reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR 410.000 is made
				only to hospital outpatient department and hospital licensed health centers
				participating in MassHealth on the date of service.
(A)
In State
.
(1) To participate in MassHealth, acute
			 hospital outpatient departments and hospital-licensed health centers located in
			 Massachusetts must
(a) operate under a
			 hospital license issued to an acute hospital by the Massachusetts Department of
			 Public Health;
(b) have a signed
			 provider agreement that specifies a payment methodology with the MassHealth
			 agency; and
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.405 - Noncovered Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency does not pay for any of the following services:
(1) nonmedical services, such as social,
			 educational, and vocational services;
(2) cosmetic surgery;
(3) canceled or missed
			 appointments;
(4) telephone
			 conversations and consultations;
(5) court testimony;
(6) research or the provision of
			 experimental, unproven, or otherwise medically unnecessary procedures or
			 treatments, specifically including, but not limited to, sex-reassignment
			 surgery, thyroid cartilage reduction and any other related surgeries and
			 treatments, including pre- and post-sex-reassignment surgery hormone therapy.
			 Notwithstanding the preceding sentence, the MassHealth agency will continue to
			 pay for post-sex-reassignment surgery hormone therapy for which it had been
			 paying immediately prior to May 15, 1993;
(7) the provision of whole blood; however,
			 administrative and processing costs associated with the provision of blood and
			 its derivatives are covered; and
(8) 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 infertility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.406 - Payment

Current through Register 1525, July 5, 2024
(A) Acute hospital outpatient departments and
			 hospital-licensed health centers in Massachusetts are paid for services
			 provided to eligible members according to the rate for services established in
			 the signed MassHealth provider agreement, subject to the limitations set forth
			 in 130 CMR 410.406.
(B) For
			 purposes of making payments to acute hospital outpatient departments and
			 hospital-licensed health centers in Massachusetts, the following limitations
			 apply.
(1) The MassHealth agency does not pay
			 for outpatient services provided to a member who is an inpatient at the same or
			 a different hospital on the same day.
(2) The MassHealth agency pays only for
			 emergency outpatient services provided to a member on the day that the member
			 is discharged from the hospital, whether from the same or a different
			 facility.
(3) If a member receives
			 outpatient services at one facility and, later on the same day, is admitted as
			 an inpatient to another facility, the MassHealth agency pays both hospitals for
			 services.
(4) When a member is
			 admitted to inpatient status through the emergency department or outpatient
			 department, the hospital must bill for only the inpatient stay. The MassHealth
			 agency does not pay for services furnished in the emergency department or
			 outpatient department on the admitting day.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.408 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) For certain
			 outpatient services described in
			 130 CMR 410.000, the
			 MassHealth agency requires that the hospital outpatient department obtain prior
			 authorization. No payment is made for outpatient services whenever a hospital
			 is required, but fails, to obtain prior authorization from the MassHealth
			 agency or its designee. It is the responsibility of the hospital to obtain the
			 necessary prior authorization.
(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
Outpatient Hospital Manual
. For more information on requests
			 for prior authorization,
see
130 CMR
			 450.303:
Prior
			 Authorization
.
(D) Members
			 enrolled with a MassHealth managed care provider require service authorization
			 before certain behavioral health services are provided. For more information,
			 see
			 130 CMR
			 450.124:
Behavioral
			 Services
.
(E) The hospital
			 must obtain prior authorization for the following outpatient therapy services:
(1) more than 20 occupational-therapy visits
			 or 20 physical-therapy visits, including group-therapy visits, for a member
			 within a 12-month period; and
(2)
			 more than 35 speech/language therapy visits, including group-therapy visits,
			 for a member within a 12-month period.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.410 - Assurance of Member Rights

Current through Register 1525, July 5, 2024
No provider shall use any form of coercion in the provision of
				any services (for example, abortion, sterilization, and family planning).
				Neither the MassHealth agency nor any provider, nor any agent or employee of a
				provider, shall mislead any member into believing that a decision to receive
				any services reimbursable under
				130 CMR 410.000 will
				adversely affect the member's entitlement to benefits or services for which the
				member would otherwise be eligible. The MassHealth agency has strict
				requirements for the confidentiality of patient records for all medical
				services reimbursable under MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.411 - Emergency Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency covers emergency services provided in a hospital emergency department
			 without prior authorization.
(B)
			 For services provided in the emergency department, handwritten or time-stamped
			 documentation of the length of the member's stay in the emergency room must be
			 kept in the member's record or on an easily accessible hospital log.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.412 - Utilization Management Program and Mental Health and Substance Use Disorder Admission Screening Requirements

Current through Register 1525, July 5, 2024
(A)
Utilization Management Program
. The MassHealth agency
			 pays for procedures and acute hospital stays that are subject to the acute
			 hospital Utilization Management Program only if the applicable requirements of
			 the program as described in
			 130
			 CMR 450.207 through
			 450.209
			 are satisfied. Appendices A and D of the
Acute Outpatient Hospital
			 Manual
contains the name, address, and telephone number of the contact
			 organization for the Utilization Management Program and describes the
			 information that must be provided during the review process.
(B)
Mental Health and Substance
			 Use Disorder Admissions
. The MassHealth agency will pay for mental
			 health and substance use disorder services provided in an acute inpatient
			 setting only if the admitting provider has satisfied the screening requirements
			 established by MassHealth policy, bulletin or other issuance.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.414 - Observation Services

Current through Register 1525, July 5, 2024
(A)
Reimbursable Services
. MassHealth covers medically
			 necessary observation services provided by acute inpatient hospitals.
			 Reimbursable observation services may exceed 24 hours, and do not need to be
			 provided in a distinct observation unit. To qualify for reimbursement of
			 observation services, the medical record must specifically document when those
			 services began and ended, the purpose of observation, and the name of the
			 physician who ordered it. Acute inpatient hospitals will be reimbursed for
			 these observation services on an outpatient basis in accordance with the signed
			 provider agreement with the MassHealth agency.
(B)
Nonreimbursable
			 Services
.
(1) Nonreimbursable
			 observation services include but are not limited to:
(a) services that are not reasonable or
			 necessary for the diagnosis or treatment of the member; and
(b) routine preparation and recovery services
			 associated with diagnostic testing or outpatient surgery.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.415 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				outpatient hospital 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 410.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.420 - 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 410.420(B)
			 and pharmacotherapy treatment, including nicotine replacement therapy (NRT), in
			 accordance with
			 130 CMR
			 406.000.
(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 410.420(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
			 health care 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 410.000 - Outpatient hospital services › Section 410.431 - Sterilization Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Covered Services
. The MassHealth agency pays for
			 sterilization services performed by a licensed physician in an acute hospital
			 outpatient department for a 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
			 410.432, and such consent is documented in
			 the manner described in
			 130 CMR
			 410.433.
(2) The member is at least 18 years of age 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 410.000 - Outpatient hospital services › Section 410.432 - 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 410.432(A) and (B), and such consent is
				documented as specified in
				130 CMR
				410.433.
(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 410.432(B)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.433 - 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. (Instructions for obtaining the
				Consent for Sterilization forms are located in Subchapter 5 of the
Outpatient Hospital Manual
.)
(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 410.000 - Outpatient hospital services › Section 410.434 - Abortion Services: Reimbursable Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for abortion services performed by a
				licensed physician, physician assistant, certified nurse practitioner, or
				certified nurse midwife in a hospital outpatient department only when all of
				the following conditions are met:
(A)
			 the abortion is performed in accordance with law;
(B) the abortion is medically necessary-that
			 is, according to the medical judgment of a licensed physician, or, consistent
			 with M.G.L. c. 112, § 12M and the time limitations established therein a
			 physician assistant, certified nurse practitioner, or certified nurse midwife,
			 necessary in light of all factors affecting the pregnant individual's health;
			 and
(C) the abortion service is
			 claimed according to the requirements in
			 130 CMR
			 410.435.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.436 - Abortion Services: Out-of-state Abortions

Current through Register 1525, July 5, 2024
The MassHealth agency will pay for an abortion performed in an
				out-of-state facility only if the abortion meets the conditions specified in
				130 CMR
				410.434 and if prior authorization is
				requested and received from the MassHealth agency.
(A) The member, the referring provider, or a
			 referral agency may request prior authorization from the MassHealth agency in
			 writing. The request must be made in accordance with the instructions for
			 requesting prior authorization for abortion services in Subchapter 5 of the
Outpatient Hospital Manual
.
(B) If the MassHealth agency authorizes the
			 abortion, it will issue a prior authorization number directly to the
			 out-of-state facility. The facility must enter the prior authorization number
			 on the claim form when requesting payment from the MassHealth agency.
(C) Out-of-state abortion services will be
			 authorized only when such services are not available in a Massachusetts
			 facility.
(D) Prior authorization
			 is not required for abortion services provided in the situations described in
			 130 CMR
			 410.404(B)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.437 - Family Planning Services

Current through Register 1525, July 5, 2024
The MassHealth agency will pay for outpatient hospital services
				related to family planning. These services may include, but are not limited to,
				the following:
(A) nonpermanent
			 contraceptive care;
(B)
			 comprehensive medical examination;
(C) diagnosis and treatment of medical
			 problems specific to reproduction as well as diagnosis of and appropriate
			 referral for other medical problems;
(D) sexually transmitted infection (STI) and
			 treatment;
(E) cervical cancer
			 screening (Pap smear);
(F) breast
			 examination;
(G) laboratory
			 services related to family planning (for example, Pap smear, gonorrhea culture,
			 vaginal culture and smear, blood test for sexually transmitted infection (STI),
			 hematocrit, complete blood count, urinalysis, and pregnancy testing);
			 and
(H) family planning counseling,
			 including discussions about family planning, human reproduction, and methods of
			 contraception.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.438 - 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 410.438(C), for use as an anesthetic as described
			 in
			 130 CMR
			 433.454(C):
Acupuncture as an Anesthetic
, and for use for detoxification
			 as described in
			 130 CMR
			 418.406(C)(3):
Acupuncture Detoxification
.
(B)
General
. 130 CMR
			 410.438 applies specifically to acupuncture services rendered in a hospital by
			 physicians and 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
.
(1)
Qualified
			 Providers
. MassHealth pays a hospital for acupuncture services
			 only when the provider rendering the service is:
(a) a physician; or
(b) 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 410.000 - Outpatient hospital services › Section 410.441 - Early Intervention Program Services

Current through Register 1525, July 5, 2024
(A)
			 An early intervention program provides services such as therapy and social,
			 medical, educational, and developmental services for children aged three years
			 or younger who are at biological, environmental, or established risk, and for
			 their families.
(B) The MassHealth
			 agency pays for services provided as part of an organized early intervention
			 program by hospital outpatient departments. These services must be furnished in
			 compliance with the MassHealth regulations governing early intervention program
			 services in
			 130 CMR 440.000.
			 (
See
Subchapter 5 of the
Outpatient Hospital
			 Manual
for instructions about obtaining the
Early Intervention
			 Program Manual
, which contains the necessary regulations.)
(C) Acute and nonacute hospital-based early
			 intervention programs are paid according to the regulations governing early
			 intervention services in
			 130 CMR 440.000:
Early Intervention Program Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.442 - Home Health Agency Services

Current through Register 1525, July 5, 2024
(A) A home health
			 agency is a public or private agency or organization, or a subdivision of such
			 an agency or organization, that is primarily engaged in furnishing part-time
			 skilled nursing and other therapeutic services to patients in their
			 homes.
(B) The MassHealth agency
			 pays for home health services provided by hospital-based home health agencies.
			 These services must be furnished in compliance with the MassHealth regulations
			 governing home health agency services in
			 130 CMR
			 403.000:
Home Health Agency
.
			 (
See
Subchapter 5 of the
Outpatient Hospital
			 Manual
for information about obtaining the
Home Health Agency
			 Manual
, which contains the necessary regulations.)
(C) Acute hospital-based home health agencies
			 will be paid according to the outpatient payment methodology established by the
			 signed MassHealth provider agreement.
(D) Non-acute hospital-based home health
			 agencies are paid according to the regulations governing home health services
			 in
			 130 CMR
			 403.000:
Home Health
			 Agency
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.443 - Adult Day Health Program Services

Current through Register 1525, July 5, 2024
(A)
			 An adult day health program is an organized program of health care and
			 supervision, restorative services, and social activities whose general goal is
			 to provide an alternative to long-term institutional care.
(B) The MassHealth agency pays for services
			 provided as part of an organized adult day health program by a hospital
			 outpatient department. These services must be furnished in accordance with the
			 MassHealth regulations governing adult day health programs in
			 130
			 CMR 404.000:
Adult Day Health
			 Services
. (
See
Subchapter 5 of the
Outpatient
			 Hospital Manual
for information about obtaining the
Adult Day
			 Health Manual
, which contains the necessary regulations.)
(C) Acute hospital-based adult day health
			 programs will be paid according to the outpatient payment methodology
			 established by the signed MassHealth provider agreement.
(D) Nonacute hospital-based adult day health
			 programs will be paid according to the regulations governing adult day health
			 services in
			 130
			 CMR 404.000:
Adult Day Health
			 Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.444 - Adult Foster Care Services

Current through Register 1525, July 5, 2024
(A) An adult foster
			 care program provides personal care services in a family-like setting to
			 elderly or disabled individuals who are at imminent risk of institutional
			 placement.
(B) The MassHealth
			 agency pays for services provided by hospital-based adult foster care programs.
			 These services must be furnished in compliance with
			 130 CMR
			 408.000:
Adult Foster Care Services
.
			 (
See
Subchapter 5 of the
Outpatient Hospital
			 Manual
for information about obtaining the
Adult Foster Care
			 Manual
.)
(C) Acute
			 hospital-based adult foster care programs will be paid according to the
			 outpatient payment methodology established by the signed MassHealth provider
			 agreement.
(D) Nonacute
			 hospital-based adult foster care programs will be paid according to
			 130 CMR
			 408.000:
Adult Foster Care
			 Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.445 - 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 hospital outpatient departments that are enrolled with
			 MassHealth as psychiatric day treatment programs. These services must be
			 provided in compliance with the MassHealth regulations governing psychiatric
			 day treatment program services in
			 130 CMR 417.000:
Psychiatric Day Treatment Program Manual
. (See Subchapter 5 of
			 the
Outpatient Hospital Manual
for instructions about
			 obtaining the
Psychiatric Day Treatment Program Manual
, which
			 contains the necessary regulations.)
(C) Acute hospital-based psychiatric day
			 treatment programs are paid according to the outpatient payment methodology
			 established by the signed MassHealth provider agreement.
(D) Nonacute hospital-based psychiatric day
			 treatment programs are paid according to the regulations governing psychiatric
			 day treatment services in
			 130 CMR 417.000:
Psychiatric Day Treatment Program Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.446 - Dental Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for dental services provided by hospital outpatient departments.
			 These services must be provided in compliance with the MassHealth regulations
			 governing dental services in
			 130 CMR
			 420.000:
Dental Services
.
			 (
See
Subchapter 5 of the
Outpatient Hospital
			 Manual
for information about obtaining the
Dental
			 Manual
, which contains the necessary regulations.)
(B) Acute hospital-based providers of dental
			 services are paid according to the outpatient payment methodology established
			 by the signed MassHealth provider agreement.
(C) Nonacute hospital-based providers of
			 dental services are paid according to the regulations governing dental services
			 in
			 130 CMR
			 420.000:
Dental Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.451 - Therapist Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for occupational, physical, and speech/language therapy provided in
			 hospital outpatient departments by or under the supervision of licensed
			 therapists. Therapist services include the following:
(1) individual treatment;
(2) comprehensive evaluation;
(3) group therapy; and
(4) design and fitting of an adaptive
			 device.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.452 - Therapist Services: Service Limitations

Current through Register 1525, July 5, 2024
(A)
			 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 410.452(B).
(B)
			 In certain instances, the specialized knowledge and judgment of a 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 therapist, all information that
			 supports the medical necessity for performance of such services by a licensed
			 therapist, rather than a non-therapist, must be documented in the medical
			 record.
(C) For each type of
			 therapy, the MassHealth agency pays for no more than one individual visit and
			 one group therapy session for a member per day.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.453 - Therapist Services: Recordkeeping Requirements

Current through Register 1525, July 5, 2024
In addition to the information required in
				130 CMR
				410.409, the member's record must include the
				following:
(A) a licensed physician's
			 or licensed nurse practitioner's written referral for evaluation, referral for
			 treatment, and renewal of referral (if applicable) every 60 days
			 (
see
130 CMR
			 410.451(B));
(B) the written comprehensive evaluation
			 report (
see
130 CMR
			 410.451(C));
(C) the name, address, and telephone number
			 of the member's primary physician;
(D) a treatment notation for each date on
			 which therapy was provided that includes at least the following:
(1) the specific therapeutic procedures and
			 methods used;
(2) the amount of
			 time spent in treatment; and
(3)
			 the signature and title of the person who provided the service;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.455 - Laboratory Services: Introduction

Current through Register 1525, July 5, 2024
(A)130 CMR
			 410.455 through
			 410.459
			 establish the requirements and procedures for clinical laboratory services
			 provided by hospital outpatient departments. A clinical laboratory service
			 includes the following types of services: microbiological, serological,
			 chemistry, hematological, radioimmunoassay, cytological, immunological,
			 pathological, or other examinations of materials derived from the human body to
			 provide information for the assessment of a medical condition or for the
			 diagnosis, prevention, or treatment of any disease.
(B) The MassHealth agency does not pay
			 separately for routine specimen collection and preparation for the purpose of
			 clinical laboratory analysis (for example, venipuncture; urine, fecal, and
			 sputum samples; Pap smears; cultures; and swabbing and scraping for removal of
			 tissue.) Specimen collection and preparation is considered part of the
			 laboratory service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.456 - Laboratory Services: Payment

Current through Register 1525, July 5, 2024
(A)
Maximum Allowable Fees
. The MassHealth agency pays an
			 acute or a private chronic disease and rehabilitation hospital outpatient
			 department for laboratory services in accordance with the rates set forth in
			 regulations at
			 101
			 CMR 320.00:
Clinical Laboratory
			 Services
, and 114.3 CMR 16.00:
Surgery and
			 Anesthesia
, as applicable, subject to the conditions, exclusions, and
			 limitations set forth in
			 130 CMR 410.000.
(B)
Usual and Customary
			 Fee
. The term usual and customary in the hospital outpatient
			 department laboratory contest means the lowest fee charged by a hospital
			 outpatient department laboratory for any laboratory service (including both
			 individual and profile tests) specified in the hospital outpatient department's
			 charge book or by such hospital, with the exception of a fee offered for a bulk
			 purchase. (A bulk purchase is a single purchase of a laboratory service (one or
			 more tests) to be uniformly and concurrently performed on a minimum of 40
			 specimens of the same type. A single purchase of various, non-uniform
			 laboratory services, such as by a physician, is not considered a bulk purchase,
			 regardless of the number of specimens presented by such a purchaser to the
			 hospital outpatient department laboratory.)
(C)
Profile or Panel
			 Tests
.
(1) A profile or panel
			 test is 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 hospital outpatient department laboratory performing
			 the tests.
(b) The group of tests
			 is performed by the hospital outpatient department laboratory at a usual and
			 customary fee that is lower than the sum of that hospital outpatient department
			 laboratory'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 410.000 - Outpatient hospital services › Section 410.457 - Laboratory Services: Request for Services

Current through Register 1525, July 5, 2024
In order to receive payment for a laboratory service, a
				hospital outpatient department must have received a written request by an
				authorized prescriber, as defined in
				130 CMR 401.402:
Definitions
, to perform the service. Such written request must
				comply with the requirements specified in
				130 CMR
				401.416:
Reimbursable
				Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.458 - Laboratory Services: Recordkeeping Requirements

Current through Register 1525, July 5, 2024
In addition to meeting the record keeping requirements
				specified in
				130 CMR
				410.409, the hospital outpatient department
				must keep a suitable record of each specimen and laboratory test result for at
				least six years from the date on which the results were reported to the
				authorized prescriber. Such a record must contain the information specified in
				130 CMR
				401.417:
Recordkeeping
				Requirements
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.459 - Laboratory Services: Specimen Referral

Current through Register 1525, July 5, 2024
A hospital outpatient department may refer a specimen to an
				independent laboratory that is eligible to participate in MassHealth, or to
				another hospital laboratory that is eligible to participate in MassHealth. To
				be eligible, a hospital laboratory must be in a hospital that is licensed by
				the Massachusetts Department of Public Health and that is an approved Medicare
				provider. The referring hospital outpatient department laboratory must inform
				the prescriber of the name and address of the testing laboratory. The testing
				laboratory must inform the referring hospital outpatient department laboratory
				of the results of the test. Only the referring laboratory is authorized to bill
				the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.461 - Pharmacy Services: Drugs Dispensed in Pharmacies Including, but Not Limited to, Hospital-based Pharmacies

Current through Register 1525, July 5, 2024
(A)
			 Coverage of drugs and medical supplies dispensed to MassHealth members by
			 MassHealth pharmacy providers, and related prescription requirements for
			 prescribing clinicians, are governed by
			 130 CMR
			 406.000:
Pharmacy Services
and
			 130
			 CMR 410.468
(B)
								130
			 CMR 410.468 refers to prescription drugs
			 dispensed in pharmacies, not to drugs administered in the office
			 (Physician-administered Drugs) and is only applicable to 340B-covered
			 Entities.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.468 - Participation in the 340B Drug-pricing Program for Pharmacy Services

Current through Register 1525, July 5, 2024
(A)
Notification of
			 Participation
. Except for drugs that cost $100,000 (gross cost per
			 utilizer per year) that are designated as excluded from coverage for MassHealth
			 members through the 340B Drug Pricing Program, a hospital outpatient department
			 or a hospital-licensed health center that is a 340B-covered entity may provide
			 drugs to MassHealth members through the 340B Drug Pricing Program provided that
			 it notifies the MassHealth agency that the 340B-covered entity is registered
			 and approved by the federal Office of Pharmacy Affairs (OPA). Any high-cost
			 drug designated for exclusion from coverage for MassHealth members through the
			 340B Drug-Pricing Program will be communicated by provider bulletin or other
			 written issuance from the MassHealth agency, and be consistent with all
			 requirements of M.G.L. c. 118E, §13L, and shall include an opportunity for
			 eligible providers to provide input regarding the designation. The MassHealth
			 agency may designate up to 25 drugs for exclusion from coverage for MassHealth
			 members through the 340B Drug Pricing Program. Any exclusion from coverage for
			 MassHealth members through the 340B Drug Pricing Program does not apply to
			 claims paid using the adjudicated payment amount per discharge (APAD) or
			 adjudicated payment per episode of care (APEC) methodology, other than for
			 drugs listed on the Acute Hospital Carve-Out Drugs List section of the
			 MassHealth Drug List.
(B)
Subcontracting for 340B Outpatient Pharmacy Services
.
(1) A hospital outpatient department or
			 hospital-licensed health center that is a 340B-covered entity may contract with
			 a MassHealth pharmacy provider to dispense 340B drugs for the 340B-covered
			 entity's MassHealth patients. All such subcontracts between the 340B-covered
			 entity and a pharmacy provider must be in writing, ensure continuity of care,
			 specify that the hospital pays the pharmacy, specify that such payment
			 constitutes payment in full for 340B drugs provided to MassHealth members, be
			 consistent with all applicable provisions of
			 130 CMR
			 406.000:
Pharmacy Services
, and are
			 subject to MassHealth agency approval.
(2) The hospital is legally responsible to
			 MassHealth for the performance of any subcontractor. The hospital must ensure
			 that every pharmacy subcontractor is licensed by the Massachusetts Board of
			 Registration in Pharmacy and is a MassHealth pharmacy provider, and that
			 services are furnished in accordance with
			 130 CMR
			 406.000:
Pharmacy Services
and all
			 other applicable MassHealth requirements, including but not limited to, those
			 set forth in
			 130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.471 - Mental Health Services: Introduction

Current through Register 1525, July 5, 2024
A mental health program is a comprehensive group of diagnostic
				and treatment services, as outlined in
				130 CMR
				410.474, furnished to mentally or emotionally
				disabled persons and their families under the direction of a licensed
				psychiatrist. The MassHealth agency pays for mental health services provided in
				hospital outpatient departments subject to the restrictions and limitations in
				130 CMR
				410.472 through
				410.479.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.472 - Mental Health Services: Noncovered Services

Current through Register 1525, July 5, 2024
(A)
Nonmedical Services
. The MassHealth agency does not
			 pay for nonmedical mental health services. These services include, but are not
			 limited to, the following:
(1) vocational
			 rehabilitation services;
(2)
			 sheltered workshops;
(3)
			 educational services;
(4)
			 recreational services (play therapy, the use of play activities with a child in
			 an identified treatment setting as an alternative to strictly verbal expression
			 of conflicts and feelings, is not considered a recreational service and is
			 covered);
(5) life-enrichment
			 services (ego-enhancing services such as workshops or educational courses
			 provided to functioning persons); and
(6) telephone conversations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.475 - Mental Health Services: Staffing Requirements

Current through Register 1525, July 5, 2024
(A)
Provider
			 Responsibilities
.
(1) The
			 hospital outpatient department must employ a multidisciplinary staff to furnish
			 mental health services under the direction of a licensed
			 psychiatrist.
(2) The hospital
			 outpatient department 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 hospital outpatient
			 department employ mental health professionals from all the disciplines listed
			 in 130 CMR 410.475(B), staff members who provide services to members must be
			 qualified as set forth in 130 CMR 410.475(B) for their respective
			 disciplines.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.476 - Mental Health Services: Treatment Procedures

Current through Register 1525, July 5, 2024
(A) A staff member from one of the
			 disciplines described in 130 CMR 417.475(B) must conduct a comprehensive
			 evaluation of each member prior to initiation of therapy. For members younger
			 than 21 years old, a CANS must be completed during the initial
			 behavioral-health assessment before initiation of therapy and be updated at
			 least every 90 days thereafter by a CANS-certified provider, as described in
			 130 CMR
			 410.475(B). The CANS is not
			 required during an assessment that is conducted as part of the emergency
			 department screening.
(B) The
			 hospital outpatient department 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 hospital outpatient department will ensure that one professional staff
			 member (the primary therapist) assumes primary responsibility for each member.
			 This responsibility will include
(1) within
			 four client 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
			 utilization review;
(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
			 410.475(B), completes the
			 CANS in accordance with 130 CMR 410.476(A).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.477 - 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
			 410.475.
(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.