cost must be attached to the claim. Claims without this
			 information are denied.
(E) The
			 MassHealth agency pays only for prescription drugs that are approved by the
			 U.S. Food and Drug Administration and manufactured by companies that have
			 signed rebate agreements with the U.S. Secretary of Health and Human Services
			 pursuant to
			 42 U.S.C.
			 1396r-8. Payment is calculated in accordance
			 with
			 101 CMR
			 331.00:
Prescribed Drugs
.
(F) The MassHealth agency does not pay for a
			 biological if the Massachusetts Department of Public Health distributes the
			 biological free of charge.
(G)
			 Payment for drugs may be claimed in addition to an office visit.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.449 - Fluoride Varnish Services

Current through Register 1525, July 5, 2024
(A)
Eligible Members
. Members must be younger than 21
			 years old to be eligible for the application of fluoride varnish.
(B)
Qualified
			 Personnel
. Physicians, certified nurse practitioners, clinical
			 nurse specialists, registered nurses, licensed practical nurses, physician
			 assistants, and medical assistants may apply fluoride varnish subject to the
			 limitations of state law. To qualify to apply fluoride varnish, the individual
			 must complete a MassHealth-approved training on the application of fluoride
			 varnish, maintain proof of completion of the training, and provide such proof
			 to the MassHealth agency upon request.
(C)
Fluoride Varnish Services:
			 Claim Submission
.
(1) A provider
			 may bill for an office visit, in addition to the fluoride varnish application,
			 only if fluoride varnish was not the sole service, treatment, or procedure
			 provided during the visit.
(2)
			 Physicians, independent certified nurse practitioners, and clinical nurse
			 specialists or group practice employers of such clinicians, may submit claims
			 for fluoride varnish services when those clinicians provide fluoride varnish
			 services directly to MassHealth members. A group practice employer of a
			 physician assistant may submit claims for fluoride varnish services provided by
			 the physician assistant.
See
Subchapter 6 of the
Physician Manual
for service code descriptions.
(3) As an exception to
			 130 CMR
			 450.301(A), a physician that
			 is an employer of a non-independent certified nurse practitioner, registered
			 nurse, licensed practical nurse, or medical assistant, may submit claims for
			 fluoride varnish services provided by that employee, but only if such services
			 are provided in accordance with 130 CMR 433.449(A) and (B), and payment is
			 claimed in accordance with
			 130 CMR
			 450.301(B).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.451 - Surgery Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Provider Eligibility
. The MassHealth agency pays a
			 physician for surgery only if the physician is scrubbed and present in the
			 operating room during the major portion of the operation. (
See
130 CMR
			 433.421(B)(2)  for the
			 single exception to this requirement.)
(B)
Nonpayable
			 Services
. The MassHealth agency does not pay for
(1) any experimental, unproven, cosmetic, or
			 otherwise medically unnecessary procedure or treatment;
(2) the treatment of male or female
			 infertility (including, but not limited to, laboratory tests, drugs, and
			 procedures associated with such treatment); however, MassHealth does pay for
			 the diagnosis of male or female infertility;
(3) reconstructive surgery, unless the
			 MassHealth agency determines, pursuant to a request for prior authorization,
			 the service is medically necessary to correct, repair, or ameliorate the
			 physical effects of disease or physical defect, or traumatic injury;
(4) services billed under codes listed in
			 Subchapter 6 of the
Physician Manual
as not payable;
(5) services otherwise identified in the
			 MassHealth regulations at
			 130 CMR
			 433.000 or
			 450.000 as not payable;
			 and
(6) services billed with
			 otherwise covered service codes when such codes are used to bill for nonpayable
			 circumstances as described in
			 130 CMR
			 433.404.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.452 - Surgery Services: Payment

Current through Register 1525, July 5, 2024
Surgical services and other invasive procedures are listed in
				the surgery and medicine section of the American Medical Association's
Current Procedural Terminology (CPT)
code book. The MassHealth
				agency pays for all medicine and surgery CPT codes in effect at the time of
				service, except for those codes listed in Section 602 of Subchapter 6 of the
Physician Manual
, subject to all conditions and limitations
				described in MassHealth regulations at
				130 CMR
				433.000 and
				450.000:
Administrative and Billing Regulations
.
(A)
Visit and Treatment/Procedure
			 on Same Day in Same Location
. The MassHealth agency pays a
			 provider for either a visit or a treatment/procedure, whichever fee is greater.
			 The MassHealth agency does not pay for both a preoperative evaluation and
			 management visit, and a treatment/procedure provided to a member on the same
			 day when they are performed in the same location. For minor surgeries and
			 endoscopies, the MassHealth agency does not pay separately for an evaluation
			 and management service on the same day as the surgery or endoscopy. The
			 limitations in 130 CMR 433.452(A) do not appy to a significant, separately
			 identifiable evaluation and management service provided by the same provider on
			 the same day of the procedure or other services. For payment information about
			 obstetrical care, refer to
			 130 CMR
			 433.421.
(B)
Payment for Global Surgical
			 Package
. The payment for a surgical procedure includes a standard
			 package of preoperative, intraoperative, and postoperative services. The
			 services are included in the global surgical package regardless of setting
			 including, but not limited to, hospitals, ambulatory surgical centers, and
			 office settings.
(1) The following services
			 are included in the payment for a global surgery when furnished by the provider
			 who performs the surgery:
(a) preoperative
			 visits;
(b) intraoperative
			 visits;
(c) complications following
			 surgery;
(d) postoperative
			 visits;
(e) postsurgical pain
			 management;
(f) miscellaneous
			 services related to surgery including, but not limited to, dressing changes;
			 local incisional care; removal of operative pack, cutaneous sutures and
			 staples, lines, wires, tubes, drains, casts, and splints; insertion,
			 irrigation, and removal of urinary catheters, routine peripheral intravenous
			 lines, nasogastric tubes, and rectal tubes; and changes and removal of
			 tracheostomy tubes; and
(g) visits
			 related to the surgery to a patient in an intensive care or critical care unit,
			 if made by the surgeon. Intensive or critical care visits unrelated to surgery
			 are not included in the global surgical package.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.455 - Abortion Services

Current through Register 1525, July 5, 2024
(A)
Payable Services
.
(1) The MassHealth agency pays for an
			 abortion service if both of the following conditions are met:
(a) the abortion is a medically necessary
			 abortion, or the abortion is performed upon a victim of rape or incest when
			 such rape or incest has been reported to a law enforcement agency or public
			 health service within 60 days of the incident; and
(b) the abortion is performed in accordance
			 with law.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.456 - Sterilization Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Covered Services
. The MassHealth agency pays for a
			 sterilization service provided to an eligible member only if all of the
			 following conditions are met.
(1) The member
			 has voluntarily given informed consent for the sterilization procedure in the
			 manner and at the time described in
			 130 CMR
			 433.457, and such consent is documented in
			 the manner described in
			 130 CMR
			 433.458.
(2) The member is at least 18 years old at
			 the time consent is obtained.
(3)
			 The member is not a mentally incompetent individual or an institutionalized
			 individual.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.457 - Sterilization Services: Informed Consent

Current through Register 1525, July 5, 2024
A member's consent for sterilization will be considered
				informed and voluntary only if such consent is obtained in accordance with the
				requirements specified in 130 CMR 433.457(A) and (B), and such consent is
				documented as specified in
				130 CMR
				433.458.
(A)
Informed Consent
			 Requirements
.
(1) The person who
			 obtains consent (a physician, nurse, or counselor, for example) must orally
			 provide all of the following information and advice to the member requesting
			 sterilization:
(a) advice that the member is
			 free to withhold or withdraw consent for the procedure at any time before the
			 sterilization without affecting the right to future care or treatment and
			 without loss of any federal- or state-funded program benefits to which the
			 member otherwise might be entitled;
(b) a description of available alternative
			 methods of family planning and birth control;
(c) advice that the sterilization procedure
			 is considered irreversible;
(d) a
			 thorough explanation of the specific sterilization procedure to be
			 performed;
(e) a full description
			 of the discomforts and risks that may accompany or follow the procedure,
			 including an explanation of the type and possible effects of any anesthetic to
			 be used;
(f) a full description of
			 the benefits or advantages that may be expected as a result of the
			 sterilization; and
(g) advice that
			 the sterilization will not be performed for at least 30 days, except under the
			 circumstances specified in 130 CMR 433.457(B)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.458 - Sterilization Services: Consent Form Requirements

Current through Register 1525, July 5, 2024
Informed consent for sterilization must be documented by the
				completion of the MassHealth agency's Consent for Sterilization form in
				accordance with the following requirements.
(A)
Required Consent
			 Form
.
(1) One of the following
			 Consent for Sterilization forms must be used:
(a) CS-18 - for members 18 through 20 years
			 of age; or
(b) CS-21 - for members
			 21 years of age or older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.459 - Hysterectomy Services

Current through Register 1525, July 5, 2024
(A)
Nonpayable Services
. The MassHealth agency does not
			 pay for a hysterectomy provided to a member under the following conditions.
(1) The hysterectomy was performed solely for
			 the purpose of sterilizing the member.
(2) If there was more than one purpose for
			 the procedure, the hysterectomy would not have been performed but for the
			 purpose of sterilizing the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.473 - Clinical Nurse Specialist (CNS) Services

Current through Register 1525, July 5, 2024
(A)
General
. 130 CMR 433.473 applies specifically to
			 clinical nurse specialists. In general, however, subject to compliance with
			 state and federal law, the requirements and limitations elsewhere in
			 130 CMR
			 433.000 that apply to a physician also apply to a
			 clinical nurse specialist (CNS), 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
			 CNS or group practice for CNS 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 CNS or group
			 practice is not an employee or contractor of the hospital or other facility in
			 which the CNS services were performed, or is not otherwise paid by the hospital
			 or facility for their services;
(3)
			 the CNS participates in MassHealth pursuant to the requirements of
			 130
			 CMR 433.473(C);
			 and
(4) for an out-of-state CNS the
			 requirements of
			 130
			 CMR 433.403(C)  are
			 met.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 434.000 establishes
				the requirements for the provision of psychiatric hospital outpatient services
				under MassHealth. The MassHealth agency pays for outpatient visits and
				ancillary services (such as radiographic views, laboratory tests, and pharmacy
				items) that are medically necessary and appropriately provided. The quality of
				such services must meet professionally recognized standards of care. All
				psychiatric inpatient hospitals participating in MassHealth that provide
				psychiatric hospital outpatient services must comply with the MassHealth
				regulations, including but not limited to MassHealth regulations set forth in
				130 CMR 434.000 and
				450.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers psychiatric hospital outpatient
			 services only when provided to eligible MassHealth members, subject to the
			 restrictions and limitations described in MassHealth regulations.
			 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 434.000 - Psychiatric Hospital Outpatient Services › Section 434.404 - Exclusion of MassHealth Managed Care Members

Current through Register 1525, July 5, 2024
130 CMR 434.000 does not
				apply to members participating in a MassHealth managed care plan. Participation
				in a MassHealth managed care plan is subject to change. Providers are
				responsible for verifying member status on a daily basis. For more information
				see
				130 CMR
				450.117.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.405 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR 434.000 will be
				made only to the outpatient department of a psychiatric hospital participating
				in MassHealth on the date of service.
(A)
In-state
. To
			 participate in MassHealth, psychiatric inpatient hospitals located in
			 Massachusetts must
(1) operate under a
			 psychiatric inpatient hospital license issued by the Massachusetts Department
			 of Mental Health;
(2) have a signed
			 provider contract with the MassHealth agency that specifies the conditions of
			 participation in MassHealth; and
(3) participate in the Medicare
			 program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.406 - Non reimbursable Services

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency will not pay for any of the following services:
(1) nonmedical services, such as social,
			 educational, and vocational services;
(2) maintenance therapy for occupational,
			 speech, or physical therapy services;
(3) canceled or missed
			 appointments;
(4) telephone
			 conversations and telephone consultations;
(5) court testimony;
(6) research or the provision of
			 experimental, unproven, or otherwise medically unnecessary procedures or
			 treatments;
(7) the provision of
			 whole blood; however, administrative and processing costs associated with the
			 provision of blood and its derivatives are reimbursable;
(8) vocational rehabilitation
			 services;
(9) sheltered
			 workshops;
(10) recreational
			 services;
(11) life-enrichment
			 services;
(12) alcohol or drug
			 drop-in centers; and
(13) the
			 treatment of male or female infertility (including, but not limited to,
			 laboratory tests, drugs, and procedures associated with such
			 treatment).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.407 - Payment

Current through Register 1525, July 5, 2024
(A) Payment for psychiatric hospital
			 outpatient services in Massachusetts will be made at the rate for services
			 established in the signed provider contract with the MassHealth agency, subject
			 to the limitations set forth in 130 CMR 434.407.
(B) For purposes of making payments, the
			 following limitations apply.
(1) The
			 MassHealth agency will not pay for psychiatric hospital outpatient services
			 provided to a member who is an inpatient at the same or a different hospital on
			 the same day.
(2) If a member
			 receives psychiatric hospital outpatient services at one facility and, later on
			 the same day, is admitted as an inpatient to another facility, the MassHealth
			 agency will pay both hospitals for services.
(3) When a member is admitted to inpatient
			 status through the emergency room or outpatient department, the MassHealth
			 agency will pay for only the inpatient stay. The MassHealth agency will not pay
			 for services furnished in the emergency room or outpatient department on the
			 admitting day.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.408 - Certification

Current through Register 1525, July 5, 2024
Psychiatric inpatient hospitals must receive certification from
				the MassHealth agency before providing psychiatric day treatment program
				services (for requirements,
see
130 CMR
				434.421 ).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.409 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) For certain
			 outpatient services described in
			 130 CMR 434.000, the
			 MassHealth agency requires that the psychiatric inpatient hospital obtain prior
			 authorization. No payment will be made for such services unless prior
			 authorization has been obtained from the MassHealth agency. Members
			 participating in a MassHealth managed care plan require service authorization
			 before certain mental health and substance abuse services are provided. For
			 more information,
see
130 CMR
			 450.124.
(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) All requests
			 for prior authorization must be submitted in accordance with the instructions
			 in Subchapter 5 of the
Psychiatric Hospital Outpatient Services
			 Manual
.
(D) Time
			 requirements for response from the MassHealth agency and rules that apply in
			 determining the period within which the MassHealth agency will act on specific
			 requests for prior authorization are set forth in the MassHealth administrative
			 and billing regulations in
			 130 CMR 450.000. A service
			 is authorized on the date the MassHealth agency transmits its decision
			 concerning the request for prior authorization to the provider.
(E) Written notification of the prior
			 authorization decision will be sent to the provider and will indicate approval,
			 deferral because additional information is necessary, modification, or denial.
			 In the case of a denial, the member will also be notified. Notification of
			 denial will include the reason for the decision. The member or the provider has
			 the right to resubmit a request and furnish additional information. The member
			 may appeal the modification or denial of a prior authorization request within
			 30 days after the date of the notice of denial. Procedures for such an appeal
			 are set forth in
			 130 CMR 610.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.411 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				psychiatric outpatient hospital services for EPSDT-eligible members in
				accordance with
				130
				CMR 450.140
et seq
., without
				regard to service limitations described in
				130 CMR 434.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.421 - Psychiatric Day Treatment Program Services

Current through Register 1525, July 5, 2024
(A) A psychiatric day treatment program is a
			 planned combination of diagnostic, treatment, and rehabilitative services
			 provided to mentally or emotionally disturbed persons who need more active or
			 inclusive treatment than is typically available through a weekly visit for
			 outpatient mental health services, but who do not need full-time
			 hospitalization or institutionalization. Such a program uses multiple,
			 intensive, and focused activities in a supportive environment to enable these
			 individuals to acquire more realistic and appropriate behavior patterns,
			 attitudes, and skills for eventual independent functioning in the
			 community.
(B) The MassHealth
			 agency pays for services provided as part of an organized psychiatric day
			 treatment program by the outpatient department of a psychiatric hospital. These
			 services must be furnished in compliance with MassHealth regulations governing
			 psychiatric day treatment program services in
			 130 CMR 417.000. (See
			 Subchapter 5 of the
Psychiatric Outpatient Hospital Manual
for
			 instructions about obtaining the
Psychiatric Day Treatment Program
			 Manual
, which contains the necessary regulations.)
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.426 - Mental Health Services: Staff Composition Requirements

Current through Register 1525, July 5, 2024
(A)
Provider
			 Responsibilities.
(1) The
			 psychiatric inpatient hospital must have a balanced multidisciplinary staff to
			 furnish mental health services under the direction of a licensed
			 psychiatrist.
(2) The psychiatric
			 inpatient hospital must designate a professional staff member as director of
			 clinical services and a licensed psychiatrist as medical director.
(3) A licensed psychiatrist must be on call
			 during all hours of operation.
(4)
			 Although the MassHealth agency does not require that the psychiatric inpatient
			 hospital employ mental health professionals from all the disciplines listed in
			 130 CMR 434.426(B), staff members who provide services to members must be
			 qualified as set forth in 130 CMR 434.426(B) for their respective
			 disciplines.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.427 - Mental Health Services: Operating and Treatment Procedures

Current through Register 1525, July 5, 2024
(A) A professional staff member must conduct
			 a comprehensive evaluation of each member prior to initiation of therapy. For
			 members under the age of 21, a CANS must be completed during the initial
			 behavioral-health assessment before initiation of therapy and updated at least
			 every 90 days thereafter by a CANS-certified provider, as described in
			 130 CMR
			 434.426(B).
(B) The psychiatric inpatient hospital must
			 accept for treatment, refer for treatment elsewhere, or both, any member for
			 whom the intake evaluation substantiates a mental or emotional
			 disorder.
(C) The psychiatric
			 inpatient hospital will ensure that one professional staff member (the primary
			 therapist) assumes primary responsibility for each member. This responsibility
			 includes
(1) within four member visits,
			 preparation of a comprehensive written treatment plan that is based on the
			 initial evaluation, incorporates short- and long-term treatment goals, and
			 establishes criteria for determining when termination of treatment is
			 appropriate;
(2) ongoing care
			 management;
(3) review of each case
			 at termination of treatment and preparation of a termination summary that
			 describes the course of treatment and any aftercare program or resources in
			 which the member is expected to participate; and
(4) ensuring that a CANS-certified provider,
			 as described in
			 130 CMR
			 434.426(B)  completes the
			 CANS in accordance with 130 CMR 434.427(A).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.428 - Mental Health Services: Utilization Review Plan

Current through Register 1525, July 5, 2024
A mental health program must have a utilization review plan
				that is acceptable to the MassHealth agency and that meets the following
				conditions.
(A) A utilization review
			 committee will be formed, composed of the clinical director (or a designee), a
			 psychiatrist, and one other professional staff member from each core discipline
			 represented who meets all the qualifications for the discipline, as outlined in
			 130 CMR
			 434.426(B).
(B) The utilization review committee will
			 review a representative sample of cases at least in the following
			 circumstances:
(1) within 90 days after
			 initial contact;
(2) when a member
			 has required more than 50 visits every 12 months and has not required
			 hospitalization or extensive crisis intervention during that period;
			 and
(3) following
			 termination.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services › Section 434.429 - 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
			 434.410, 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 DSM IV 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 copy
			 of the 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 434.000 - Psychiatric Hospital Outpatient Services › Section 434.430 - Mental Health Services: Service Limitations

Current through Register 1525, July 5, 2024
(A)
Length and Frequency of Sessions.
(1) The MassHealth agency pays 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 pays for only one
			 session of the types of services listed in 130 CMR 434.430(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 434.000 - Psychiatric Hospital Outpatient Services › Section 434.431 - 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 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.401 - Introduction

Current through Register 1525, July 5, 2024
All providers of chronic disease and rehabilitation inpatient
				hospital services participating in MassHealth must comply with the regulations
				of the Division governing MassHealth, including, but not limited to, Division
				regulations set forth in
				130 CMR 435.000 and in
				130 CMR
				450.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The Division covers chronic disease and rehabilitation
			 inpatient hospital services only when provided to eligible MassHealth members,
			 subject to the restrictions and limitations described in the Division's
			 regulations.
			 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 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
Introduction
. Payment for the services described in
			 130 CMR 435.000 will be
			 made only to chronic-disease and rehabilitation hospitals participating in
			 MassHealth as of the date of service.
(B)
In State
. To
			 participate in MassHealth, a chronic-disease or rehabilitation hospital located
			 in Massachusetts must:
(1) be licensed or
			 operated by the Massachusetts Department of Public Health or the Massachusetts
			 Department of Mental Health as a chronic-disease or rehabilitation hospital or
			 unit;
(2) accept payment according
			 to the methods and amounts as described in
			 130 CMR 435.405
			 as payment in full for services; and
(3) participate in the Medicare
			 program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.405 - Rates of Payment

Current through Register 1525, July 5, 2024
(A) Payments to
			 in-state hospitals for services furnished to MassHealth members are equal to
			 the rate established in the signed provider agreement with the MassHealth
			 agency.
(B) Payments to
			 out-of-state hospitals are made in accordance with
			 130 CMR
			 450.233. The Medicaid program rate
			 methodology of that state will apply when such methodology is compatible with
			 the MassHealth agency's claims-processing system. Otherwise, the MassHealth
			 agency and the out-of-state facility will negotiate a rate comparable to the
			 median or weighted average in-state rate for similar facilities.
(C) The hospital must accept the amount of
			 payment established by 130 CMR 435.405 as payment in full for all care and
			 services provided by the hospital for which payment is available under
			 MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.406 - Billing Exceptions

Current through Register 1525, July 5, 2024
(A) The hospital
			 may bill separately only for those drugs and durable medical equipment
			 prescribed for take-home use that a member is unable to obtain directly from a
			 pharmacy or durable medical equipment supplier. The charges for such drugs and
			 durable medical equipment must be submitted on the claim form specified in the
			 billing instructions.
(B) A
			 hospital under contract to provide a managed-care program may not bill
			 separately for take-home drugs and durable medical equipment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.407 - Definitions

Current through Register 1525, July 5, 2024
(A) The cost of any treatment or testing
			 provided outside the hospital is allowed for in the rate-determination process
			 and is not separately reimbursable.
(B) All administrative and processing costs
			 associated with the provision of blood and its derivatives are allowed for in
			 the rate-determination process and are not separately reimbursable.
(C) Private hospital rooms are not
			 reimbursable except where medically necessary. Payment for medically necessary
			 private hospital rooms is included in the rates of payment set forth under
			 130 CMR
			 435.405(A).
(D) Research and the provision of
			 experimental procedures are not reimbursable.
(E) Leave-of-absence days taken by a member
			 are not reimbursable. For billing purposes, leave-of-absence days are to be
			 treated in the same way as discharge and admission days. Thus, the day on which
			 the member leaves the chronic-disease or rehabilitation hospital to start a
			 leave of absence is not reimbursable, regardless of the hour of discharge,
			 while the day on which the member returns is reimbursable.
(F) Rest-home (level IV) services are not
			 reimbursable.
(G) For members 21
			 years of age and older, the first 45 administrative days of a member's
			 admission or continued stay are not reimbursable.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.408 - Screening Program for Chronic-disease and Rehabilitation Hospitals

Current through Register 1525, July 5, 2024
(A)
Introduction
.
			 The screening program applies to all in-state and out-of-state chronic-disease
			 and rehabilitation hospitals, except those participating in a managed-care
			 program for all inpatients (see
			 130 CMR 435.402 ).
			 The screening program described in 130 CMR 435.408 is intended to ensure that
			 medical and nursing services are medically necessary. The Division pays for
			 chronic-disease and rehabilitation hospital services only when the Division or
			 its agent determines, pursuant to a screening, that such services are medically
			 necessary and authorizes such services prior to admission or
			 conversion.
(B)
Screening
.
(1) To
			 initiate admission or conversion screening, the hospital must telephone the
			 Division or its agent prior to the proposed admission or anticipated conversion
			 and must:
(a) describe the medical condition
			 that necessitates a chronic-disease or rehabilitation hospital admission or
			 continued stay; and
(b) state the
			 anticipated length of stay.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.409 - Level-of-Care Criteria for Members in Chronic Disease and Massachusetts Department of Public Health Hospitals

Current through Register 1525, July 5, 2024
(A)
Introduction
. Services in chronic disease and
			 Massachusetts Department of Public Health hospitals are reimbursable only when
			 the member meets the level-of-care criteria in 130 CMR 435.409(B)(1) or
			 (2).
(B)
Level-of-Care
			 Criteria
. In determining medical necessity, the Division or its
			 agent applies the criteria in 130 CMR 435.409(B)(1) and (2). In addition, the
			 Medicare Adult Appropriateness Evaluation Protocol (AEP) utilized by the Peer
			 Review Organization (PRO) is used as a guide. To be medically necessary, an
			 admission to or continued stay in a chronic disease or Massachusetts Department
			 of Public Health hospital must meet one of the following two criteria, in
			 compliance with
			 130 CMR
			 450.204.
(1) The member must require services that:
(a) can be provided safely and effectively at
			 a chronic disease hospital level. Such services must be ordered by a physician
			 and documented in the member's record; and
(b) include at least daily physician
			 intervention or the 24-hour availability of medical services and equipment
			 available only in a hospital setting.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.410 - Level-of-Care Criteria for Rehabilitation Hospitals

Current through Register 1525, July 5, 2024
(A)
Introduction
. A
			 member is considered appropriate for rehabilitation hospital placement only
			 when a medical need exists for an intensive rehabilitation program that
			 includes a multidisciplinary approach to improve the member's ability to
			 function to his or her maximum potential. Factors must be present in the
			 member's condition that indicate the potential for functional movement or
			 freedom from pain. A member who requires therapy solely to maintain function is
			 not considered an appropriate rehabilitation hospital patient.
(B)
Level-of-Care
			 Criteria
. The Medicare rehabilitation hospital level-of-care
			 criteria and the criteria below are used by the Division or its agent to
			 determine the medical necessity of rehabilitation hospital placement. The
			 hospital must provide a rehabilitation program that:
(1) includes specialized skilled nursing
			 services, physical therapy, occupational therapy, and any other services that
			 are necessary for the rehabilitative program (such as speech therapy,
			 prosthetic, or orthotic services);
(2) is organized and directed by a physician
			 who is board-certified in rehabilitation medicine; and
(3) is designed to achieve specified goals
			 within a given time frame.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.411 - Utilization Review

Current through Register 1525, July 5, 2024
(A) The hospital
			 must determine the medical or administrative necessity of each continued
			 inpatient hospital stay of a member in accordance with the level-of-care
			 criteria in
			 130
			 CMR 435.409 and
			 435.410.
			 For those members requiring a less-than-hospital level of care, the hospital
			 must determine the appropriate care in accordance with the MassHealth agency's
			 medical eligibility criteria in
			 130 CMR
			 456.000:
Long Term Care
			 Services
.
(B) The
			 MassHealth agency may designate an agent to determine the medical or
			 administrative necessity of each inpatient hospital stay.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.412 - Reimbursable Administrative Days

Current through Register 1525, July 5, 2024
(A) For
			 members younger than 21 years old, the MassHealth agency will pay a hospital
			 for up to 30 administrative days for each admission or each continued stay
			 resulting from a conversion, as defined in
			 130 CMR 435.402. The
			 MassHealth agency may pay a hospital for administrative days exceeding the
			 30-day limit for members younger than 21 years old, when the hospital can
			 demonstrate to the satisfaction of the MassHealth agency or its agent, that the
			 hospital has
(1) experienced extraordinary
			 difficulty in placing the member, including the specific reasons for such
			 extraordinary difficulty; and
(2)
			 exhaustively explored all potential appropriate placements.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.413 - Nonreimbursable Administrative Days

Current through Register 1525, July 5, 2024
Administrative days after the 45-day period described in 130
				CMR 435.407G ) are not reimbursable when:
(A) a hospitalized member is awaiting
			 services or an appropriate placement is currently available, but the hospital
			 has not transferred or discharged the member because of the hospital's
			 administrative or operational delays;
(B) the MassHealth agency or its agent
			 determines that appropriate noninstitutional or institutional placement or
			 services are available within a reasonable distance of the member's
			 noninstitutional (customary) residence and the member, the member's family, or
			 any person legally responsible for the member refuses the placement or
			 services; or
(C) the MassHealth
			 agency or its agent determines that appropriate noninstitutional or
			 institutional placement or services are available within a reasonable distance
			 of the member's noninstitutional (customary) residence and advises the hospital
			 of the determination, and the hospital or the physician refuses or neglects to
			 discharge the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.414 - Readmission after Medical Absence

Current through Register 1525, July 5, 2024
When a member who was transferred for treatment to an acute
				inpatient hospital no longer needs acute inpatient hospital care but does meet
				the level-of-care criteria in
				130
				CMR 435.409(B)  or
				435.410(B),
				the chronic disease or rehabilitation hospital from which the member was
				transferred must readmit the member to the first available bed, in accordance
				with admission screening requirements (see
				130
				CMR 435.408 ).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.415 - Notification of Denial

Current through Register 1525, July 5, 2024
The Division or its agent notifies the member, the hospital,
				and the member's attending physician whenever it determines that the hospital
				admission or continued stay, or any part thereof, is not medically or
				administratively necessary. The Division or its agent notifies the hospital and
				the member's attending physician whenever it determines that the hospital stay
				is no longer appropriate at a chronic disease or rehabilitation hospital level
				of care, but is administratively necessary. The Division or its agent notifies
				the member, the hospital, and the member's attending physician whenever it
				determines that the hospital stay is no longer administratively necessary due
				to the refusal of an appropriate placement in accordance with
				130 CMR
				435.413.