reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.434 - Schedule of Operations

Current through Register 1525, July 5, 2024
(A) The center must
			 operate at least one freestanding location that is open and operated at least
			 40 hours per week.
(B) A mental
			 health center operated by a licensed community health center must be open at
			 least 20 hours per week.
(C) When
			 the center is closed, after-hours coverage must be provided to triage needs and
			 personnel shall be available to offer referral to qualified professionals,
			 emergency services, or other mechanisms for effectively responding to a crisis,
			 in accordance with the requirements set forth at
			 130
			 CMR 429.421(A)(5).
(D) Each center designated as a Behavioral
			 Health Urgent Care provider pursuant to
			 130
			 CMR 429.405(D)  must offer
			 extended availability on Mondays through Fridays outside the hours of 9:00 A.M.
			 through 5:00 P.M. At minimum, such centers must offer at least eight hours of
			 extended availability per week during weekdays and at least two four-hour
			 blocks of availability on weekends per month.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.435 - Utilization Review Plan

Current through Register 1525, July 5, 2024
The mental health center must have a utilization review plan
				that meets the following conditions.
(A) A utilization review committee must be
			 composed of the clinical director or the clinical director's designee and two
			 other professional staff members who meet all the qualifications for their
			 discipline, as outlined in
			 130
			 CMR 429.424. The composition of the
			 utilization review committee must be reported to MassHealth as set forth in
			 130
			 CMR 429.406.
(B) The utilization review committee must
			 review each member's case in accordance with the Department of Public Health
			 regulations found at
			 105
			 CMR 140.540:
Case Review
and
			 following the member's discharge from services at the center.
(C) The utilization review committee must
			 verify for each case that:
(1) the diagnosis
			 is, or has been, adequately documented;
(2) the treatment plan is, or was,
			 appropriate and specifies the methods and duration of the projected treatment
			 program;
(3) the treatment plan is
			 being, or has been, carried out;
(4) the treatment plan is being, or has been,
			 modified as indicated by the member's changing status;
(5) there is, or was, adequate follow-up when
			 a member misses appointments or drops out of treatment;
(6) there is, or was, progress toward
			 achievement of short and long-term goals; and
(7) for members younger than 21 years old,
			 the CANS has been completed at 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 429.000 - Mental Health Center Services › Section 429.437 - Written Policies and Procedures

Current through Register 1525, July 5, 2024
Each mental health center must have and observe written
				policies and procedures that include:
(A) a statement of its philosophy and
			 objectives and of the geographical area served;
(B) an intake policy
(C) admission procedures, including criteria
			 for client admission and procedures for multidisciplinary review of each
			 individual referral;
(D) treatment
			 procedures including, but not limited to, development of the treatment plan,
			 case assignment, case review, discharge planning, and follow-up on members who
			 leave the center voluntarily or involuntarily;
(E) a medication policy that includes
			 prescription, administration, and monitoring data;
(F) a referral policy, including procedures
			 for ensuring uninterrupted and coordinated member care upon transfer;
(G) procedures for walk-in members, and
			 clinical emergencies during operating and nonoperating hours;
(H) recordkeeping policies, including what
			 information must be included in each record, and procedures to ensure
			 confidentiality;
(I) personnel and
			 management policies, including policies for hiring, training, evaluation,
			 supervision and termination protocol for all staff;
(J) a utilization review plan; and
(K) explicit fee policies with respect to
			 billing third-party payers, cancellation procedures, and fee
			 reductions.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.438 - Administration

Current through Register 1525, July 5, 2024
(A)
Organization
. Each center must establish an
			 organization chart showing major operating service programs of the center, with
			 staff divisions, administrative personnel in charge of each service program,
			 and their lines of authority, responsibility, and communication.
(B)
Fiscal
			 Management
. Each center must establish a system of business
			 management to ensure accurate accounting for sources and uses of funds, and
			 proper expenditure of funds within established budgetary constraints and grant
			 restrictions.
(C)
Data
			 Management
. Each center must develop and maintain a statistical
			 information system to collect member, service utilization, and fiscal data
			 necessary for the effective operation of the center.
(D)
Personnel
			 Management
. Each center must establish and maintain personnel
			 policies and personnel records for each employee.
(E)
Staff Development and
			 Supervision
.
(1) Each staff
			 member must receive supervision appropriate to the person's skills and level of
			 professional development. Supervision must be documented and must occur within
			 the context of a formalized relationship with the supervisor and in accordance
			 with 130 CMR
			 429.423(A). Documentation of
			 supervision must be maintained by the supervisor.
(2) Each center must establish and implement
			 procedures for staff training and evaluation. These procedures must require all
			 staff who must be certified to administer the CANS, as described in
			 130
			 CMR 429.423, to complete the certification
			 process established by the EOHHS.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.439 - Satellite Clinics

Current through Register 1525, July 5, 2024
All clinic locations must meet, independently of its parent
				clinic, all requirements set forth in
				130 CMR
				429.000. Satellite locations must be able to offer in
				person services for up to 20 hours per week; use of telehealth is acceptable
				when agreed upon by the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.440 - Outreach

Current through Register 1525, July 5, 2024
Services rendered in a member's home, place of residence, or an
				appropriate, mutually-agreed-upon community-based location by clinicians who
				are employed by the mental health center may be billed by the clinic when
				provided in accordance with the requirements of
				130 CMR
				429.000. All services provided in community-based
				settings must be provided in accordance with all provisions in
				130 CMR
				429.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.441 - Service Limitations

Current through Register 1525, July 5, 2024
(A)
Diagnostic and Treatment Services
. The MassHealth
			 agency pays for diagnostic and treatment services only when a professional
			 staff member, as defined by
			 130
			 CMR 429.424, personally provides these
			 services to the member or the member's family or personally consults with a
			 professional outside of the center. The services must be provided to the member
			 on an individual basis and are not reimbursable if they are an aspect of
			 service delivery, as defined in
			 130
			 CMR 429.408(B).
(B)
Multiple Visits on a Same
			 Date of Service
. The MassHealth agency pays for only one visit of
			 a single type of service (except for diagnostics) provided to an individual
			 member on one date of service. Return visits on the same date of service are
			 not reimbursable except for the provision of Crisis Intervention.
(C)
Multiple
			 Therapies
. The MassHealth agency pays for more than one mode of
			 therapy used for a member during one week when it is clinically justified, and
			 when any single approach has been shown to be necessary but insufficient. The
			 need for multiple therapies must be documented in the member's
			 record.
(D)
Case
			 Consultation
.
(1) The MassHealth
			 agency pays only for a case consultation that involves a personal meeting with
			 a professional of another agency. Personal meetings may be conducted
via
audio-only telephonic, audio-video, or in person
			 meetings.
(2) The MassHealth agency
			 pays for case consultation only when written communication and other
			 nonreimbursable forms of communication clearly will not suffice. Such
			 circumstances must be documented in the member's record. Such circumstances are
			 limited to situations in which both the center and the other party are actively
			 involved in treatment or management programs with the member (or family
			 members) and where a lack of direct communication would impede a coordinated
			 treatment program.
(3) The
			 MassHealth agency does not pay a center for court testimony.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 429.000 - Mental Health Center Services › Section 429.442 - 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 mental health center 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 431.000 - Independent Diagnostic Testing Facility › Section 431.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 431.000 establishes
				the requirements for the provision and reimbursement of independent diagnostic
				testing facility services under MassHealth. The MassHealth agency pays for
				independent diagnostic testing facility services that are medically necessary
				and appropriately provided in accordance with
				130 CMR
				450.204:
Medical Necessity
.
				All IDTF providers participating in MassHealth must comply with all MassHealth
				regulations including, but not limited to,
				130 CMR 431.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for IDTF services only when
			 provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of Emergency Aid to the Elderly, Disabled and Children
			 Program
. For information on covered services for recipients of the
			 Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
The MassHealth agency pays for the services described in
				130 CMR 431.000 only when
				performed by eligible providers of IDTF services who are participating in
				MassHealth on the date of service. The participating provider is responsible
				for the quality of all services for which payment is claimed, the accuracy of
				such claims, and compliance with all regulations applicable to IDTF services
				under MassHealth. In order to claim payment, the participating provider must be
				the IDTF that actually performed the service. An IDTF must have one or more
				supervising physicians who are responsible for the personal, direct, or general
				supervision of the facility and its personnel in accordance with Medicare
				requirements at 42 CFR § 410.323(B)(3), the operation and calibration of
				the equipment, and the quality of the testing performed.
(A)
Participating
			 Providers
: The following diagnostic testing facilities are
			 eligible to participate in MassHealth as IDTF providers:
(1) diagnostic imaging centers: centers that
			 perform a variety of tests, including ultrasounds, positron emission tomography
			 (PET) scans, and other imaging studies;
(2) freestanding MRI centers: independent MRI
			 Centers that perform MRI or magnetic resonance angiography (MRA) services in
			 accordance with standards developed by the American College of Radiology
			 (ACR);
(3) portable X rays: all
			 suppliers of portable x-ray services who are in compliance with 42 CFR 486 Part
			 C and are certified under the Medicare program;
(4) sleep centers: clinics that perform
			 diagnostic tests to determine the existence and type of sleep disorders;
			 and
(5) mammography vans: mobile
			 facilities that provide radiological tests for breast cancer.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.405 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
(A) The
			 Massachusetts Division of Health Care Finance and Policy (DHCFP) determines the
			 maximum allowable fees for all IDTF services purchased by government agencies.
			 DHCFP publishes a comprehensive listing of IDTF services and rates. Payment is
			 always subject to the conditions, exclusions, and limitations set forth in
			 130 CMR 431.000. Payment
			 for a service will be the lower of the following:
(1) the provider's usual and customary fee to
			 the general public for the same or a similar service; or
(2) the maximum allowable fee listed in the
			 applicable DHCFP fee schedule.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.406 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) Some tests
			 listed in Subchapter 6 of the
Independent Diagnostic Testing Facility
			 Manual
are designated "I.C.", an abbreviation for individual
			 consideration. A fee has not been established for these services. Payment for
			 an individual-consideration service is determined by the MassHealth agency's
			 professional advisers, based on the IDTF's description of the test, which must
			 be included with the claim.
(B) If
			 a service is not listed in Subchapter 6 of the
Independent Diagnostic
			 Testing Facility Manual
, an IDTF may submit a claim by using the
			 appropriate "unlisted service" service code. Payment for an unlisted service is
			 determined by individual consideration, based on the facility's description of
			 the service, which must be included with the claim.
(C) The MassHealth agency considers the
			 following factors when determining the appropriate payment for an
			 individual-consideration service:
(1) the
			 amount of time required to perform the procedure;
(2) the degree of skill required to perform
			 the procedure;
(3) policies,
			 procedures, and practices of other third-party payers;
(4) prevailing diagnostic testing ethics and
			 accepted custom of the diagnostic testing community; and
(5) other standards and criteria as may be
			 adopted by DHCFP or the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.407 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) The IDTF must
			 obtain prior authorization for services that are designated "P.A." in the
			 service descriptions listed in Subchapter 6 of the
Independent
			 Diagnostic Testing Facility Manual
.
(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
			 found in Subchapter 5 of the
Independent Diagnostic Testing Facility
			 Manual
. No payment will be made for such services unless prior
			 authorization has been obtained from the MassHealth agency before the delivery
			 of service. The MassHealth agency will not grant retroactive
			 prior-authorization requests.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.408 - Separate Procedures

Current through Register 1525, July 5, 2024
Certain procedures are designated "S.P." in the service
				descriptions in Subchapter 6 of the
Independent Diagnostic Testing
				Facility Manual
. "S.P." is an abbreviation for separate procedure. A
				separate procedure is one that is commonly part of a total service and
				therefore does not generally warrant a separate fee, but will be paid
				separately if the other portions of the service are not
				performed.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.409 - Ordering of Tests

Current through Register 1525, July 5, 2024
The member's treating clinician must order all diagnostic
				tests. The supervising physician for the IDTF, whether or not for a mobile
				unit, may not order tests to be performed by the IDTF, unless the supervising
				physician is the member's treating physician and is not otherwise prohibited
				from referring to the IDTF. The supervising physician is the member's treating
				physician if he or she furnishes a consultation or treats the member for a
				specific medical problem and uses the test results in the management of the
				member's medical problem.
(A)
Order Requirements
.
(1) A testing facility that furnishes a
			 diagnostic test ordered by the treating clinician may not change the diagnostic
			 test or perform an additional diagnostic test without a new order.
(2) An order is a communication from the
			 treating clinician requesting that a diagnostic test be performed for a member.
			 The order may conditionally request an additional diagnostic test for a
			 particular member if the result of the initial diagnostic test ordered yields
			 to a certain value determined by the treating clinician (
e.g
.,
			 if test X is negative, then perform test Y). An order may include the following
			 forms of communication:
(a) A written document
			 signed by the treating clinician, which is hand-delivered, mailed, or faxed to
			 the testing facility; or
(b) A
			 telephone call by the treating clinician to the testing facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.410 - Payment

Current through Register 1525, July 5, 2024
(A)
Global Fee
.
			 Payment for a diagnostic procedure performed at an IDTF will include facility
			 costs, technical costs, and professional costs.
(B)
Terminated
			 Procedures
. Upon review, the MassHealth agency may pay for
			 procedures which were unable to be completed after the procedure was
			 initiated.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.411 - Service Descriptions and Limitations: Levels of Physician Supervision

Current through Register 1525, July 5, 2024
Independent diagnostic testing facilities must provide the
				appropriate level of physician supervision for each procedure in accordance
				with Medicare requirements at 42 CFR § 410.323(b)(3). The definition of
				each level of physician supervision is set forth in
				130 CMR
				431.402.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.412 - Service Descriptions and Limitations: Sleep Centerss

Current through Register 1525, July 5, 2024
(A) Sleep Centers enrolled as IDTFs may bill
			 for at-home pulse oximetry services. The MassHealth agency will pay only for
			 pulse oximetry tests and polysomnography used to determine sleep
			 disorders.
(B) For sleep testing to
			 be performed in an IDTF, the supervising physician must be certified by boards
			 in psychiatry and neurology, internal medicine with pulmonary specialty, or in
			 sleep medicine. IDTF technologists must be certified in electroneurodiagnostic
			 testing or registered in polysomnography.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.413 - Covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for IDTF services necessary for the
				diagnosis, detection, and treatment of disease, and for the maintenance of the
				health of MassHealth members, subject to all restrictions and limitations
				described in
				130 CMR 431.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.414 - Noncovered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for the following
				services:
(A) tests performed for
			 experimental or investigational purposes, or that are themselves experimental
			 or investigational; and
(B) tests
			 performed for forensic purposes or any purpose other than those described in
			 130 CMR 431.413,
			 including but not limited to:
(1) tests
			 performed to establish paternity; and
(2) post-mortem examinations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 431.000 - Independent Diagnostic Testing Facility › Section 431.415 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) The IDTF is
			 responsible for assuring the medical necessity of the tests and maintaining
			 test results in the member's health record.
(B) IDTFs must maintain a medical-record
			 system promoting quality and confidential member care in accordance with
			 105 CMR
			 140.000:
Licensure of Clinics
. This
			 system must collect and retain data in a comprehensive and efficient manner and
			 permit the prompt retrieval of information. Accurate and complete medical
			 records must be maintained for each member receiving testing services from the
			 IDTF. The data maintained in the member's medical record must also be
			 sufficient to justify any further diagnostic procedures. The medical record
			 must be clear and legible, and readily accessible to health-care practitioners
			 and the MassHealth agency. The medical record must be maintained by the IDTF
			 for at least six years.
(C) The
			 medical record must contain, at a minimum, the following information:
(1) the member's name, address, telephone
			 number, date of birth, and MassHealth identification number;
(2) the date of service;
(3) the name, title and signature of the
			 referring clinician;
(4) a written
			 order for the tests to be performed;
(5) the name, title, and signature of the
			 person performing the service;
(6)
			 the name of the supervising physician;
(7) pertinent findings on examination;
			 and
(8) tests performed and
			 results.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.401 - Introduction

Current through Register 1525, July 5, 2024
All therapists participating in MassHealth must comply with
				MassHealth regulations, including but not limited to
				130 CMR
				432.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers therapist services only when provided
			 to eligible MassHealth members, subject to the restrictions and limitations
			 described in the MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.405 - Provider Eligibility: Out of State

Current through Register 1525, July 5, 2024
To participate in MassHealth, an out-of-state therapy provider
				must
(A) participate in the Medicaid
			 program in the state in which it is located;
(B) be licensed by and be in good standing
			 with their state's licensing authority;
(C) provide therapy services consistent with
			 the provisions of
			 130 CMR
			 450.109:
Out-of-state
			 Services
;
(D) obtain a
			 MassHealth provider number before providing therapy services;
(E) provide services in accordance with
			 130 CMR 432.411:
Payable Services
; and
(F) notify the MassHealth agency in writing
			 within 14 days of any change in any of the information submitted in the
			 provider application in accordance with
			 130 CMR
			 450.223(B):
Provider
			 Contract: Execution of Contract
including, but not limited to, change
			 of ownership, change of address, and addition or deletion of a branch
			 office.
(G) As set forth at
			 130 CMR 432.411(E) and
			 (F), the MassHealth agency pays for services
			 provided by out of state therapists or, by out of state PTAs, OTAs, and SLPAs
			 when consistent with Medicaid requirements regarding therapy assistants in the
			 state in which they are located, subject to the supervision requirements of
			 130 CMR
			 432.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.406 - Provider Responsibilities

Current through Register 1525, July 5, 2024
(A)
Therapy Provider Service Location Site Visits
. An
			 unscheduled therapy service location site visit may be conducted by MassHealth
			 or its designee, to assess compliance with MassHealth rules and regulations
			 including, but not limited to, those described in 130 CMR 432.406(B) and (C),
			 under the following circumstances:
(1) for a
			 physical therapy services group practice or individual physical therapist that
			 is not a Medicare provider and is newly enrolled in MassHealth; or
(2) for any MassHealth enrolled therapy
			 provider at the sole discretion of the MassHealth agency or its designee.
See
130 CMR
			 450.212:
Provider Eligibility:
			 Eligibility Criteria
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.411 - Payable Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for the following therapist services
				subject to the conditions and limitations of
				130 CMR
				432.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
:
(A) individual treatment;
(B) initial therapy evaluation and
			 reevaluations;
(C)
			 co-treatment;
(D) group
			 therapy.
(E) The MassHealth agency
			 pays for services set forth at 130 CMR 432.411(A) through (D) when provided by
			 therapists or by PTAs, OTAs, and SLPAs subject to the supervision requirements
			 of
			 130 CMR
			 432.000.
(F) Service provided by supervised PTAs,
			 OTAs, or SLPAs must be billed using the MassHealth provider ID of the
			 supervising MassHealth-enrolled therapist.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.412 - Nonpayable Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay a therapy provider for any
				of the following services:
(A) indirect
			 services such as staff meetings, staff supervision, member screening, and
			 development or use of instructional texts and reusable treatment
			 materials;
(B) nonmedical services
			 such as vocational, social, and recreational services;
(C) unproven or experimental treatment, as
			 described in
			 130 CMR
			 450.204(E);
(D) mental health services; and
(E) services provided by unlicensed persons
			 including, but not limited to, aides and students, even if under the
			 supervision of a licensed therapy provider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.413 - Nonpayable Circumstances

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay a therapist for services
				provided under any of the following circumstances.
(A) The therapist provided the service in an
			 inpatient or long-term care facility and is paid by the inpatient or long-term
			 care facility to provide that service, whether or not the cost of the service
			 is included in the MassHealth agency's or other payer's rate of payment for
			 that facility.
(B) The therapist
			 receives compensation from the state, county, or municipality, unless they are
			 supplementing their income by providing services during off-duty
			 hours.
(C) Under comparable
			 circumstances, the therapist does not customarily bill private patients who do
			 not have health insurance.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.414 - Service Limitations

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays a therapist for no more than one individual treatment and one group
			 therapy session per member per day. For a further description of payable
			 service codes and modifiers,
see
Subchapter 6 - Service Codes
			 and Descriptions of the
Therapist Manual
.
(B) The MassHealth agency does not pay for a
			 treatment claimed for the same date of service as an evaluation or
			 reevaluation, since the evaluation or reevaluation fee includes payment both
			 for a written report and for any treatment provided at the time of the
			 evaluation or reevaluation.
(C) The
			 MassHealth agency pays a therapist for providing services in a
			 Medicare-certified long-term-care facility subject to
			 130 CMR 432.413(A)
			  and only in the following circumstances:
(1) the member is not covered for therapy
			 services under Medicare Part A or B; or
(2)
(a) the
			 member is covered for therapy services under Medicare, but the facility or the
			 therapist has submitted the claim to Medicare, and Medicare has denied payment;
			 and
(b) the therapist has obtained
			 prior authorization as necessary in accordance with
			 130 CMR
			 432.417.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.415 - Prescription Requirements

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for only those treatments and evaluations for which the therapist
			 has obtained written prescriptions from the member's prescribing provider.
			 Electronic prescriptions (escripts) are allowable if they comply with state and
			 federal requirements and are transmitted by the member's prescribing provider
			 in accordance with the MassHealth agency's administrative and billing
			 instructions.
(B)
Initial Prescription
. The initial prescription must be
			 written on the prescribing provider's letterhead, must be dated prior to the
			 initiation of the prescribed services, and must contain the following
			 information:
(1) the member's name;
(2) the member's diagnosis that requires
			 therapy services;
(3) the reason
			 for the prescription;
(4) the date
			 of prescription; and
(5) the
			 prescribing provider's signature and contact information, including name, NPI,
			 and telephone number.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.416 - Evaluations and Plan of Care Requirements

Current through Register 1525, July 5, 2024
(A)
Initial Evaluation
. An initial evaluation is an
			 in-depth assessment of a member's medical condition or disability, or both, and
			 level of functioning to determine the need for therapy. When therapy is
			 indicated, it is used to develop a plan of care. The evaluation is conducted by
			 a licensed therapist in response to the prescribing provider's initial
			 prescription for therapy services and must occur prior to the start of therapy
			 care. The MassHealth agency will only pay for one initial evaluation relative
			 to an initial prescription. Documentation of the therapy initial evaluation
			 must include a written report for the member's medical record that contains at
			 least the following information:
(1) the
			 member's name and address;
(2) the
			 member's diagnosis (specific and relevant to the medical condition requiring
			 therapy services);
(3) list of
			 precautions, if applicable, relevant to the member's illness, injury or
			 disability requiring therapy services;
(4) a medication list;
(5) a detailed treatment plan describing the
			 type, amount, frequency, and duration of therapy and indicating the diagnosis,
			 prognosis, anticipated goals, and location where therapy will take place, or
			 the reason treatment is not indicated;
(6) additional health care evaluations, as
			 indicated;
(7) a description of the
			 member's psychosocial and health status that includes:
(a) the present effects of the member's
			 current condition, disability or injury/illness requiring therapy
			 services;
(b) a brief history, the
			 date of onset, and any past treatment of the condition, disability, or
			 injury/illness;
(c) the member's
			 level of functioning, including physical and functional limitations, both
			 current and before onset of the current condition, disability or
			 illness/injury, if applicable;
(d)
			 any other significant physical or mental disability that may affect
			 therapy;
(e) sensory and cognitive
			 status, if applicable; and
(f)
			 social supports, if applicable.
(8) identification of any current durable
			 medical equipment (DME) used by the member;
(9) identification of any other
			 medical/health services concurrently being provided to the member;
(10) a description of any conferences with
			 the member, member's family, member's clinician, or other interested
			 persons;
(11) a detailed plan of
			 care, which must meet the conditions at 130 CMR 432.416(C);
(12) the therapist's signature and the date
			 of the evaluation; and
(13) for
			 speech/language therapy only:
(a) assessments
			 of speech production skills, stimulability, receptive and expressive language
			 skills, augmentative and alternative communication skills, fluency, voice or
			 swallowing;
(b) documentation of
			 the member's cognitive linguistic functioning; and
(c) a description of the member's
			 communication needs and motivation for therapy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.417 - Prior Authorization

Current through Register 1525, July 5, 2024
(A)
General Terms
.
(1)
			 Prior authorization (PA) must be obtained from the MassHealth agency or its
			 designee as a prerequisite to payment for visits in excess of the number of
			 visits described in 130 CMR 432.417(B). Without such prior authorization, the
			 MassHealth agency will not pay therapy providers for services in excess of the
			 number of visits described in 130 CMR 432.417(B).
(2) 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
			 third party health insurance payment, including Medicare.
See
130 CMR
			 450.303:
Prior Authorization
for additional information about prior authorization.
(3) Approvals for prior authorization specify
			 the number of hours, visits, or units for each service that are medically
			 necessary and payable each calendar week and the duration of the prior
			 authorization period. The authorization is issued in the member's name and
			 specifies frequency and duration of care for each service approved per calendar
			 week.
(4) The therapy provider must
			 submit all prior authorization requests in accordance with
			 130 CMR
			 450.303:
Prior Authorization
and any relevant MassHealth agency instructions.
(5) In conducting prior authorization review,
			 the MassHealth agency or its designee will apply any applicable MassHealth
			 medical necessity guidelines and may refer the member for an independent
			 clinical assessment to inform the determination of medical necessity for
			 therapy services.
(6) If the number
			 of prior-authorized services need to be adjusted because the member's medical
			 needs have changed, the therapy provider must request a prior authorization
			 adjustment from the MassHealth agency or its designee.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.418 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
Payment for any service listed in
				130 CMR
				432.000 is conditioned upon its full and complete
				documentation by the provider in the member's medical record. Records must be
				retained by the provider in accordance with
				130 CMR 450.205(G)
				 and any other guidance provided by the
				MassHealth agency. The therapist is responsible for the complete documentation
				of therapy services provided, including therapy services provided under the
				therapist's supervision. The record must include the following:
(A) the prescribing provider's initial
			 written prescription, and, if applicable, prescription renewals every 60 days
			 (
see
130 CMR
			 432.415);
(B) the written initial evaluation report
			 and, if applicable, any subsequent reevaluation (
see
130 CMR
			 432.416);
(C) the name, NPI, and telephone number of
			 the member's prescribing provider;
(D) the written documentation for each date
			 on which therapy was provided, including the following:
(1) the date on which therapy was
			 provided;
(2) the amount of time
			 spent in therapy;
(3) the specific
			 therapeutic procedures and methods used;
(4) the teaching tools provided to the
			 member, their family, or other persons;
(5) the member's response to
			 treatment;
(6) any changes in the
			 member's condition;
(7) the
			 problems encountered or changes in the plan of care or goals, if any;
(8) the location where the service was
			 provided, if different from that in the evaluation or reevaluation
			 report;
(9) the therapist's
			 signature and, if applicable, the signature of the licensed physical therapy
			 assistant, the licensed occupational therapy assistant, or licensed
			 speech/language therapy assistant; and
(10) written documentation demonstrating
			 measurable, objective, and functional progress as a direct result of treatment,
			 excluding those who meet criteria in
			 130 CMR
			 432.414(D).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.419 - Payment for Therapy Services

Current through Register 1525, July 5, 2024
The Executive Office of Health and Human Services establishes
				the rates payable for therapy services.
See
101 CMR
				339.00:
Restorative Services
. Payment
				is always subject to the conditions, exclusions, and limitations set forth in
				130 CMR
				432.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.420 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary therapy
				services for EPSDT-eligible members in accordance with
				130
				CMR 450.140 through
				130
				CMR 450.150, without regard to service
				limitations described in
				130 CMR
				432.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.421 - Quality Management and Utilization Review

Current through Register 1525, July 5, 2024
(A) A therapy provider must participate in
			 any quality management and program integrity processes as required by the
			 MassHealth agency including making any necessary data available and providing
			 access to visit the therapy provider's place of business upon request by
			 MassHealth or its designee.
(B) A
			 therapy provider must submit requested documentation to the MassHealth agency
			 or its designee for purposes of utilization review and provider review and
			 audit, within the MassHealth agency's or its designee's time specifications.
			 The MassHealth agency or its designee may periodically review a member's plan
			 of care and other records to determine if services are medically necessary in
			 accordance with
			 130 CMR
			 450.204:
Medical Necessity
.
			 The therapy provider must provide the MassHealth agency or its designee with
			 any supporting documentation the MassHealth agency or its designee requests, in
			 accordance with M.G.L. c. 118E, § 38 and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.422 - Prohibited Marketing Activities

Current through Register 1525, July 5, 2024
A therapy provider must not
(A) with the knowledge that a member is
			 enrolled in a MassHealth capitated program, engage in any practice that would
			 reasonably be expected to have the effect of steering or encouraging the member
			 to disenroll from the MassHealth capitated program in order to retain the
			 therapy provider to provide therapy services on a fee-for-service
			 basis;
(B) offer to a member, or
			 their family or caregivers, in person or through marketing, any inducement to
			 retain the therapy provider to provide therapy services, such as a financial
			 incentive, reward, gift, meal, discount, rebate, giveaway, or special
			 opportunity;
(C) pay a "finder's
			 fee" to any third party in exchange for referring a member to the therapy
			 provider; or
(D) engage in any
			 unfair or deceptive acts or practices in connection with any
			 marketing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.402 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for physician services only
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in the MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of Emergency Aid to the Elderly, Disabled and Children
			 Program
. For information on covered services for recipients of the
			 Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.403 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
Participating Providers
.
(1)
									130 CMR
			 433.000 applies to medical, radiology, laboratory,
			 anesthesia, and surgery services provided to members by physicians
			 participating in MassHealth as of the date of service.
(2) To be eligible for payment, a physician
			 must be physically present and actively involved in the treatment of the
			 member. Time periods specified in the service descriptions refer to the amount
			 of time the physician personally spends with the member, except in the
			 instances noted where the service can be performed under the direct supervision
			 of the physician. For surgery, the physician must be scrubbed and must be
			 present in the operating room during the major portion of an
			 operation.
(3) Provider
			 participation requirements for certified nurse practitioners, certified nurse
			 midwives, certified registered nurse anesthetists, clinical nurse specialists,
			 psychiatric clinical nurse specialists, and physician assistants are also
			 addressed in
			 130 CMR
			 433.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.404 - Nonpayable Circumstances

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency does not pay a physician for services provided under any of the
			 following circumstances.
(1) The services were
			 provided by a physician who individually or through a group practice has
			 contractual arrangements with an acute, chronic, or rehabilitation hospital,
			 medical school, or other medical institution that involve a salary,
			 compensation in kind, teaching, research, or payment from any other source, if
			 such payment would result in dual compensation for professional, supervisory,
			 or administrative services related to member care.
(2) The services were provided by a physician
			 who is an attending, visiting, or supervising physician in an acute, chronic,
			 or rehabilitation hospital but who is not legally responsible for the
			 management of the member's case with respect to medical, surgery, anesthesia,
			 laboratory, or radiology services.
(3) The services were provided by a physician
			 who is a salaried intern, resident, fellow, or house officer. 130 CMR 433.404
			 does not apply to a salaried physician when the physician supplements his or
			 her income by providing services during off-duty hours on premises other than
			 those of the institution that pays the physician a salary, or through which the
			 physician rotates as part of his or her training.
(4) The services were provided in a state
			 institution by a state-employed physician or physician consultant.
(5) Under comparable circumstances, the
			 physician does not customarily bill private patients who do not have health
			 insurance.