Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.207 - Utilization Management Program for Acute Inpatient Hospitals

Current through Register 1525, July 5, 2024
(A)
Introduction
.
			 130 CMR 450.207 through
			 450.209
			 describes the Utilization Management Program for acute inpatient hospitals. The
			 purpose of this program is to ensure that certain medical services for which
			 the MassHealth agency pays are medically necessary and provided in the
			 appropriate setting. To this end, the MassHealth agency conducts reviews before
			 elective admissions (admission screening) and after discharge but before
			 payment (prepayment review). The MassHealth agency also conducts utilization
			 reviews of inpatient admissions and outpatient services on a postpayment basis
			 pursuant to
			 130 CMR
			 450.237. The term "admitting provider" as
			 used in 130 CMR 450.207 through
			 450.209
			 refers to the provider (for example, physician or dentist) who admits the
			 member to the facility and who assumes primary responsibility for the member's
			 care and the admitting provider's designee, where appropriate. The requirements
			 of the Utilization Management Program detailed in 130 CMR 450.207 through
			 450.209
			 apply to both in-state and out-of-state hospitals.
(B)
General
			 Provisions
.
(1)
Appendix
. The MassHealth agency has issued an appendix
			 to the provider manual for each facility and admitting provider affected by the
			 Utilization Management Program. This appendix contains a list of information
			 the admitting provider must provide for each review, and the name, address, and
			 telephone number of the MassHealth agency's agent for the Utilization
			 Management Program.
(2)
Stipulations
. The Utilization Management Program does
			 not waive or replace any other MassHealth agency requirements, such as
			 prior-authorization or consent-form requirements.
(3)
Payment
			 Restrictions
.
(a) The MassHealth
			 agency will pay the acute inpatient hospital for services subject to the
			 Utilization Management Program only if the admitting provider has complied with
			 the requirements in 130 CMR 450.207 through
			 450.209
			 and the service is medically or administratively necessary.
(b) Payments are subject to all general
			 conditions and restrictions of the MassHealth agency.
(c) A provider may not bill the member for
			 any medical care for which the MassHealth agency has denied payment due to the
			 provider's failure to comply with the requirements of the Utilization
			 Management Program.
(4)
Exceptions
. Proposed admissions of the following
			 members, are exempt from the requirements of the Utilization Management
			 Program, regardless of admitting diagnosis:
(a) members whose hospitalization is
			 court-ordered;
(b) recipients of
			 the EAEDC Program; and
(c) members
			 for whom MassHealth is not the primary payer of the acute inpatient admission,
			 including but not limited to members covered by an MCO, Accountable Care
			 Partnership Plan, SCO, ICO, commercial insurance, or Medicare. However, if the
			 primary payer denies coverage before the member is admitted or if the member
			 has Medicare Part B only, the admission of the member is not exempt from the
			 requirements of the Utilization Management Program.